It’s been a flurry of activity leading up to the implementation of the “new MDS.” For months our industry has been doing what we do best — rising to the occasion. 

Countless MDS training sessions, manuals, tip cards and software updates have filled our inboxes and daily industry news. However, if the arbiter of success isn’t making it past the Oct. 1 start date, then what is?

With this in mind, I turned to some of the best and brightest at Zimmet Healthcare: Alicia Cantinieri, Melanie Tribe-Scott and Amy Greer. In total, the three of them have completed dozens of public and private training sessions on the new MDS. But what I wanted to learn from them were any early warning signs that the transition wasn’t going well. Their response made me sound the alarm: “Fasten your seatbelts: It MIGHT be a bumpy ride.” However, they also offered several sage tips that should help you avoid unnecessary potholes.

States that are already using or converting to a Patient Driven Payment (PDPM) methodology for CMI are primarily using the Nursing component. Accurate documentation and coding of the resident’s “usual performance” in MDS Section GG is crucial, as well as the capture of diagnoses and other higher-acuity items. 

In states that are continuing to use the Optional State Assessment (OSA) or have rates frozen while the state adopts a PDPM system, MDS coding on OBRA assessment is also important as the OBRA assessments after Oct. 1 may be used in rate development or rate setting. 

As always, it’s crucial for the MDS and supporting documentation to be accurate. 

Therefore, three months out, do the following:

1. Self-audit or have a third party audit a random sample of OBRA assessments; the size of the sample depends on the number of assessments completed. Does the MDS coding have support in the medical record? Would another MDS assessor code the items the same way from the available documentation?

2. Review your facility’s process for collecting Section GG data. Is data gathered from all shifts? Is there evidence of multidisciplinary collaboration?

3. Review diagnoses coded on the MDS. Does the documentation support for diagnoses follow the RAI Manual guidelines? 

Double down on triple-check for Med A residents coding in Section K and Section O. Both of these sections added a new column that is required for PPS assessments at the start of the Medicare stay. The PDPM group will still pull from the “while a resident” column, as always. However, the extra column may cause some confusion. If the dietitian or MDS coordinator doesn’t fully understand the coding instructions, then reimbursement may be missed. For example, oxygen during the first three days of the Med A stay needs to be coded at both O0110C1a on admission and O0110C1b while a resident.

The same situation may occur in Section K. If the resident received tube feeding during the first three days of the Medicare stay, this must be coded at both K05201a and K05201b.

Regarding the PHQ-2 to 9, the facility should expect to see a decline in residents with a depression end-split, but not necessarily on the quality measure (QM). However, that decline in the end-split should not be extreme. A facility that was reporting a PDPM depression rate of 30% should not drop to 0%. If there IS an extreme decline, additional training may be required to ensure social services, or whoever is completing the assessment, understands the interview process for the PHQ-2 to 9. 

Therefore, three months out, do the following:

1. Monitor your PHQ-2 to 9 scores by pulling a report from your software.

2. Pay close attention to PDPM Section GG function scores.

3. Pay close attention to SLP and Nursing component scores dependent on Section K.

Although the Discharge Function Measure has a complicated formula and risk adjustment, if status on discharge indicates no improvement or minimal improvement from admission to discharge for many residents receiving rehab, it’s likely to be a red flag. This could indicate a lack of carryover from the rehab gym to performance back on the floor. With a focus on successful discharge to the community and rehospitalizations, ensuring the resident can translate performance in the gym to the unit and ultimately to their home as appropriate is key. 

Also remember that the data reporting threshold for QRP items will increase from 80% of the assessments to 90% for FY 2026. This affects MDS assessments beginning with CY 2024. A low data reporting percentage is related to “dashing” (—) the required data elements. Education or system changes may be needed to ensure the data reporting is at 90% or higher. With the additional assessment items on the new MDS, hitting 90% may be more of a challenge. Not only are there new QRP items, such as B1300 Health Literacy and transfer of health information, but we are also not well practiced in capturing these items. How have you operationalized their data capture?

Therefore, four months out, do the following:

1. Review the QRP Threshold Report in CASPER. If the facility is significantly below 90% after one complete quarter of data, it is critical to determine the reason why and make corrections if possible. 

2. Review the process for the UR meetings and discharge planning. Are the functional gains made by the resident in rehab translating to the rest of the day on the unit prior to discharge? 

3. Again, self-audit or have a third-party audit MDS assessments for accuracy. 

The new MDS will affect Five-Star ratings, especially the QMs domain. With the elimination of Section G, four of the QMs will be affected (Increased ADLs, Pressure Ulcers, Improvement in Function, and Move Independently Worsened). These measures historically were calculated using data from Section G, but they will now use data from Section GG. In April 2024, these four measures will be “frozen” on Nursing Home Compare for three months to allow CMS to “catch up.” 

