H

ow many times have you heard, “So, what do you do for a living?” Most people know the role of a nurse, a doctor, a pharmacist, or a physical therapist. But how about a Minimum Data Set (MDS) coordinator? Every job description is probably a little bit different, but generally the team coordinator ensures timely completion of the MDS assessment form and the Resident Assessment Protocols (RAPs) and development of the care plans. The team usually includes the nurse—licensed practical nurse (LPN) or registered nurse (RN)—social services director, activities director, and dietitian or dietary manager. It may also include a pharmacist, medical records director, therapy director, and nurse practitioner or physician. The MDS coordinator may or may not have other management or supervisory duties, and he or she may or may not be responsible for completing sections of the MDS and RAPs.
       Since the MDS is a federal government tool used to assess the uniqueness of a resident, it is useful for gathering statistics and measuring outcomes pertaining to, for example, fall prevention or pressure ulcer prevention programs. Anyone reading the MDS can use it as a tool for evaluating the resident at a certain period of time. It paints a picture of the resident. It is up to the MDS coordinator to make sure that the MDS is completed.
       The MDS coordinator is not, however, responsible for the accuracy of the information on the MDS. Persons who review the MDS should point out any inaccuracies or discrepancies. Of course, the person responsible for a specific section is the person who assesses and is accountable for that section. Just as there are many persons who complete the sections, there are just as many opinions. It is wise to include the most accurate picture of the resident, whether it involves cognition, communication, behavior problems, etc. Other responsibilities of the MDS coordinator include developing individualized care plans and leading resident care conferences.
       The MDS coordinator also sets the Assessment Reference Date (ARD) for admissions, annual, and quarterly MDSs. These dates may vary, and it is the MDS coordinator who makes the determination. After the ARDs are set, the care plan dates are set. Determining these dates is sometimes the responsibility of the social services director.
       Are MDS coordinator responsibilities part of your job as the director of nursing (DON) or assistant DON? Commonly, many companies list the Resident Assessment Instrument (RAI) process as part of these nursing management jobs. Either way, 1 person, the MDS coordinator, is ultimately responsible for the process.

Questions and Answers

       “Dear Mabel: What does ‘Minimum Data Set’ actually mean?” (licensed practical nurse, Washington)
       Answer: Minimum Data Set means the minimum amount of information about a resident that clinicians need to know in order to provide care for a nursing home resident. A care plan is developed based on this information. Those involved in reimbursement for a Medicare resident know that this information is used to calculate the resource utilization group (RUG) level for reimbursement.
       “Dear Mabel: How can I get all my work done within my time frame? How can I go faster when it comes to completing the MDS?” (registered nurse, Arizona)
       Answer: The ebb and flow of the work contains many variables. Some weeks or seasons may be heavier than others. It is like this with most jobs. As they say, “When the going gets tough, the tough get going.” There are several strategies to improve work flow. One is to prioritize. Determine the most important jobs to get done and plan to complete them within your predetermined time frame. Second, enlist the help of others. Sometimes this means having others file, develop care plans, or complete the MDS for you. Also, some ARDs may be adjusted to lighten one day’s work load. Adjusting your work hours may also help. Working undisturbed, while it is quiet, is the best way to not to lose your train of thought. Interruptions may cause a person to lose his or her place in a chart and can delay the completion process.
       There are several strategies to improve your speed. First, have all of the information you need before you begin; keep all of your interviews and details at your fingertips. Second, make sure you are uninterrupted, because completing the MDS is the task at hand and may take a while to complete. Third, if typing is your weak point, get a typing program and practice what you need the most, whether it is working the mouse to point and click or typing key words. Always plan for emergencies, as healthcare is full of surprises. Lastly, let your supervisor know if the work is not getting completed in a timely manner for any reason. (If you have strategies that have helped you to improve the speed of your work, please feel free to send them in and we might publish them in a future issue of ECPN.)
       “Dear Mabel: I just started working in a nursing home after 5 years in a hospital. I work the skilled unit and keep hearing how important it is to document everything because of the Prospective Payment System (PPS) and Medicare Part A. What are these things, and why do they make my life so miserable?” (licensed practical nurse, Kentucky)
       Answer: You have asked a simple question, but there is nothing simple when it comes to government agencies or programs. The PPS was developed for Medicare skilled nursing facilities and pays facilities an all-inclusive rate for all Medicare Part A beneficiary services. Payment is determined by a case mix classification system that categorizes patients by the type and intensity of resources used. There are many sections of the MDS that affect reimbursement. Every skilled nursing facility has a different reimbursement rate based on various factors.
       One of first factors is whether the facility is considered urban or rural. The rate is also dependent on the facility’s “pattern of reimbursement” (ie, case mix), which is researched for every facility. In a payment system adjusted for case mix, the amount of reimbursement to the nursing facility is based on the resource intensity of the resident as measured by items on the MDS. These are grouped according to RUG levels. What are RUG levels? According to the MDS 2.0 User’s Manual, RUG, or RUG-III for version III, is “a category-based classification system in which nursing facility residents classify into 1 of 44 or 34 RUG-III groups. Residents in each group utilize similar groups and patterns of resource. Assignment of a resident to a RUG III group is based on certain item responses on the MDS. Medicare uses the 44-group classification. Many state Medicaid programs use the 34-group classification.”
       There are several major classification groups, including: rehabilitation, extensive services, special care, clinically complex, impaired cognition, behavior problems, and reduced physical function.

