Questions and Answers From the American Association of Nurse Assessment Coordinators - AANAC - Brief Article

Nursing Homes, Oct, 2001

Editor's Note: Record keeping for the Medicare Prospective Payment System (PPS) has always been a daunting prospect. Rescue is at hand in the form of the American Association of Nurse Assessment Coordinators (AANAC). Consisting of nurses who have been designated as the PPS point persons in their facilities, AANAC is dedicated to helping facilities achieve accurate and timely resident assessment and appropriate Medicare reimbursement. One of AANAC's principal features is an online chat group for members who exchange observations, questions and answers about PPS-related problems. AANAC experts review all questions and peer review the answers to ensure that members receive accurate information. Here, and published quarterly in Nursing Homes/Long Term Care Management, is a sampling of common questions submitted to AANAC and their answers.

Q: Our sister facility has state surveyors visiting, and they found an MDS with some ADLs coded incorrectly. Should the facility inactivate the old assessment sent already and do a "Significant Correction Assessment"? If so, using what ARD? If not, what should they do?

A: Yes, the facility should submit a Correction Request form for the assessment in question. The next step is determining whether a Significant Change of Status has occurred. If so, an SCSA will need to be completed ASAP.

If it was simply a "data entry" error and does not constitute an uncorrected major error (an error such that a care plan derived from the assessment would not suit the resident's needs), then they would complete and transmit a Significant Correction of a Prior Assessment (also completed ASAP, but no longer than 14 days from the date of detection). It would be coded as an 04 in AA8a with a current ARD. Remember that an 04 assessment is comprehensive, so RAPs and Care Planning must also be completed. Significant Correction Assessments are appropriate for OBRA-required clinical assessments only. If an error is found in a Medicare PPS-only assessment, a Significant Correction is not appropriate, and the modification process should be utilized.

Q: Question 2-29 in the new HCFA (CMS) Q&As says that we should divide the week's total IV fluid by 7, even if the fluids were administered for fewer than 7 days in the assessment period. What if the fluid administration is for a 5-day Medicare MDS? Would I divide by 5, since there are only 5 days in the assessment period?

A: This item is asking for an average over the 7-day observation period, not an average over the days that the fluids were administered. Thus, dividing by 7 is correct. In addition, since this item allows you to capture data preadmission, the observation period is a true 7 days. In the scenario you give there are 5 days in-house and 2 days prior to admission. Dividing by 7 is appropriate. If you wish to capture 7 days of the IV fluids you are delivering in your facility, push back the ARD to day 7. This would be an appropriate use of grace days.

Q: The March 2001 Q&A from CMS that states that a cut requiring sutures or a butterfly Band-Aid should be coded as a surgical wound makes no sense. We now check "surgical wound care" for the treatment of the cut, as well. How can this be correct?

A: Remember that the MDS definitions don't always quite fit conventional definitions because it is the intensity of services that is being captured on the MDS that is used to identify resource utilization. In this case, the intensity of service required by the resident is closer to that of a surgical wound than of a simple cut or abrasion. Another example is the definition of continence. We don't generally think of someone with an indwelling catheter as being continent, but the intensity of services such a person requires approximates that of someone who is continent more than someone who is incontinent of urine-and that is the way it is coded on the MDS.

Q: I had a patient who was in our transitional care unit for rehab. After her 14-day MDS, I wanted to do a Significant Change of Status, Improved, instead of waiting for the 30-day. So I coded AA8a as 3, but left AA8b blank, as I did not know what to put there. I have to redo this MDS as it was rejected for a clerical error when I sent it to the state. Billing says the code for them (on the Significant Change of Status, Improved) came up RVC00, and Medicare will not pay this. What do I code in AA8b?

A: To be identified as a Medicare assessment, the SCSA must be dually coded as an OMRA. This is the official word from Dana Burley of CMS, who has reiterated this as-yet unwritten policy at AANAC's semiannual conferences.

With thanks to Rena R. Shephard, RN, BA, FACDONA, AANAC president and president of RRS Healthcare Consulting Services, San Diego, California. NH