W

ow! May and June were certainly active months in the MDS arena. New Questions and Answers (Q&As) and a brand new form, the MDS PPS assessment form (MPAF), were released in these two months. All the professionals we have spoken to are abuzz with questions and comments. It seems that another layer of confusion and anxiety may have been added to the already muddied waters concerning MDS completion.
       The MPAF was developed and released in an attempt to relieve some of the paperwork burden for PPS assessments. The creation of another assessment form with unclear usage guidelines has caused a myriad of problems to emerge. "It all depends" seems to be the most frequent advisory statement concerning the use of the MPAF form. The form itself is really a "no brainer." Instead of the 10-page full form, it is only three and a half pages. There are no new entries, simply a compilation of old familiar entries. Thus, there are no new definitions to learn. Consequently, the form is shorter and somewhat quicker to complete. However, trying to determine if and when it is permissible to use the MPAF could consume any timesavings.
       Basically, there are five PPS assessments based on timeframes. These are the 5, 14, 30, 60, and 90-day PPS assessments. If the resident is new to the facility, OBRA calls for an admission assessment at the 14-day timeframe. An admission OBRA MDS assessment requires the use of the full 10-page form complete with RAPs. This eliminates one of the times the MPAF form could be used, either the 5-day PPS or the 14-day PPS. Now we are down to four times where it might be possible to use the shortened three and a half page MPAF form. The resident's stay continues uneventfully as a Part A Medicare resident until the 90-day assessment period. To be practical, the facility wants to combine the 90-day and quarterly assessment. In this scenario, state rules would prevail over the use of the MPAF form. Some states may be able to use the MPAF form for the quarterly, and some may not. Since this varies by state, check with your state Office of Medicaid Policy and Procedure (OMPP) for a definitive answer.
       Continuing our countdown, we are now down to three times this form might be used. An easy way to remember when the MPAF form would always be appropriate is if AA8a = 0, and AA8b = 1, 2, 3, 4, 5, 7, or 8. Anytime a PPS assessment is combined with an OBRA assessment you must follow your state's protocol for that OBRA assessment. Some MDS coordinators refer to OBRA assessments as AA8a > 0, such as a 05, 01, or 03. If you are ever unsure which form to use, remember CMS has stated a full form will always work. It's a little extra work but a sure hedge against a delinquent record.
       You will not be able to submit MPAF forms if your software company has not updated to the MPAF form. Our understanding is that most software companies have met the July 1, 2002 date of implementation. The Resident Assessment Validation and Entry (RAVEN) software system has stated they will have MPAF software ready to ship on July 1, 2002. RAVEN is the data entry software system developed by CMS, formerly HCFA, for submission of MDS data. These software programs are available free of cost. If you are interested, you may call (800) 339-9313, or go to the CMS website, http://www.cms.hhs.gov. We have also heard of some problems with state submissions related to work at the state level preparing to receive MPAF submissions.
       If you are working for a corporate extended care facility, your corporate MDS department may make a corporate-wide decision about the use of the MPAF. Some corporations are instructing their facilities not to use the MPAF until further notice. There will definitely be a learning curve with regard to when and how to use this form. Nevertheless, the payoff in terms of timesavings will be worth it.
       In fact, the MPAF form is not as confusing or as much trouble in the field as are the new Q&As of May 2002. We are receiving the most comments on Section M. Considering that previously Section M was slightly difficult, now it is totally illogical. Through the new Q&As, we are instructed to stage all skin ulcers. A skin ulcer is then defined as "a local loss of epidermis and variable levels of dermis and subcutaneous tissue." The cause for the ulcer is not a factor in staging all skin ulcers, i.e., syphilitic gummas, pemphigoid bullae, burns, etc., must all be staged, except for rashes, such as their example of peritoneal dermatitis. Peritoneal dermatitis is apparently considered a rash and, as such, is not staged. It would be counted in M4 as a rash, unless, according to the graph CMS released, peritoneal dermatitis occurs on a pressure point. All of which leads us to assess for peritoneal pressure areas. That would be the lining of the abdominal cavity, right? How can there be dermatitis on the internal lining of the abdomen?
       A logical person would have to believe CMS is referring to perineal dermatitis. Perineal dermatitis may commonly occur among incontinent individuals. If the resident has perineal dermatitis without any of the rash occurring on pressure points, for instance, the ischial tuberosities, you would not count this as an open area or a pressure area. It would code under M4 as a rash. However, if the perineal dermatitis occurred over a pressure point, the ischial tuberosities for example, then it is coded in M1, M2, and M4. M1 could either be a stage I or a stage II depending on whether the area is open or not. This scenario makes sense. Appeals have been made to CMS to clarify the use of the word "peritoneal." On June 13, 2002, they did issue clarifications but did not change the use of the term "peritoneal dermatitis."
       Q&A 5-12 is creating some uproar. In response to a question about sending a MDS as part of a transfer, we are advised to "provide the new facility with the resident's medical record, including any MDS assessments that were completed for that resident." Does this mean all MDSs since 1996, only PPS assessments, only current PPS assessments, or only 15 months worth of MDSs? No one seems to know.
       Continuing, Q&A 5-14 is also causing some confusion. It seems at first glance to be saying you have 15 days, not 14, to complete an initial assessment. This is not the case. Do not be tempted to misinterpret this response. Initial assessments only have 14 days with the day of admission counting as day one.
       Personally, we like Q&A 5-61 the best, not only because the answer makes sense but also because CMS states their previous logic was in error, and they are changing a mistake. We all make mistakes, even CMS. As mere mortals who complete the MDS, we often have to admit our mistake daily in a very public manner, i.e., the whole facility knows when we make a mistake. So, despite all the heartache and headache endured due to CMS rules and regulations, it is nice to know they are mortal also. This Q&A states that successful interventions may not eliminate the cause of the problem. Therefore, if the problem still exists, it should be included on the MDS. Q&A 5-61 refers to Section K and a chewing and/or swallowing problem being eliminated by the provision of a therapeutic diet. CMS now instructs us to code for the problem and the successful interventions.
       There are 105 Q&As in the May 2002 release. CMS sets new policy through the use of these Q&As, so you must read and know them. Complete copies of the MPAF form and the May 2002 Q&As are available at http://cms.hhs.gov/providers/snfpps/snfpps_pubs.asp.
       The original purported goal of the MDS was to improve resident care. Through PPS it has quickly become a billing statement. CMS, as the keeper of the MDS, must do better. Mabel thinks clarification should clarify and simpler forms should simplify. Mabel says good luck understanding these new clarifications and implementing the new simple form. Keep your head up, and keep the questions coming!
The publisher, HMP Communications, and the authors disclaim responsibility for any injury to persons or property resulting from any ideas or products referred to in this article.