Care teams now at risk as MDS changes roll out

It’s been widely billed as the biggest change to the Minimum Data Set in more than a decade, and on Sunday, version 1.18.11 of the MDS 3.0 finally kicks in.

But potential trouble spots already exist for the unprepared provider.

After stalling an update during the pandemic, the Centers for Medicare & Medicaid Services dropped its long-awaited draft revisions just over a year ago. Since then, providers have waited anxiously as various changes to MDS sections, the RAI user’s manual, interview scripts and other tools have been rolled out in piecemeal fashion.

Now, it’s go-time. With so many major changes — the elimination of Section G, replacement of the PHQ-9 with a potentially shorter test, the addition of SPADES and new data points for quality reporting purposes — it might be easy to overlook some less obvious updates in coding practices and processes.

There are plenty of items that drew less concern in much of the public conversation but nonetheless merit attention now to ensure solid documentation, coding and reimbursement processes are in place during and after the transition. 

Just the increase in the number of required reportable items alone is staggering, jumping from 99 data elements to 230 in v1.18.11, noted Joel VanEaton, master teacher and executive vice president of PAC Regulatory Affairs and Education for Broad River Rehab. 

And it’s more important than ever that providers not skip or leave blank sections for which they’re unprepared or untrained. The final SNF PPS rule for fiscal 2024 requires nursing homes to submit 100% of Quality Reporting Program data on 90% of the MDS assessments submitted, up from 80%. 

“From the SNF QRP perspective, a single misplaced dash is all it will take to lose 2% off next year’s market basket update,” VanEaton said. “These items include all items required to calculate the SNF QRP quality measures as well as the additional Standardized Patient Data Elements (SPADEs), like race and ethnicity and social determinants of health.”

McKnight’s Long-Term Care News asked Van Eaton and other assessment and coding experts for their take on areas that should be high on the radar heading into the weekend.

Prep for the changeover

From now until a few days after the switch, there could be significant confusion when admitting and discharging patients, experts noted. 

“Providers need to be prepared to complete supporting documentation based on the assessment reference date (ARD), not the admission date,” said Jessiie McGill, curriculum development specialist for AAPACN. “The ARD of the assessment determines what item set is used. If the ARD is Sept. 30, 2023, or earlier, the facility will use the 1.17.2 item set. If the ARD is Oct. 1, 2023, or later, the facility will use the 1.18.11 item set.”

For instance, if a resident was admitted on Sept. 25, but the ARD is set for Oct. 1, the 1.18.11 item set will be used.

“If facilities are not prepared, this could result in missing supporting documentation in many areas of the MDS,” McGill warned. “For example, if the facility had not previously been collecting GG data on OBRA admission, they may miss that GG data is required for the first three days of the stay. Likewise, they may not have supporting documentation for the MDS items with new ‘on admission’ categories that will be required for K0520, Nutritional Approaches and O0110, Special Treatments, Procedures, and Programs.”

Facilities also need to ensure they have new processes in place to facilitate completion of the scripted interview and resident voice items for all assessments with an ARD Oct. 1 or later. Such items must be completed within the seven-day look-back period.

For patients discharged after Oct. 1, new MDS items affect the Part A PPS discharge assessment if the assessment reference is Oct. 1 or later.

In states where payment systems haven’t been updated to reflect new federal assessment and payment changes, things could be even more complicated — making for an especially busy Friday.

“Those states where case mix will be frozen as of Sept. 30 will need to be keenly aware of the cut-off date and identify those residents who may need an MDS prior to that cut-off,” said  Maureen McCarthy, president and CEO of Celtic Consulting. “Optimizing the current case mix index system, prior to the transition, should be considered. A side-by-side analysis should have been performed to determine the new CMI levels for those moving to a Medicaid PDPM payment model, rather than a freeze.”

Be ready to reconcile meds

One of the major new discharge provisions requires providers to share and document the transfer of medication information to the patient, family member or next-level caregiver.

“Educate floor nurses regarding documentation of the medication reconciliation and the methods used to educate the resident or provider,” advised Amy Stewart, chief nursing officer for AAPACN. “The facility will need documentation in the medical record that includes how and when this was done for it to be captured on the MDS. Also, if it is not done, documentation should include why it wasn’t completed.”

Also important at discharge, noted Stewart, is collection of health literacy information by the clinical or nursing department for use in the discharge care plan.

The resident voice items for ethnicity, race, transportation barriers, health literacy, and social isolation must also be asked during the look-back period for the assessment.

“Although the [Health Literacy] item is only asked of Medicare Part A beneficiaries, the organization may want to consider asking all residents that may be discharged to the community,” Stewart suggested. “Discharged residents who lack an understanding of discharge instructions, including follow up with their physician and medications, may end up back in the hospital or have an emergency room visit.”

Approach Section GG with staff in mind

“Providers are waiting to get direction on GG data collection,” McCarthy said about the new section for coding self-care and mobility needs. “No two providers are the same. Some are having CNAs document and then having nursing do the assessment. Some are having the nurses document.”

If you’re still feeling your way through this new process, McCarthy says it may be smart to allow staffing to dictate your final plan.

“If you are agency-heavy in CNA, then that’s probably not the discipline to have completing such crucial documentation,” she said. “If aides are fairly stable and nursing is agency heavy, then having your regular CNAs is probably safer. Then MDS can do the assessment portion. We always have the option of including the therapists as well, but many would not be on caseload under Medicaid, therefore, we need to have a solid plan on how to address the functional assessment of each resident, not just those on rehab caseload.”

The team also should keep in mind the GG data is now based on a three-day lookback rather than seven days.

Don’t forget Care Area Assessments

“The CAAs have been overlooked by and large in the haste to prepare for the updated MDS,” VanEaton said. “Facility interdisciplinary teams need to pay attention to the revisions to Chapter 4 and Appendix C.”

Among the most prominent changes, in addition to the new PHQ and Section GG, are:

• Three new line items for delirium, pain and limits to participation in rehabilitation therapy, which VanEaton said will require the team to analyze concepts they have not encountered before in CAAs.
• Item J1900, falls with major injury, has been added to several areas as an expanded approach to further analyzing the impact of falls.
• Item J1400, terminal condition, has been added to several CAAs to further consider the impact on resident care plan needs.
• Social isolation now shows up specifically in CAA7, psychosocial wellbeing, as it relates to loneliness. “Considering this as a social determinant of health within the CAA resources will be a new concept for IDTs that will need to assimilate it into care planning,” VanEaton said.