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ear Mabel: I am a wound, ostomy, continence nurse (WOCN) trying to find information regarding documentation of pressure ulcers in the nursing home environment. I work in acute care and have been told that in the nursing home the pressure ulcers are reverse staged to show progress for Medicare reimbursement. Is this correct?” (registered nurse/wound, ostomy, continence nurse)
       Answer: The short answer would be yes. However, there is never a short answer when it comes to the Minimum Data Set (MDS). While it is true in long-term care (LTC) that we are required by the federal government to downstage pressure ulcers for reimbursement, most LTC facilities use the National Pressure Ulcer Advisory Panel’s (NPUAP) guidelines for staging pressure ulcers on all documents other than the MDS. The MDS, however, is a beast all its own. It is often hard for those who do not complete it to understand it. (Who are we kidding? It is often hard for those of us who complete it all the time to understand it!) All of the over 300 entries on a comprehensive MDS are highly defined. Nothing is left to common sense or accepted nursing, dietary, or activity standards.
       Money is the major factor driving this difference in staging to continue. A “healing stage 3 ulcer” usually does not require the same degree of interventions that a “stage 3 ulcer” would require. Justifiably, the federal government does not want to pay for care that is not received. Through downstaging, the Centers for Medicare and Medicaid Services (CMS) believes reimbursement will more closely match the care received. Currently, the MDS is undergoing massive revisions. The newer version, to be called the MDS 3.0, is set to debut sometime in early 2005. The NPUAP and CMS are discussing revisions that would more accurately capture healing pressure ulcers and cost issues while also preventing the clinically inappropriate practice of downstaging.
       “Dear Mabel: I get confused on section Q2 of the MDS when it asks if there has been a significant change in condition since the last assessment when I am doing a 14-day Prospective Payment System (PPS) assessment that is also the initial assessment. Should I compare the health status of the resident to the 5-day assessment?” (licensed practical nurse)
       Answer: No, you should not compare an Omnibus Budget Reconciliation Act (OBRA) assessment to an assessment required by PPS for Medicare Part A reimbursement. They are separate. The 5-day PPS assessment will not be entered into your state database, unless it is marked as the initial assessment. Since you have said you are completing the initial OBRA-required assessment along with the 14-day PPS assessment, as far as the state is concerned, this is the first assessment you have sent. We know this sounds crazy. It sounds crazy to us too, but that is the way it has worked out. Because the MDS meets so many needs for so many different agencies, it has made completion very complex. Be very careful when comparing a PPS assessment to an OBRA assessment.
       In order to tell which is which, go to section AA8a and AA8b of the MDS. If you have any number in AA8a other than a “0,” it is an OBRA assessment. Now this does not mean you cannot also have a number in AA8b, and goody for you if you do. That would mean you were able to get double duty out of one assessment. You would have an OBRA and a PPS assessment at the same time. The hitch comes in when you do just have a “0” at AA8a. That means the assessment is not an OBRA assessment. Therefore, nothing on that assessment will be considered an OBRA assessment. Even if you mark section Q2 as improved or declined, there is a disclaimer at that point also. A significant change in status assessment (SCSA) must be completed with any identified significant change in the health status of a resident, unless the change is ongoing, i.e., improvement associated with a continuing course of therapy or antibiotics or the change is a normal recurrent or fluctuating change in status. Whenever a significant change in status is identified in a resident and the forgoing exclusions do not apply, a SCSA must be completed using appropriate OBRA coding. Again, if you can complete both an OBRA and a PPS assessment, all the better for you. If you do not complete an OBRA when a significant change in status is noted, you could be cited for failure to assess and implement needed changes in the plan of care.
       The MDS arena has been fairly quiet of recent. CMS did announce the appointment of Herbert Kuhn to head up the Medicare Management Center part of CMS. Mr. Kuhn has most recently worked as a vice president at Premier Inc., a not-for-profit hospital group. With all the recent changes in the Medicare programs, he has taken on a burdensome task, and we wish him every success in his new endeavor.
       If you get a call from DAVE, it is not an old friend. It is the Data Assessment and Verification (DAVE) project. DAVE began doing national offsite audits of Medicare Part A PPS assessments as of January 2004. If you receive a call from DAVE, they will be asking you to provide them with information to verify the coding on your MDS. For those of us who live in states utilizing the MDS for Medicaid reimbursement, we have been through state audits. A DAVE audit is very similar. If you have never experienced an audit before, get ready to be really busy.
       The good thing is DAVE will only audit those entries on the MDS that fall under a RUG. RUG refers to the resource utilization group into which a resident is grouped. The particular entries that make up the requirements for each different RUG are called elements. For example, if a resident rugs or ranks into a rehabilitation group, the number of days and minutes a resident receives therapy will be a major component in rugging that individual. The DAVE person will want to see all therapy notes, tracking sheets, and attendance sheets. Other major components are the four late loss activities of daily living (ADL), which are found in section G on the MDS. Almost every RUG score starts with the score from these four late loss ADL, which are eating, transferring, bed mobility, and toileting. Documentation must be done to capture both self performance and support provided. For those states required to so by Medicaid, LTC facilities have developed ADL grids that capture at a minimum each ADL for each shift during the assessment reference period.
       A DAVE audit is very similar to an additional documentation request (ADR) by the financial intermediary (FI) for Medicare in your region. Treat it as the same and you will do well. DAVE has official CMS authority to report any facility whose records do not support Medicare payment to the FI for that facility. To quote directly from an announcement CMS published on its website, “If the (DAVE) team detects egregious situations, health and safety issues, or potential fraud or abuse, the team will immediately notify the appropriate stakeholders.” The website for DAVE is http://www.cms.hhs.gov/providers/psc/DAVE/Homepage.ASP.
       We would like to end this column with a helpful hint. There is no quality indicator (QI) for pain yet. Hopefully, there will be when the new MDS 3.0 comes out, thus making it the 25th QI. There is, however, a quality measure (QM) addressing pain. The QM regarding pain has been causing quite a stir since the inception of the QM. (See pages 24 and 25 of the January/February 2004 issue of ECPN.) QMs were enhanced to now include 14 measures as of January 22, 2004. With all these acronyms floating around, it is easy to confuse the two.
       If you have a question for Mabel, you can e-mail us at MabelMDS@aol.com.