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ear Mabel: Recently, one of our residents was sent to the hospital for a flap revision of a stage 4 pressure ulcer. How do I code that?” (registered nurse, Indiana)
Answer: Once the surgery is complete, the pressure area becomes a surgical wound. This is addressed on page 3-166 in section M4, letter g, of the Resident Assessment Instrument (RAI) user’s manual as follows: “Surgical Wounds—Includes healing and nonhealing, open or closed surgical incisions, skin grafts, or drainage sites on any part of the body.” A flap is somewhat like a skin graft that is performed over a repaired wound. It would be helpful to also assess for loss of sensation to this area. Remember to include surgical wound care under M5f. If you are not performing any surgical wound care, you cannot count the area as a surgical wound. If the area of the flap should develop an open area related to pressure, you would have to code for that also. Good luck, as we all know flap revisions are delicate and require much care.

“Dear Mabel: When the state agency audited us for accuracy on our Minimum Data Set (MDS) submissions, one of our records was invalidated, because I had coded for quadriplegia on a resident with a spinal cord injury. They stated since the resident could use one hand to point to items he wanted, the resident was not a quadriplegic. Our physician has a diagnosis of quadraplegia listed for this resident and refuses to change it. Why can’t I count this diagnosis from a physician?” (licensed practical nurse, Indiana)
Answer: We agree with you in spirit; however, if you look at your RAI manual on page 3-129, under I1z, you will find the definition of quadriplegia for use in coding the MDS. It is, “Paralysis (temporary or permanent impairment of sensation, function, motion) of all four limbs. Usually caused by cerebral hemorrhage, thrombosis, embolism, tumor, or spinal cord injury. Spastic quadriplegia, secondary to cerebral palsy, should not be coded as quadriplegia.”
       It sounds like your resident is functionally a quadriplegic. However, that is not what coding the MDS is about. What appears to make sense and what is actually coded are not always one and the same. When it comes to coding the MDS, the definition of the diagnosis given in the RAI manual overrides the physician. You will be beating your head against a brick wall if you try to fight this one.
       Because the MDS is an instrument used by so many for so much, it is impossible to gather accurate data if we do not all use the same definitions. Whether you believe the diagnosis is valid or not is not central in this case. You need to ask yourself if the resident meets the definition as listed in the RAI manual when answering any and all questions on the MDS. It will increase your accuracy and decrease your need for antacids.
All that said, you may want to consider coding your resident at I1v if he truly does not have use of both the upper and lower limbs on one side. Perhaps the more accurate diagnosis would be I1x, paraplegia. Both of those definitions can be found in the RAI manual on page 3-129.
       Now, for the real kicker: If you look at page 3-127, it states under “Intent” at the first bullet, “The disease conditions in this section require a physician-documented diagnosis in the clinical record.” (The added emphasis is in the manual.) This is saying that while it is possible for the MDS to disallow a physician diagnosis, it is not possible to count a diagnosis unless a physician has diagnosed the condition. Consequently, don’t waste your time at that wall beating your head; just do as the definitions and the manual direct. You and your facility will be better off for it.

“Dear Mabel: Our computer software fills out the Resident Census and Conditions of Residents form (672) and the Roster/Sample Matrix form (802), but I don’t always understand where it gets the answers. Is there any way to get more information on these forms and how they are completed?” (registered nurse, Georgia)
Answer: Yes. There is a website that supplies instructions on how to complete these forms, which are required by the Centers for Medicare and Medicaid Services (CMS) during surveys. Go to http://cms.hhs.gov/Medicaid/mds20/mdsforms.asp. Also, most software providers usually have a sample of the cross walk for forms 672 and 802.

“Dear Mabel: We admitted a Medicare Part A resident on June 9, 2004, and discharged him on June 13, 2004, back to the hospital. He then readmitted on June 25, 2004, and was again discharged to the hospital on June 28, 2004. On June 29, 2004, he readmitted and again was discharged to the hospital on July 12, 2004. For all of his stays, I was able to complete the 5-day Prospective Payment System (PPS) assessment. For all of his discharges, I submitted a “08” or discharge prior to initial assessment. Our business officer says I should have completed a 14-day PPS assessment and an Initial Omnibus Budget Reconciliation Act (OBRA) assessment on July 12, 2004. I disagree. Who is right?” (registered nurse, North Dakota)
Answer: You are right. The 5-day PPS assessment must be done to set the rate for reimbursement on all Medicare Part A admissions, which you did. Thus, you will be paid for all of the days the resident was in your building, provided a skilled service was conducted. Completing a 14-day PPS assessment would not be necessary in this case. As far as the OBRA initial assessment is concerned, it is your prerogative to complete the assessment or not, since the resident discharged on day 14. Since the 5-day PPS assessment had already set your rate of reimbursement, this also would have been unnecessary. Given that this was a Medicare Part A admission, you would be paid for the day of discharge anyway. Thus, you did the right thing.
       The latest word from MDS pundits who are on the front lines, so to speak, is that the MDS 3.0 will not be ready until at least 2007. Remember the discussion about the MDS 3.0 coming out in 2003? Clearly, it is an immensely complex instrument, serving a variety of stake holders. With any luck, by taking longer to revamp the current MDS, the new one will better meet all the demands placed upon it.
       The Data Assessment and Verification project (DAVE) has prepared a tip sheet for its own staff and is sharing it with all persons coding the MDS. You can request it by sending an e-mail to DAVE-Project@csc.com, or contact the DAVE project at (800) 561-9812. This tip sheet contains helpful guidelines to ensure consistency within your assessments. For example, if section G5a (modes of locomotion—cane/walker/crutch) is checked, then G6e (transfer aid) should be checked. The previous illustration is courtesy of the CMS DAVE Project, Computer Sciences Corporation.
       CMS launched a new website called “Sharing Innovations in Quality (SIQ) Repository of Clinical Standards and Guidelines.” The website is http://siq.air.org/. The site is aimed at surveyors and long-term care professionals. It contains several links to great resources about weight loss, pressure ulcers, fire ants, arthritis, pain, etc. We highly recommend this site and will be surfing there often.
       CMS released a June revision of the MDS RAI manual concerning section P1ao, Hospice Care. The definition has been changed to read as follows (emphasis is per CMS): “Hospice Care—The resident is identified as being in a hospice program for terminally ill persons where an array of services is necessary for the palliation and management of terminal illness and related conditions. The hospice must be licensed by the state as a hospice provider and/or certified under the Medicare program as a hospice provider.” Previously, it was not necessary that the services be certified or licensed by the state or Medicare. So, be careful coding out there!
       If you have a question for Mabel, you can e-mail us at MabelMDS@aol.com.