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Hello, everybody. My name's Dave Malitz. This is Bob Godbout. We're -- together,
we are Stepwys Systems, and we're both statisticians. Bob did the specifications
for RUGs and for the CAAs, and I did for the specs for the data submission specs
and for the RUG-III Crosswalk. So, my sympathies, you get to listen for an hour
and 45 minutes to two statisticians talking. So, we'll try to make it relatively
interesting and we're going to be talking about -- I'll be talking about Section
A and X - that's x-ray, and Bob will be talking about Z. So, these are the three
administrative sections of the MDS. To our way of thinking, they're the most
interesting. So, we'll cover those three, and then we'll let everybody else mop
up the clinical details for the other 16 sections in the middle. So, that'll
take a couple of days, though. Okay, let me see if I can make this thing work.
Okay, you know, I'll be talking about the intent of Section A; describe the
information required; and, hopefully explain how to code it accurately. Section
A is the identification section. It documents a variety of data and the intent
is to obtain key information that identifies the resident and the facility where
the resident resides and also to specify the reason for assessment and the type
of provider, whether it's a swing bed or nursing home.
The first set of items are A0100 and A0200, which contain facility data. These
allow identification of the nursing home submitting the data, and you enter the
numbers in the spaces that are provided, and you can see we've got the National
Provider ID. Oh, by the way, I forgot to mention. For our -- my presentation,
and really all the rest of them this week that are going to be going through
section by section, if you haven't already discovered it in the packet you got,
there is an MDS 3.0 with all the items on it. So, you might want to pull that
out, if you haven't already, and follow along. It might make it easier to follow
some of the presentations.
Okay, so in A0100, we've got three items we cover about the facility: the
National Provider ID, Identification Number; the CMS Certification Number - the
CCN, which has previously been known as the Medicare ID - the Facility Medicare
ID, which currently is only six-character ID - but we left extra spaces, just in
case; and, then the State Provider ID, which would be assigned by the state
Medicaid agency. And all of these -- the National Provider ID is 10 characters
long, and we allow 10 characters for that, but the CCN and the state provider
number can be shorter than the number of spaces provided. So, in that case, you
would left justify those and leave the remaining spaces empty.
There's a new item, A0200, which specifies the type of provider - which can be
either a nursing home or a swing bed provider - and this is a new item because
for the first time -- of course with MDS 2.0, we've had a separate flavor,
essentially, of the MDS for nursing homes and for swing beds; and, for MDS 3.0,
we've decided to consolidate those into a single set of items. So, and, the
requirements are for nursing homes that are Medicare- or Medicaid-certified:
must complete an MDS to meet their OBRA requirements. That's no change at all
from before, and SNFs and swing bed providers need to complete assessments for
SNF PPS, and both nursing homes and swing bed providers must complete item sets
for every entry into the facility or the appropriate type of discharge. And
then, of course, any intervening assessments that are required as well.
The next set of items are A0310 and A0410, which indicate the type of assessment
or the reasons for assessment. A0310 identifies the information that's required
to complete the type of assessment. Assessments can be completed for multiple
reasons, just like on MDS 2.0. For example, you can combine OBRA and PPS
assessments into a single assessment, and when you do combine assessments, you
need to meet all the requirements for both of those. Say, if you're combining
two types of assessments, you need to combine all the requirements for both
types of assessment; and, we've supplied item sets for the different types of
assessment. The different item subsets, we call them - or ISCs, item subsets -
and those, if you look at each type, it shows all the items that are required
for the various types of assessments.
A0310A is the "Federal OBRA Reason for Assessment" item. This is comparable to
8A on the MDS 2.0, and in fact, there haven't really been any changes. Although
they're re-ordered, I think. Yeah, they are re-ordered. This is still the same
types of assessments that you've been dealing with on MDS 2.0. So, there's not a
big change with A310A. There is one change, and Ellen alluded to this, this
morning, about -- and actually, I'm not sure that this is a change - but, in any
event, there is a policy that when there's a hospice benefit is either opted in
or opted out, that there's a requirement to do a significant change in status
assessment and that - that applies to, let's see -- yeah, if the nursing home
resident elects or revokes the Medicare hospice benefit, the nursing home is
required to complete a significant change in status assessment. The hospice
benefit doesn't need to be Medicare to require significant change in status, and
a significant change in status assessment is required every time the hospice
benefit is elected or revoked; and this is true even if a recent MDS was already
completed. And the purpose of this is to ensure coordination and communication
between the nursing home and that hospice that's going to be providing the care.
A310B is the PPS reasons for assessment, and this is comparable to A8b today on
MDS 2.0, and we've got the ones you're used to. We've got the 5-, 14-, 30-, 60-,
90-day; and the re-admission return assessment; the PPS re-admission; and
return. We also have a new option for an unscheduled PPS assessment, and then
there's a "99", which is when -- you use to indicate that it's not a PPS
assessment.
A310C is a new item that indicates whether the assessment is related to the
start or end of therapy and these -- this item needs to be completed on every
assessment. You can either indicate that, no, it's not -- it's not an OMRA - or
Other Medicaid Required Assessment, or you can indicate that it's a start of
therapy assessment, an end of therapy assessment, or both start and end of
therapy assessment. And, if it's a start of therapy assessment, the ARD must be
five to seven days after the first day of therapy services. In other words,
after the first therapy services begin. If it's code 2, an "End of Therapy," it
needs to be -- the ARD needs to be one to three days after the last day of
therapy services were provided, and if it's a code 3, both -- both a start and
end, then the ARD for the -- must meet both of those criteria. There's an
exception to this if it's a short stay assessment, and Ellen talked about that
some this morning. And then I think on Friday, when, well, SNF -- I mean when
PPS policy is covered, I think that will be covered in some more detail. This is
- okay.
