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ear Mabel: A resident was admitted to our skilled unit with over 15 diagnoses from the hospital. Specifically, I am having a problem with two of these, congestive heart failure and dehydration. He is on a large dose of a diuretic, has good output, and yet does not exhibit any signs or symptoms of dehydration. Should I code him for dehydration?" (licensed practical nurse, Kansas)
       Answer: If the resident is a Medicare Part A, you first need to set your Assessment Reference Date (ARD) for the 5-day assessment. You will want to consider combining the "initial" Omnibus Budget Reconciliation Act (OBRA) assessment with the 5-day Prospective Payment System (PPS) assessment. Initial assessments are not used to set quality indicators (QIs), although they are used for quality measures (QMs). QMs are not currently using dehydration as a QM. If the resident is not a Medicare Part A, you will need to complete an OBRA assessment before the 14th day. Either way, if your first assessment is the initial admit, it would be sensible to code the diagnosis of dehydration at that time. Since the resident came to you with this diagnosis, you will have time for continued assessment for signs and symptoms of dehydration, to evaluate the effectiveness of the diuretic, and to monitor the resident's intake. It will be necessary as well to address the issue in your resident assessment protocols (RAPs). It may be possible to avoid addressing dehydration on future assessments, depending on how effective the drug regime is and how the resident responds. However, if the diagnosis continues to require nursing assessment and evaluation, you must address it. See Section I, which states to include a diagnosis, it must "have a relationship to current ADL status, cognitive status, mood and behavior status, medical treatments, nursing monitoring, or risk of death." It further explicitly states not to include diagnoses that no longer affect the resident's functioning or care plan.
       Question: "A resident was admitted with a new tracheotomy and severely debilitated on Part A Medicare. Physical therapy and occupational therapy were initiated in an attempt to rehabilitate the resident to the point that he could help with transfers. On the 5-day PPS, his resource utilization group (RUG) was in the Extensive Services, which pays higher than therapies. By the 14th day, therapies were discontinued because they were thought to be ineffective. The resident's 14-day PPS and initial assessment also coded in the Extensive Services related to his trach, IVs, and wound care, even though we did capture some therapy minutes. Do I need to do an Other Medicare Required Assessment (OMRA)?" (registered nurse, certified, Tennessee)
       Answer: No, you do not need to do an OMRA if the resident classified into a higher paying nonrehabilitation category. Your facility will still have to pay for the therapies, of course, from the reimbursement received. The rule is to do an OMRA whenever therapies stop. However, if you never were in a rehab category it is not necessary to do an OMRA.
       Question: "As I was preparing to send a 60-day PPS assessment, I was told by my financial officer that she is unable to bill for the last 30 days because our computer does not have a record of one ever having been done. After much frantic looking, I found I had not transmitted the 30-day PPS assessment. I am over a month late. What do I do?" (registered nurse, Washington)
       Answer: Transmit immediately. You may be late transmitting, but that will not cost you anything. If you don't transmit, you will lose all payment for that period. As long as your time frames on the Minimum Data Set (MDS) are correct, you will be paid. Also, we advise you to look deeply into how and why you missed sending this assessment. At a minimum, a weekly financial and nursing meeting to review the current status of all PPS assessments, RUG categories, and discharge status would prevent this from happening again. It will definitely save you a lot of gray hairs.
       Question: "After 45 days of Medicare Part A therapy for a hip fracture, the resident decided to go home. He was advised by the doctor, therapists, and nurses not to go, but he left anyway. The doctor refused to write a discharge order. What do I do as far as the MDS goes? Will we get paid since he discharged against medical advice?" (registered nurse, Iowa)
       Answer: As far as the MDS goes, you must submit a "discharge, return not anticipated form." As far as reimbursement goes, there is an old wives' tale floating around long-term care that the facility will not be paid by Medicare when someone discharges against medical advice (AMA). However, it is just that: an old wives' tale. Discharge AMA may have an unfortunate outcome for the resident; however, it sounds like you did the right thing in advising him to stay. Nevertheless, if your assessments were timely and appropriate, you will be paid.
       Question: "We have a resident who walks in the hall only when therapy comes up and walks her. In the past when this has occurred during an assessment reference period, I have not coded it. Now, another nurse assessment coordinator (NAC) says I should. Which one of us is right?" (licensed practical nurse, Indiana)
       Answer: We are afraid we have bad news. Your NAC friend is right. The intent of the MDS is to find out how the resident functioned, not how they functioned with only certain departments assisting them. The basic questions to ask and answer when completing this section are: Did the resident walk? If so, how much did she do for herself, and how much help did she receive? Federal guidelines require that you go back and do a modification on all the records you may have coded inappropriately. In the future, always remember when coding for "walk in corridor," it does not matter who assists with the walking. If it occurs, it must be coded.
