“D

ear Mabel: What are ‘grace days’ and when can I use them?” (registered nurse, Missouri)

Answer: Grace days are a concept the federal government, specifically the Centers for Medicare and Medicaid Services (CMS), came up with when the Prospective Payment System (PPS) for Medicare Part A was first introduced. It seems even the government realized that when working with real human beings, and not just pieces of paper, anything can and will happen.
       Grace days allow the assessment reference date (ARD) to be adjusted according to resident needs and perhaps even staffing issues at long-term care facilities. As we have said previously, in order to complete an assessment, a period in time must be specified. This is often called a “look-back period.” It enables anyone who looks at the assessment to know exactly what occurred in that finite distinct time period. Mistakes are avoided, misunderstandings are decreased, and accuracy is increased. It becomes possible to verify actual care provided through documentation. It reminds us of that old saying, “Everyone is on the same page in the hymn book.” Without this unambiguous set point in time, chaos would rule.
       Grace days are only available for use on PPS assessments. They are not offered with Omnibus Budget Reconciliation Act (OBRA) assessments. If you are familiar with the Minimum Data Set (MDS), think of grace days as being available for assessments coded at section AA8b only.
       For a 5-day PPS assessment (AA8b = 1), the normal ARDs are days 1 through 5; grace days may be used for days 6 through 8. If the ARD is set for any other day, it will result in an error. The facility will only be able to bill at the default rate for days that fall outside these set parameters. This is true for all assessments. If you do not set the ARD correctly, it will cost your facility money (see Table 1).
       When the concept of grace days was first introduced, there was a strong disclaimer issued at the same time. It stated that assessments using grace days were considered late. The disclaimer went on to say consistent and/or frequent use of grace days would result in an onsite review of assessment scheduling practices. That is a pretty scary consequence for the use of grace days. Who wants the federal government in their building? In response to this warning, most facilities bent over backward to avoid the use of grace days.
       It is not necessary to move heaven and earth to avoid the use of grace days. It is perfectly permissible to use grace days when needed. For example, let’s say your resident came in for hip fracture therapy and developed pneumonia in the hospital. Because the resident fatigued easily and was debilitated, the resident could not complete a full five days of therapy in the acceptable ARDs for a 14-day PPS assessment. At this point, it would be completely acceptable to use a grace day or two to complete the needed days of therapy to obtain an accurate resource utilization group (RUG) for the resident. It is not cheating. It is life. Humans do not fit well into boxes. How nice was it for the federal government to realize that and build in some wiggle room?
       It is too bad that the threat of being surveyed by the federal government has prevented long-term care facilities from using a legal and acceptable means of obtaining a fair reimbursement. Our advice is do not be afraid to use these grace days. They are there for your convenience and benefit. Use grace days with the same respect and consideration you give your residents, and you will be fine.
       Now for the news—and news it is. Everyone is talking about the new revisions to the Resident Assessment Instrument (RAI) manual released this April.
       It appears that most of these changes are really clarifications. These clarifications are going to make life for MDS coordinators a little less stressful. The revisions are available on the CMS website at http://www.cms.hhs.gov/medicaid/mds20/man-form.asp. At this site, you can download each separate page with the changes on it. The pages then can easily be added to your manual if you have one in a notebook that will allow additions and deletions.
       The biggest change for the MDS coordinator is in section AD. It will no longer be necessary for the registered nurse assessment coordinator to sign on the Background Face Sheet unless he or she actually worked on the Background Face Sheet.
       Section M, “Skin Condition,” has undergone some much needed illumination. It reemphasizes that staging for the MDS assessment is based on what is actually seen during the look-back period. The new revision goes on to state that facilities may adopt National Pressure Ulcer Advisory Panel (NPUAP) standards for their clinical practice, but those standards cannot be used to stage ulcers for the MDS. This long-standing issue was also the topic of our last column and has caused a lot of misunderstanding. This new wording should assist clinicians in their practice and MDS coordinators in their coding.
       We were surprised and tickled by one entry. On page 3-193, P31, the following addition was made: “Dentures are not considered to be prostheses for coding this item.” We are in favor of accurate, even stringent coding, but coding dentures as a prosthesis to enable the implementation of a restorative program for “Amputation/Prosthesis Care” would certainly take a stretch of the imagination. However, since it is included in these revisions, it does make one wonder.
       We certainly hope you will download the new revisions and review them. Of all the recent changes, these have been the most helpful and perhaps the funniest. Keep on coding and coping.
       If you have a question for Mabel, you can e-mail us at MabelMDS@aol.com.