There has been a slogan that has circulated on social media recently that goes like this: “Fall is proof that change is beautiful.”

Hmm… I suppose individual perspective is the key to whether that is true.

I remember one time when I was a much younger inexperienced man, I mistakenly left my car in neutral on a slight hill after changing the oil. 

I went into the house to retrieve a grocery list and discovered, after hearing a loud bang, that my car had rolled down the hill into my neighbor’s barn. 

The changes that I faced then weren’t so beautiful. Thankfully no one was hurt, but my wallet and my pride suffered some serious loss. Lesson learned.

This fall has brought a cornucopia of changes to nursing homes. I’m sure you feel the weight.  Not all of them have been what we expected. The quality measure changes, for example, contain some surprising crossover from section G to GG “equivalent.”

Four weeks post implementation, the Centers for Medicare & Medicaid Services continues to make significant revisions to the MDS coding guidelines as well with the release of the sixth versions of the data set, an item set supplemental document and two errata documents. CMS had three-plus years to get this right. What happened that so many revisions are having to be made?

Whatever the reason, the most significant revision occurred with the release of these errata documents, in particular the coding guideline revisions to the depression interview, now the PHQ-2 to 9. 

Added

p. D-2: D0100 serves as a gateway item for the Resident Mood Interview (PHQ-2 to 9©) and D0500, Staff Assessment of Resident Mood (PHQ-9-OV©). The assessor will complete the Staff Assessment only when D0100 is coded 0, No. The assessor does not complete the Staff Assessment based on resident performance during the Resident Mood Interview.

p. D-3: Resident refusal or unwillingness to participate in the interview would result in Item D0100 being coded 1, Yes, and code 9, No response being entered in Column 1. Symptom Presence. Assessors should proceed to Item D0700, Social Isolation in the case of resident refusal or unwillingness to participate.

p. D-5: If both D0150A1 and D0150B1 are coded 9, leave D0150A2 and D0150B2 blank, then end the PHQ-2©, leave D0160, Total Severity Score blank, and skip to D0700, Social Isolation.

p. D-6: If both D0150A1 and D0150B1 are coded 9, leave D0150A2 and D0150B2 blank, then end the PHQ-2©, leave D0160, Total Severity Score blank, and skip to D0700, Social Isolation.

p. D-11: If only the PHQ-2© is completed because both D0150A1 and D0150B1 are coded 9, leave D0150A2 and D0150B2 blank, then end the PHQ-2©, leave D0160, Total Severity Score blank, and skip to D0700, Social Isolation.

p. D-11: If symptom frequency in items D0150A2 through D0150I2 is blank for 3 or more items, the interview is deemed NOT complete. Total Severity Score should be coded as “99,” do not complete the Staff Assessment of Mood, and skip to D0700, Social Isolation.

p. D-13: When staff determine the resident is not interviewable (i.e., D0100 = 0, No), scripted interviews with staff who know the resident well should provide critical information for understanding mood and making care planning decisions.

p. D-13: 1. Interview staff from all shifts who know the resident best. Conduct the staff interview in a location that protects resident privacy.

p. 6-37: Evaluate for depression. Signs and symptoms of depression are used as a third-level split for the Special Care High category. Residents with signs and symptoms of depression are identified by the Patient Mood Interview (PHQ-2 to 9©) or the Staff Assessment of Patient Mood (PHQ-9-OV©). Instructions for completing the PHQ-2 to 9© are in Chapter 3, Section D. Item D0100 is a gateway question to determine when the Patient Mood Interview (D0100 is coded 1, Yes) or the Staff Assessment of Patient Mood is to be conducted (D0100 is coded 0, No). Refer to Appendix E for cases in which the PHQ-2 to 9© or PHQ-9-OV© is complete but all questions are not answered. For the PHQ-2 to 9©, if either D0150A2 or D0150B2 is coded 2 or 3, continue asking the questions below, otherwise end the PHQ interview. Assessors should proceed to D0700, Social Isolation in the case of resident refusal or unwillingness to participate. The following items comprise the PHQ-2 to 9© and PHQ-9-OV© for the Patient and Staff assessments, respectively:

