The Centers for Medicare & Medicaid Services released the final version of the new Resident Assessment Instrument manual Thursday to all but complete the biggest revamp of the MDS nursing home resident assessment tool in recent years.
Some 60 changes were made to the draft document CMS first issued in April. A handful of notable updates were instituted, in addition to many smaller editing details, leaving providers “little time to spare” to prepare for their Oct. 1 implementation, said Joel VanEaton (pictured), master teacher and executive vice president of PAC Regulatory Affairs and Education for Broad River Rehab.
Thursday’s release of the “Final” version of the RAI Manual v1.18.11 was precisely the same as a version accidentally posted by CMS last week and quickly pulled back the same day.
“If you are just now getting into the [MDS] v1.18.11 prep game, don’t waste time reading the DRAFT manual,” VanEaton advised providers in an email to McKnight’s Long-Term Care News Thursday. “All the changes from v1.17.1, as well as the DRAFT 1.18.11 to Final 1.18.11 revisions, are highlighted in red font. There’s no need to engage in the most recent revisions if you haven’t already spent time in the DRAFT version.”
The “star” of the new CMS releases was the change document that detailed all the recent alterations.
CMS became much more rigid in the final version about certain discharge assessments, VanEaton pointed out.
“In the draft manual, CMS changed the guidance related to combining an OBRA discharge assessment by stating, ‘if the End Date of the Most Recent Medicare Stay (A2400C) occurs on the day of or one day before the Discharge Date (A2000), the OBRA Discharge assessment and Part A PPS Discharge assessment are both required and must be combined,’” he noted.
In the current manual v1.17.1, however, it only states “may be combined.” In the final version the “must” guidance has been applied consistently throughout, he explained.
Added text also informs providers about how to navigate assessments and modifications of assessments that crossover the Oct. 1 implementation date.
• A unique situation exists that will prevent providers from correcting the target date of any assessment crossing over October 1, 2023. That is, providers may not submit a modification to change a target date on an assessment completed prior to October 1, 2023 to a target date on or after October 1, 2023, nor can they submit a modification to change a target date on an assessment completed on or after October 1, 2023 to a target date prior to October 1, 2023.
• The item sets that are effective October 1, 2023 have had significant changes, including the omission and addition of many items. It is the target date of the assessment that identifies the required version of the item set, and, because of the substantial changes in the item sets, they are not interchangeable. Therefore, providers may not change target dates on assessments crossing over October 1, 2023.
“This will be important for providers to note,” VanEaton told McKnight’s. “It is similar to what happened with MDS 2.0 to 3.0. I keep saying they should have called this MDS 4.0.”
Even more to be done
“It’s a great thing that it’s out there now,” said Leah Klusch, executive director of the Alliance Training Center, of the finalized manual. “But we don’t know everything we have to do yet. There are still some pieces of the conversion, of what has to happen the last weeks of September and first week of October with assessments.”
Some instructions appear in Chapter 2 of the RAI manual and Chapter 3 in the new GG section, she noted, but finite details have not been released about the short but extremely important switchover weeks.
“It will be overdue if we get much into September” before seeing more conversion instructions, she explained. “We have to have time to schedule some of what I call duplicative assessments. And then some facilities have actually changed their admissions processes when they’re converting. So MDS managers will have some scheduling issues they have to look at it.”
Directions on how and when to perform certain assessments will be critical, she stressed: “Remember: We’re looking at doing [the new] Section GG on 100% of the elders in the building. In most buildings, that’s two-thirds of your population, and that’s a lot of activity.”
Klusch also highlighted that Thursday’s release confirms that PHQ-2 to 9 will be the tool used for coding mood scores.
“That opens up a whole new opportunity for training and preparation, especially on the PDPM cases,” she explained. “The teams have to look at who is doing the interviews and what their approach is and how they’re going to document those to allow the elder to express their experiences in the last 14 days, which almost always will include a hospital stay and may include trauma-related experience and might very well include a degradation of a comorbidity like CHF getting worse.”
Alicia Cantinieri, vice president of MDS policy and education for Zimmet Healthcare Services Group, agreed that providers should be “brushing up on their interviewing techniques,” particularly so they “not missing any signs or symptoms of depression for reimbursement.”
“It doesn’t mean we can’t ask the other questions” if a patient indicates little to no signs of depression, she reminded. “It just means we can’t put them (answers) on the MDS.”
She estimated coding in this section alone could be worth about $40 per patient day, depending on location and wage index, among other factors.
Other key changes
Some of the other changes to the final version highlighted by VanEaton include:
- In the draft manual, the BIMS is the only interview that continued with the guidance to complete the interview “preferably the day before or the day of the ARD.” That language was removed from the remaining scripted interviews and only the guidance, “This interview is conducted during the look-back period of the Assessment Reference Date (ARD)” remains.
That point has been enforced in the final revision as the following Step for Assessment guidance for the pain interview has been removed: “Because this item asks the resident to recall pain in the past 5 days, this assessment should be conducted close to the end of the 5-day look-back period. This should more accurately capture pain episodes that occur in the last 5 days.”
- A “very much anticipated and welcome” revision has been added to section N. CMS added a definition for “Indication” in an inset box on page N-6 consistent with the definition offered in Appendix PP of the State Operations Manual.
The definition in section N now reads, “The identified, documented clinical rationale for administering a medication that is based upon a physician’s (or prescriber’s) assessment of the resident’s condition and therapeutic goals.”
- An important clarification regarding what kind of medication may not be coded at item N0415E Anticoagulant has been added.
The manual now reads, “Do not code antiplatelet medications such as aspirin/extended release, dipyridamole, or clopidogrel as N0415E, Anticoagulant.”
- The Care Area Assessment Trigger, or CAT, for CAA 20 has been revised. CAA 20 is now triggered by the following: “Resident wants to or may want to talk to someone about returning to community as indicated by: Q0500B = 1 or 9.”
That differs from the draft manual, which indicated that CAA 20 was triggered by, “Referral made to local contact agency as indicated by: Q0610A = 1.”
MDS requires ‘team’ work
Klusch emphasized that the coming period will be one of intense training and crossover activities — and much more than just an MDS coordinator’s responsibility.
“This is very important for administrators and others,” Klusch said. “This is something that affects operations. Managers need to sit down with their team and see what training they’ve done so far and then get into it. It’s very important for MDS managers to take this opportunity to sit with operations management and clinical management and make sure everybody understands what they need to do.”
This will be especially important the closer Oct. 1 gets. She predicted that software programs to deal with the new MDS may not land in providers’ hands until the second or third week of September. That will set off “training that will be pretty aggressive and more last-minute,” she said.
“Every time we convert to a new data set, we end up risking losing the credibility of our data because some people might not have read about it,” she added. “‘Nobody told me to do it’ is not going to cut it [from employees]. It becomes too expensive as far as reimbursement and when it comes to risk management and liability. We’ll all be plenty busy from now until the middle of October.”