       Question: "If certified nursing assistants (CNAs) use a Sara Lift to transfer a resident, how should I code transfers?" (registered nurse, Louisiana)
       Answer: Sara Lifts require the resident to have the ability to hold onto the front of the device. While the resident is highly involved in the activity, the machine and/or the staff do most of the weight bearing. It would code at section G1eA as a 3 and at G1eB as a 2 or 3, depending on how many CNAs were involved.
       We would like to take this opportunity to mention the national Town Hall meeting held in June 2003 by the Centers for Medicare and Medicaid Services (CMS) to discuss the new draft of the MDS 3.0. The meeting, held in Baltimore, Maryland, was open to the public. It was also accessible by phone during and after the meeting. This was a real treat for us. It was stunning to hear so many comments from such a variety of industry members. Several representatives of the diverse disciplines concerned with the MDS made comments. Ms. Ann Gallagher, RD, representing the American Dietetic Association, made some excellent comments about the new proposed Section K in the draft of the MDS 3.0. Ms. Gallagher stated that the definitions needed to be more concise, especially if dietary would be completing this section. She also suggested more attention be paid to hydration. Ms. Peggy Dotson from the Wound Care Manufacturers stated back staging needs to be stopped, which the proposed MDS 3.0 would continue to do. She recommended adding questions related to staging to assist in defining wound healing as is done in the Outcome and Assessment Information Set (OASIS). Ms. Dotson also addressed the need to include preventative measures as a rugging, reimbursable item. Ms. Mary Ann Lyons, an administrator in long-term care, was concerned about some of the questions posed about quality of life in sections E and F. She felt that merely asking some of these questions as they are currently phrased would trigger an adverse emotional response.
       While several well spoken, well educated persons commented, we think the most succinct comment came from Ms. Sandy Speitze from the American Health Care Association (AHCA). She stated that many of the complications of the MDS 3.0 are caused by the multiple use of the instrument for disease prevention, quality of life, clinical values, quality measures, and reimbursement. Further, she stated the MDS 3.0 tries to be a "one size fits all" instrument, which is impossible. Nursing homes are not just for the elderly anymore. They encompass a broad population, including, but not limited to, pediatrics, elderly, end of life, chronically disabled, trauma survivors, drug- and/or alcohol-induced dementias, and mentally ill. Ms. Cadamont from the American Association of Homes and Services for the Aging (AAHSA) echoed these same sentiments. In her statement, she said the MDS serves many masters and doesn't serve any of them well. She called for a total revamping of the process involving representatives from all the different groups served by the MDS. This national conference could generate a better way to accomplish some of the goals established for the MDS/RAI. Ms. Cadamont also implied perhaps such goals could not be attained using one instrument without stretching it to the breaking point.
       For a full transcript of the Town Hall meeting, call Lori Anderson at (410) 786-0045. She can also give you the e-mail address for continued comments about the new MDS 3.0 draft.
       This brings us to our opinion, which we always like to share. We will continue our mission to assist others in completing the MDS in a timely, accurate manner. On the other hand, we must agree with the representatives from AHCA and AAHSA. It is true that care in long-term care facilities needs to be reformed. We have come a long way down that road. The continuing view by public officials and the public in general that "nursing homes" are just places for grandma and grandpa to go when the family can no longer provide all the services needed has just got to end. We are long-term care, or as the name of this magazine implies, extended care. We are much more varied than solely care of the geriatric patient. The term "nursing home" has got to go. We cannot emphasize that enough. Perhaps you may have noticed that we do not use that term. The reason is precisely because of the variety we have personally encountered in our careers in long-term care. We believe that words do mean something; they have the ability to shape ideas, feelings, and culture. We want a part of that change.
       Nursing homes were fine, laudable, praiseworthy institutions. They served a need in our history to provide for the elderly. Now we need institutions that are not "institutions." We in long-term care are expanding our awareness of the need for everyone to enjoy all the freedoms we hold so dear, not just the healthy and able. These freedoms have historically been hard to actualize in an "institution." The Pioneer Network is just one example of a group working on a new vision of nursing homes, or as we prefer to call them, long-term care facilities. We are interested in finding out what you call the facility in which you work. Is it a nursing home or a long-term care facility? Please e-mail us at Mablemds@aol.com.
       Until next edition, we wish happiness and fulfillment to all our buddies out there trying to do the right thing for the population they serve. You are helping to raise the standards in long-term care.