Removed

p. D-13: PHQ-2 to 9© Resident Mood Interview is preferred as it improves the detection of a possible mood disorder. However, a small percentage of residents are unable or unwilling to complete the PHQ-2 to 9© Resident Mood Interview. Therefore, staff should complete the PHQ-9© Observational Version (PHQ-9-OV©) Staff Assessment of Mood in these instances so that any behaviors, signs, or symptoms of mood distress are identified.

p. D-13: Even if a resident was unable to complete the Resident Mood Interview, important insights may be gained from the responses that were obtained during the interview, as well as observations of the resident’s behaviors and affect during the interview.

Considerations

These guidelines are pretty straight forward. CMS has now unequivocally indicated that the PHQ-9 OV is only to be conducted in cases where B0700 (Makes self-understood) is coded 3, rarely or never understood. 

Until these revisions, the RAI manual guidance allowed the staff interview for depression to be conducted when a resident was unable or unwilling to complete the PHQ-9, and more recently the PHQ-2 to 9©, Resident Mood Interview.

It wasn’t until this year, FY 2024, after the PHQ data was labeled a SPADE, or Standardized Patient Assessment Data Element, that the guidance changes occurred, and not until well after the final RAI Manual was posted. Why now?

It is interesting to note that the OASIS, LCDS and IRF-PAI all contain the PHQ-2 to 9 but no staff assessment for depression. Ostensibly this is why these revisions have occurred, to make the reporting of depression data among post-acute providers as standardized as possible. 

The fact remains, however, that CMS has noticed that the incidents of depression indicators have been an outlier under PDPM compared to the RUG 66 grouper. That means money. Parity happened for a reason. It is difficult not to think that limiting the times that the depression end split is in play was a subtext impetus for these revisions.

I am perplexed, though, as to why only the PHQ-2 to 9 has been singled out.

I find it interesting that the BIMs has not undergone the same scrutiny. Considered a SPADE as well, the BIMS also has a staff assessment component that continues to be allowed to be utilized in specific situations where the BIMs is stopped, and when there is an unanticipated discharge for a Part A resident. 

While the BIMs is also a standardized assessment embedded in the OASIS, LCDS and IRF-PAI, there is no standardized staff assessment for cognitive status in these tools either. Could it be that since cognitive performance, being only one fifth of SLP considerations under PDPM, doesn’t rise to the level of the PHQ in its financial impact on the rate?

In the end, the CAA and care plan requirements remain for residents with depressive symptoms, even if they are unable or unwilling to communicate them. Page D-13 of the RAI Manual continues to indicate, “Alternate means of assessing mood must be used for residents who cannot communicate or refuse or are unable to participate in the PHQ-2 to 9© Resident Mood Interview. This ensures that information about their mood is not overlooked.” 

Until this revision, that alternate means was PHQ-9 OV. Now, providers are left wondering what CMS means by “alternate means.” At least one thing is clear, if these residents are identified by whatever, “alternate means” is used to identify depression symptoms, the added acuity that these residents represent will not be reflected in the PDPM rate.  

Thank goodness the leaves have finally changed and, for goodness sakes, let’s hope that the leaves of the RAI manual have finally fallen into place so we can get busy with the task of implementation without hesitating for the next errata. It’s hard to be thankful for these late surprises.

Autumn is beautiful here in eastern Tennessee. The colorful foliage and cooler weather are certainly a wonder. I like sitting out by the fire pit, seeing my breath in the air, smelling the first hearth fire smoke, listening to the geese fly noisily overhead, watching the squirrels collect their winter stores, and anticipating the holidays. I am thankful for this change.

Joel VanEaton, BSN, RN, RAC-CT, RAC-CTA, is a master teacher and the executive vice president of PAC Regulatory Affairs and Education at Broad River Rehabilitation.

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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