Q&A: A resident discharged to the hospital with an unstageable pressure ulcer due to eschar (occurred in house). The wound was debrided in the hospital and then the resident returned with it being a Stage 3 pressure ulcer. Would this be presented upon reentry since it’s now a Stage 3?

MDS 3.0 and the RAI Process / NAC / Q&A

Question: A resident discharged to the hospital with an unstageable pressure ulcer due to eschar (occurred in house). The wound was debrided in the hospital and then the resident returned with it being a Stage 3 pressure ulcer. Would this be presented upon reentry since it’s now a Stage 3? …

Q&A: A resident had a chest tube placed in the hospital and removed prior to re-admission. In the 5-Day look-back period, we have orders for an ointment and dressing to the area daily until resolved. Would I capture this under surgical wound and surgical wound care?

MDS 3.0 and the RAI Process / NAC / Q&A

Question: A resident had a chest tube placed in the hospital and removed prior to re-admission. In the 5-Day look-back period, we have orders for an ointment and dressing to the area daily until resolved. Would I capture this under surgical wound and surgical wound care? Answer from Jennifer LaBay …

Q&A: Is an OBRA Discharge assessment required when a non-skilled resident has an unplanned transfer to the hospital, was not admitted, but was there for 30 hours?

MDS 3.0 and the RAI Process / NAC / Q&A

Question: Is an OBRA Discharge assessment required when a non-skilled resident has an unplanned transfer to the hospital, was not admitted, but was there for 30 hours? Answer from Carol Maher, RN, GERO-BC, RAC-MTA, RAC-MT, CPC:Yes, OBRA Discharge assessments are required when residents transfer to the hospital, emergency department, or …

Q&A: On admission, our infection control nurse asks about the COVID-19 vaccine and documents the resident’s vaccine status and acceptance or refusal of the vaccine. Since we are no longer providing the vaccine in the facility, should I be dashing this item?   

MDS 3.0 and the RAI Process / NAC / Q&A

Question: On admission, our infection control nurse asks about the COVID-19 vaccine and documents the resident’s vaccine status and acceptance or refusal of the vaccine. Since we are no longer providing the vaccine in the facility, should I be dashing this item?    Answer from Jessie McGill, RN, BSN, RAC-MTA, …

Q&A: Is a Part A PPS Discharge assessment required if the resident exhausted the 100-day benefit?

Billing and Reimbursement / NAC / Q&A

Question: Is a Part A PPS Discharge assessment required if the resident exhausted the 100-day benefit? Answer from Carol Maher, RN, GERO-BC, RAC-MTA, RAC-MT, CPC: Yes, the Part A PPS Discharge MUST be completed when Medicare benefits exhaust. The Part A PPS discharge MDS must be completed every time Medicare …

Q&A: Do the medications gabapentin/Neurontin get coded in section J, Scheduled pain medication regimen, if the doctor noted they are for pain management, and are they also coded as anticonvulsants in section N?

MDS 3.0 and the RAI Process / NAC / Q&A

Question: Do the medications gabapentin/Neurontin get coded in section J, Scheduled pain medication regimen, if the doctor noted they are for pain management, and are they also coded as anticonvulsants in section N? Answer from Scott Heichel, RN, RAC-MT, RAC-CTA, DNS-CT, QCP, ICC, IPCO: Yes. Part of the confusion can …

Q&A: When coding urinary tract infection (UTI) at I2300, if the diagnosis of UTI was made prior to resident admission, is it optional to use evidence-based criteria (e.g., NHSN), which would exclude the UTI prior to admission? 

MDS 3.0 and the RAI Process / NAC / Q&A

Question: When coding urinary tract infection (UTI) at I2300, the RAI User’s Manual states that if diagnosis of UTI was made prior to resident admission it is not necessary to evaluate for evidence-based criteria and that a documented physician diagnosis (transfer sheet or paperwork) can be used. Is it required …

Q&A: We recently had a state case-mix audit, and I had to correct an error that resulted in a new Care Area Assessment (CAA) triggering. My software gave me a warning that a significant correction was indicated. How do I know if a significant correction is needed and how do I schedule this?

MDS 3.0 and the RAI Process / NAC / Q&A

Question: We recently had a state case-mix audit, and I had to correct an error that resulted in a new Care Area Assessment (CAA) triggering. My software gave me a warning that a significant correction was indicated. How do I know if a significant correction is needed and how do …

Q&A: Should MDS Item I0020B always be the diagnosis from the qualifying hospital stay? How do I code this for a resident who has been in long-term care for many years and has no recent hospital stays?

MDS 3.0 and the RAI Process / NAC / Q&A

Question: Should MDS Item I0020B always be the diagnosis from the qualifying hospital stay? How do I code this for a resident who has been in long-term care for many years and has no recent hospital stays? Answer from Carol Maher, RN, GERO-BC, RAC-MTA, RAC-MT, CPC: I0020B is answered to …

Q&A: When coding K0100, Swallowing Disorders, can we capture signs and symptoms if they were identified when the resident was working with speech-language pathology (SLP) and on a trial diet?

MDS 3.0 and the RAI Process / NAC / Q&A

Question: When coding K0100, Swallowing Disorders, can we capture signs and symptoms if they were identified when the resident was working with speech-language pathology (SLP) and on a trial diet? Answer from Jennifer LaBay RN, RAC-MT, RAC-MTA, QCP, CRC While the RAI User’s Manual is very clear on not capturing …