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edications have been an issue with several of our readers recently. Since there have not been any recent revisions or new rules on medications, we were puzzled by this at first. However, after we began looking at the questions and the Resident Assessment Instrument (RAI), we understood how it would be easy to become baffled. We would like to start with a couple of those questions to illustrate the difficulty, and then we have some news to share.
       “Dear Mabel: We have a resident who recently had a Baclofen (Watson Laboratories, Inc., Corona, Calif) pump implanted. We do not have much to do with the actual pump but do monitor him for his response to the medication and the effectiveness of the medication. Can I count this on the Minimum Data Set (MDS), and if so, how?” (registered nurse, Minnesota)
       Answer: Yes, you certainly can and should count the Baclofen that your resident receives. Baclofen pumps are counted under Section P, Special Treatments and Procedures, at P1ac. If you look at the RAI manual, page 3-182, under Definition “c,” it states, “Record the use of an epidural pump in this item. Epidurals, intrathecal, and baclofen pumps may be coded, as they are similar to IV [intravenous] medications in that they must be monitored frequently and they involve continuous administration of a substance.” So, code it as an IV medication, and continue to monitor for efficacy and side effects.
       “Dear Mabel: One of our residents is receiving tamoxifen related to her history of breast cancer. She has been cancer free for 3 years but is still receiving this drug. Should I continue to count it?” (licensed practical nurse, Ohio)
       Answer: Yes, you should continue to count the tamoxifen as chemotherapy under section P, Special Treatments and Procedures. Again, see the RAI manual, page 3-182, Definition “a,” Chemotherapy. It states that special care “includes any type of chemotherapy (anticancer drug) given by any route.” You will need to code this at P1aa, Chemotherapy.
       We are glad that question was raised. After reviewing Section P, it became clear why people have so many questions about this unusual section. It has a 14-day look back and includes treatments received at the facility and at the hospital, as an inpatient and as an outpatient. Under the definition for chemotherapy, the RAI manual states that medications administered for the side effect (eg, megestrol acetate given to stimulate weight gain rather than to treat cancer) cannot be counted as chemotherapy. When you think about it, that does make sense.
       However, the RAI manual goes on to state that each drug should be evaluated for its intended use before coding it under chemotherapy. Blood transfusions, IVs, and IV medication given during chemotherapy cannot be coded under IVs. They must be coded under chemotherapy. In other words, it says to code according to the intended use, not the classification of the drug, treatment, or route. This appears counterintuitive. The healthcare professionals we have talked to think of IVs as a classification of their own, regardless of the intended use. And IVs are a separate entry, at P1ac, which appears to agree with the healthcare professionals. In this case, the MDS is anything but intuitive.
       Continuing in section P, the previous entry P1ab, Dialysis, has the same disclaimer. You may not count any IVs, IV medication, or blood transfusions given during dialysis anywhere else but at P1ab. To top it all off, at the very beginning of page 3-182, under intent, it states, “Do not code services that were provided solely in conjunction with a surgical procedure, and the immediate post-operative period.” (Bold wording is theirs, not ours.) Okay, got that? On to Section O, Medications.
       Section O has a 7-day look back, not a 14-day as in section P. In section O, all medications count: over the counter and prescription. However, it is not that easy. There are many disclaimers to this section. For example, medications include topical preparations, ointments, wound care creams, eye drops, vitamins, and suppositories. It does not include any preparations for preventative care. Vitamins count, but only if given as such, and not if the vitamin is part of a dietary supplement. On the other hand, herbal and alternative medicines do not count as medications. These are considered dietary supplements and must be counted at section K5f.
       As we continue, looking at section O, we come to O4, “Days Received the Following Medication.” The RAI manual directions for this area state on page 3-180, under clarification, “Code medications according to a drug’s pharmacological classification, not how it is used.” Didn’t the RAI say in section P to code a treatment according to how it is used, not how it is classified? Let us not belabor the point further. The RAI directions are perplexing and confusing at times. It would be interesting to see the instructions for these 2 sections done as an algorithm or decision tree. We are sure it would resemble a grand old oak or at least a weeping willow.
       What can we learn from this? That the MDS is an animal all its own, and each separate section is also an animal unto itself. The only way to understand this beast is to look at it 1 limb at a time. It makes an odd kind of sense that all the sections of the MDS conflict with each other. The MDS as a whole is often in total opposition to accepted clinical procedures and facility practices. We cannot change that. We can allow our voices to be heard by joining groups that represent long-term care and voicing our frustrations and concerns through an acceptable medium. In private, we can scream behind closed doors if all else fails.

MDS News

       As we reported in the May issue of ECPN, the Centers for Medicare and Medicaid Services (CMS) has delayed the implementation of the revisions to the RAI manual. June 15th is the big day at the moment. This delay is a good example of why it is a sound idea to wait as long as possible before purchasing anything related to purported changes by CMS. If you purchased a manual thinking that May 5 was the drop-dead date, you may have wasted money. We have heard, however, that the delay was related to computer issues and not content.
       We like to pass on any news about long-term care, since that is the arena for the MDS. Many of you may know that Federal Tag 315 (Tag F315) has been rewritten (see the article on page 50 for more information). Basically, Tag F315 addresses incontinency in much the same way the new Tag F314 addresses pressure ulcers. There are several pages defining and diagnosing incontinency, then the interpretations of the guideline for the surveyors and how and what to cite. It was released April 14, 2005 and becomes effective June 27, 2005. It is available as a PDF document and can be downloaded from the CMS website, http://www.cms.hhs.gov.
       In closing, we would like to share a comment made by a colleague that maybe all the changes in long-term care are a good thing. He went on to say if we are not being challenged to think in new ways and try new things we may never push ourselves to see what we are capable of. Discoveries would never be made if we were always comfortable. So, perhaps even when the changes are somewhat haphazard, it is a good thing. We as healthcare professionals dedicate ourselves to work together to ensure progress through better care techniques and practices for our residents. Long-term care has come a long way and has a long, exciting way to go. We hope to be there with you.

If you have a question for Mabel, you can e-mail us at MabelMDS@aol.com.