R

emember when life was easy--before the advent of the MDS? The MDS is a very complicated item. However, if you take it a little at a time, it is not quite so difficult. It reminds me of an old saying: "How do you eat an elephant? One bite at a time." In lecturing, I constantly hear the issues that plague long-term care clinicians in filling out the forms. With Elena's experience as a MDS coordinator and our experience from working together for longer than we would like to admit, we developed the concept of a "Dear Abby" of the MDS.
       Not knowing what to call it--we can't call it "Dear Karen" or "Dear Elena," since there are two of us--we decided to call it, "Dear Mabel." So Mabel of the MDS we will be.
       We very much want this to be a column for you to receive answers to the questions you have about the MDS. Simply call Renee Olszewski, Managing Editor, at (800) 237-7285, extension 209, with your question or e-mail your question to rolszewski@hmpcommunications.com. In a future issue of ECPN, you will see your question and our response to your question.
       In this issue, we are going to talk about section P. Section P is titled "Special Treatments, Procedures, and Programs." The interesting thing about section P is that the "look-back" period changes quite frequently throughout the sub-parts of this section. This look-back period refers to a specific time prior to the assessment reference date (ARD) or the A3a date.
       Let's take a closer look at these different time periods and how they apply throughout section P. Section P1a has a look-back period of 14 days. Section P1b contains instructions to look back seven days and not to count therapies received before admission. Sections P2, P3, and P4 also have look-back periods of seven days. However, when you go to section P5 and P6, it goes to 90 days. Sections P7 and P8 change to 14 days or since admission if less than 14 days. In section 9, it changes to a 90-day look-back period. Is it any wonder MDS coordinators don't seem to know what day of the week it is?
       Knowing how and when to set the ARD is crucial to Medicare Part A assessments or the Prospective Payment System (PPS). PPS requires several assessments be completed, among them a 5-day assessment and a 14-day assessment. Accurate and timely scheduling and completion of these assessments will greatly affect reimbursement. It is permissible to count some special treatments, procedures, or programs the resident has received in the hospital under Section P1a if the ARD is set appropriately for both the 5-day and 14-day PPS assessments. The Centers for Medicare and Medicaid Services (CMS) has set up acceptable dates to use for reference dates for all assessments. By following these parameters, it is possible to capture these areas.
       Many of the current software systems and paper form systems have tried to make our jobs easier by utilizing special coding for the areas that will place the resident in certain Resource Utilization Groups (RUGs). Referring back to section P1a, the following procedures or treatments will help to place the resident in a higher RUG, even if the procedures or treatments were only received in the hospital and are not being done at the long-term care facility:
- Chemotherapy
- Dialysis
- IV medication
- Oxygen therapy
- Radiation
- Suctioning
- Tracheal care
- Transfusions
- Ventilator or respirator use.
       There are at least two caveats to counting these treatments/procedures. The first is to be sure you have documentation from the hospital that these procedures were actually carried out or implemented. A doctor's order for them may not be sufficient. You will need a completed medication sheet or form that contains signatures for the actual administration of the procedure or treatment. To simplify record keeping, it is best to keep this documentation attached to the MDS. If you have a paperless system, you will need a method for archiving this information along with the MDS.
       This leads us to the second caveat. Since we all know that the federal government is not in the habit of giving away money, it behooves us to wonder why CMS permits us to count these treatments. As good and competent caregivers, we note that these treatments and/or procedures can have adverse reactions or residual ill effects. We need to continue to monitor the resident for these ill effects and/or adverse reactions. This should be done in the nurses' notes and/or the doctors' progress notes. Also, the condition or disease requiring these procedures/treatments should be monitored closely. This, for a change, makes only good sense to the caregiver. It would not make sense to mark the resident for chemotherapy received in the hospital and not monitor for nausea and vomiting, weight loss, fatigue, bleeding, etc.
       Using the common sense mentality of the caregiver, it becomes evident why CMS does not allow hospital therapies and doctor visits and orders in the hospital to count. These do not have ill effects or adverse reactions that need continued monitoring. So, even though it requires a lot of cautious scheduling and documentation to count some treatments and procedures, we must give the devil his due. In this area, CMS is doing the right thing--for us and for the resident.
       One final thing--remember to read and re-read your Resident Assessment Instrument (RAI) manual as often as needed to learn its definition of these procedures. Again, many of the current software systems on the market offer a quick "look-up" feature on screen. An example would be suctioning, which refers to tracheal suctioning not simple suctioning. Do not count these procedures/treatments if they do not meet the RAI definition.
       In the next issue, we will be talking about section G and the dreaded Activities of Daily Living (ADLs).