Common RUG Levels

       In the hierarchy of RUG levels, a “C” coding brings in the highest reimbursement, followed by a “B,” then an “A.” A “2” coding at the end of another RUG level brings in more than if the RUG level ends in a “1.” So the hierarchy of reimbursement (with the exception of SE3), from highest to lowest, is: RUC, RUB, RUA, RVC, RVB, RVA, SE3, RHC, RHB, RHA, RMC, RMB, RMA, RLB, RLA, SE2, SE1, SSC, SSB,SSA, CC2, CC1, SB2, SB1, CA2, CA1, IB2, IB1, IA2, IA1, PE2, PE1, PD2, PD1, PC2, PC1, PB2, PB1, PA2, PA1. There are 9 new RUG levels, including rehabilitation services and extensive services.
       The care of the resident affects the RUG level, and everything must be documented in the chart. Important and accurate observations should be recorded in the chart to ensure that the MDS will be accurate. This is not only the key to reimbursement; it is just good practice. As the MDS coordinator, you may record your observations, just as the other team members do.
       To be included in the “very high intensity” RUG, in the last 7 days a resident needs 500 minutes or more of therapy and at least 1 discipline for at least 5 days. For “high intensity,” it is 325 minutes or more of total therapy and at least 1 discipline for at least 5 days. For “medium intensity,” 150 or more minutes of total therapy and at least 5 days of any combination of the 3 disciplines are required. For “low intensity,” 45 minutes or more of total therapy, at least 3 days of any combination of the 3 disciplines, and 2 or more nursing rehabilitation services received for at least 15 minutes (each administered for 6 or more days) are required.
       The MDS 2.0 User’s Manual states that the calculation of the activities of daily living (ADL) score is 1 criterion used in all determinations of a resident’s placement in a RUG-III category, with depression being another factor. The “late loss” ADLs, which are bed mobility, transfers, eating, and toilet use, are the most predictive of resource use. Depending on the score, 1 facility may incur a higher reimbursement rate than another, given the same urban region.
       So, let us concentrate on Section G of the MDS, looking at bed mobility, transfers, and toilet use. The calculations are as follows for Column A: for bed mobility (G1a), transfers (G1b), and toilet use (G1i), score 1 point for a code of 0 or 1, which is for independent or supervision/standby assistance. Score 3 points if a 2 had been coded for limited assistance. Score 4 points if a 3 (extensive) or 4 (total assistance) or 8 was coded and the resident requires the assistance of 1 person. Score 5 points if a 3 or 4 or 8 was coded and the resident requires the assistance of 2 persons. The documentation for all 3 shifts must accurately reflect care of the resident.
       Next, the eating score is examined. If K5a (parenteral/IV) is checked, the score is 3. The score is also 3 if there is a feeding tube that supplies either 51% or more calories, or 26–50% and 501cc or more of daily fluid. If there is no intravenous (IV) or tube feeding, the score is as follows: 1 for independent, 2 for limited assistance, and 3 for extensive/dependent or if the activity did not occur.
       When looking at the RUG-III score, an ADL score of 16–18 will yield a “C,” the highest of the classifications and the most reimbursed. A score of 9–15 produces a “B,” a score of 4–8 an “A.”
       Note the difference in the RUG levels and ADL score and how it affects reimbursement. If a resident needs 2 persons to adjust him or her in bed and 2 for transfers or toileting at least 3 or more times in the last 7 days, it should be documented in the record.
       The next category is extensive services. These groups are based on various services provided. These services are parenteral/IV, IV medications, suctioning, tracheotomy care, and ventilator or respirator. Although it seems complex, the topics that impact this category are special care, clinically complex, and impaired cognition. The sub-categories are SE1, SE2, and SE3, with SE3 being the most reimbursable in this category.
       Recently, the Centers for Medicare and Medicaid Services (CMS) increased reimbursement for the SE3 category, so it now reimburses at a higher rate than a rural healthcare (RHC) rate. As you can see, the formula may seem complicated, but accurate documentation is the most important factor in determining the RUG level.

MDS News

       The Centers for Medicare and Medicaid Services has released a final rule to update the skilled nursing facility (SNF) PPS for fiscal year 2006, which contains a number of policy changes. Most notable is the refinement to the current RUG-III case-mix classification system. The number of RUGs went from 44 to 53 to account for the higher costs of beneficiaries requiring both rehabilitation and certain high-intensity medical services. Case-mix weights for the 9 new groups have the same case-mix weight as the combined ultra-high rehabilitation group/extensive care group (RUX, RUL).
       The increase of RUGs reflects the high level of variability in nursing and non-therapy ancillary costs and increases aggregate payment by about 3%. This is a permanent payment increase that will be integrated into the baseline speaking levels and continued in future years. These changes will be implemented January 1, 2006, triggering the elimination of the Balanced Budget Refinement Act of 1999 (BBRA) temporary add-on payments. Next year’s payment rates also include a “market basket” update increase of 3.1%. Payments to SNFs in fiscal year 2006 will be approximately $20 million more than last year’s levels.
       By now you have probably heard that Section W is used to record influenza and pneumococcal vaccine items on all new assessments and discharges. An “unable to determine” (dash) response has been allowed on all vaccine items, effective October 1, 2005. Let us know how it is going.
       To keep abreast of these changes, visit the CMS web site at http://www.cms.hhs.gov/providers/snfpps.

Ask Mabel
       If you have a question you would like to see addressed in a future “Ask Mabel” article, e-mail it to ryand@hmpcommunications.com.