Once the QMs are unfrozen, they will be based upon MDS data from Q3 2023. You don’t want this to be the point where you realize your facility has been missing documentation opportunities from Oct. 1 and onward. After Oct. 1, carefully review all MDS assessments on a weekly basis for coding accuracy. Don’t do this review monthly; accumulated errors will be time-consuming to correct, and possibly lower QM scores can impact your QMs star rating and possibly even your overall star rating. 

Therefore, one month out, do the following:

1. Go “old school.” Frozen QM CASPER reports will not suffice your QAPI or auditing needs. “Back of the envelope” is often as good as a dense analytical report. Manually track, audit and analyze those negative outcomes 

2. Ensure your clinical staff are educated on the changes. Are your CNAs coding accurately? Is your MDS coordinator updated and supported? 

3. Begin a QAPI for any issues that might arise during the transition (e.g., complete, accurate CNA coding; nursing documentation in ADL decline).

We’ve discussed how a facility might see a decline in residents triggering depression. It’s essential to ensure you’re properly identifying residents with depression, regardless of payer type or QM definition. Once you’ve done so, creating an appropriate care plan and evaluating its effectiveness is key to success. 

An exact cross-over between Section G and Section GG cannot be made. However, the facility should not see a significant difference in coding. For example, a resident typically coded extensive to total for ADLs in Section G should not be coded as independent to set up functional abilities in Section GG. Review and monitor for such differences prior to submission, as they may impact the care plan and Medicaid reimbursement in some states. Significant differences may indicate a need for additional CNA training or an update to the documentation system.

The facility should update verbiage in care plan templates to reflect the functional abilities in Section GG as opposed to Section G. Be sure to include new items in care plans such as social isolation, health literacy and indications for medications.

Therefore, immediately do the following if you haven’t already:

1. Provide follow-up education to CNAs on GG coding now and then two to three weeks after implementation of the new coding.

2. Supply additional education on interview techniques for the BIMS and PHQ-2 to 9.

3. Review GG coding prior to MDS submission for the first three or four weeks on all payer sources to ensure accuracy. 

Surveyors will likely focus on Section GG and the newer items. If your facility lacks supporting documentation or has no process to gather the data to make a functional assessment, there will be a problem. Facilities that choose not to have CNAs document Section GG items still need a system for daily documentation to indicate the resident’s status and care provided, provide support for rehab referrals due to a change in function, and track significant changes. Lacking these items can be detrimental to the accuracy of assessment and care planning. 

Regarding missing indications in Section N, if the assessors are checking off “no” to indications for high-risk meds, that might signal an issue with documentation. Clinical support is required from the prescriber and not simply a diagnosis with no further support or rationale in the clinical record. The SOM requires physician’s visits to include an evaluation of the resident’s condition and total program of care, including medications and treatments, and a decision about the continued appropriateness of the resident’s current medical regimen, which is in line with the indication for high-risk medications in MDS Section N. 

Therefore, three months out, do the following:

1. Self-audit or have a third-party audit documentation to support change in function in ADLs and rehab referrals. 

2. Conduct a monthly review of CNA ADL documentation and ensure their involvement in the care plan meetings. 

3. Self-audit or have a third-party audit high-risk medications and clinical rationale. Pharmacy partners would be great for this. 

One final potential bump 

Have you updated your facility assessment, policy and procedures to reflect the new MDS changes? Is your interdisciplinary team comfortable with these changes? Specifically, are your nurses educated on medication reconciliation at discharge? Do they understand indication vs. diagnosis? Who will be responsible for ensuring that this requirement is completed, accurate and documented? 

Therefore, one month out, do the following:

1. Have conversations with members of your clinical team to gauge their adjustment to the changes. Do they have any ideas that may help improve your documentation?

2. Review all policies, procedures, facility assessments and census and condition reports to ensure that they are updated and that they accurately and compliantly reflect changes to the MDS. Incorrect or outdated data can also have repercussions for your health inspection survey. 

3. Audit your medication reconciliation and discharge documentation monthly.

This “new MDS” doesn’t carry the title MDS 4.0 but maybe it should. The amount of change is significant. Do fasten your seatbelts because we will experience bumps. However, a seatbelt constructed of audits, education and QAPI will keep you safe. 

Steven Littlehale is a gerontological clinical nurse specialist and chief innovation officer at Zimmet Healthcare Services Group.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.

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