A310D is an item that is also a new one. That this -- this is to indicate a
swing bed clinical change assessment, and this is an item that's only active on
-- if the swing bed provider, if A0200 is a two. Otherwise, nursing home
assessments that skip over that item. A310E indicates whether this is the
current assessment being performed is the first assessment since the most recent
admission, and Ellen mentioned this morning that we'd struggled a bit with the
definition of what an entry means versus -- an entry means versus an admission,
and I think, in retrospect, we might have wished that we had said first
assessment since most recent entry rather than admission. But, that is the
intent of the item in any event - is that this is supposed to indicate if this
is the first assessment that's been completed since you completed the entry
record for this person. So, in other words, if a person newly comes in, they do
an entry - I mean, an entry record -- an entry tracking record. Then, the very
next assessment, would be a five-day admission, or whatever, they -- you would
complete that assessment, and on this A0310E, you would say, "Yes, it is the
first assessment since the entry," and then every subsequent assessment, you
would say no. And then you would continue on until they were discharged and came
back in again, and then you would start over with a yes. And the purpose of this
item, you'll see in some of the clinical sections, it serves as a -- to trigger
some skip patterns so that some items are asked only the first time after a
person has entered the facility, and not thereafter. So, it's sort of to keep
you from having to do an assessment item too frequently.
A0310F is the entry or discharge reporting item, and this indicates there's five
options here for whether it's an entry record; discharge return not anticipated;
a discharge return anticipated; death in facility record; or it's not an entry
or discharge record. So -- and the entry and the death in facility record are
tracking forms only. No clinical items on those. They're very brief. And then
the idea of doing full clinical items on a discharge is a newer concept now with
MDS 3.0.
A0410 designates the authority for submitting an assessment for this resident,
and in order to -- for the assessment to be submitted to the ASAP system and
ASAP is the new system that's going to be accepting MDS 3.0 data -- in order for
the data to be submitted, it has to either meet a state and/or federal
requirement and this is similar, well, actually it's identical to the item --
it's not actually an item, but there is a piece of information that's submitted
with the MDS 2.0. It's not actually an item on the MDS 2.0 form itself, but we
refer to it as "Sub Reqs", meaning Submission Requirement. It's coded the same
way, and then the rules are the same for this.
And, in thinking about it, it's almost easiest to think about it going
backwards. Option number 3 indicates that it's a federally-required submission.
So, if the resident is in a Medicare- or Medicaid-certified unit, then it's a
federally-required submission. If they're not in a Medicaid- or
Medicare-certified unit, but they're in some other part of the nursing home and
state licensure rules cover that person, then you may need to be submitting that
assessment for state purposes - in which case, you would indicate a 2. And CMS,
then, does not have authority to look at that, but the data will flow through to
the state. And then, if it meets neither of those requirements, you need to
indicate a 1 - that it's neither federal- nor state-required submission. If you
indicate a 1, that record is not going to be accepted by the ASAP system. It's
going to be kicked back out because neither the state nor CMS has authority to
see that data. So, it's going to be kicked out. And, also, I might mention now,
we'll be talking later about corrections, but -- and inactivations -- but if you
inadvertently get this incorrect and you submit a record, but then you realize,
"Oh, it should have been a 1 because it shouldn't have been submitted in the
first place," you can't just inactivate that. You actually need to contact your
RAI Coordinator, I think, and get -- and have that record manually deleted from
the system because it shouldn't be there, according to HIPAA laws.
A0500 and A2400, took through A2400, indicates resident data and, of course,
this is information that's needed to identify the resident you're completing the
assessment for. A0500 through 1300 contain personal data, such as name and
identification numbers. A1500 and 1550 contain the mental illness/mental
retardation status items. A1600 through 2400 indicates the entry and discharge
data assessment reference date and Medicare Stay information.
Starting with A0500 the legal name of the resident. Enter the resident's name as
it appears on the resident's Medicare card. That's true. If they have a -- if
they're a Medicare resident, you should use the name that's exactly as written
on the Medicare card. If you have a resident who is not a Medicare resident,
then you -should fall back on some other government-issued identification. For
example, Medicaid card, if they have one of those. If not, you might use
driver's license, birth certificate, something government-issued. The idea is
that we want some sort of a standardized name to make it easier to match up that
person's information as it's submitted on various assessments And you can see
we've got, just like on MDS 2.0 -- we've got the same name, middle initial if
they have one, last name - and they have to have a last name - and then a
suffix.
A0600 is the Social Security and Medicare numbers. You can also use a comparable
railroad insurance number if that applies to the person. Don't use an HMO
number. Enter one number per space and leave blank if not available for the
Social Security and Medicare numbers. A0700 is the Medicaid number, and of
course, helps identify the resident also. And, just like on MDS 2.0, we're using
the same conventions where you put a plus sign in the first character to
indicate that the Medicaid number is pending and an "N" if it's not applicable.
We don't have an example there. One thing I did want to mention, if I can get
back to that -- on the Social Security and Medicare numbers is that, if the
resident is a PPS resident, a Medicare resident, they have to have -- you have
to enter at least one of those - either the Medicare or Social Security number
or the record. I believe that's a rejection. I think the record will be rejected
unless you have one -- or at least one of those. You can put both in if you
want.
Gender - that's pretty straightforward, and this is supposed to match up with
the gender as indicated in the Social Security system. Birth date - this works
just like the birth date item on MDS 2.0. You use zeroes to pad any of the
numbers. So, for example - in that example there, like month one, January, is
indicated as "01," and you provide the complete birth date if that's known and
leave any unknown components blank. So, for example, if all you know is the
year, then you leave the month and the day blank and indicate the year. So, in
this particular example here: you just enter blanks for month, blanks for day
and then enter 1918; and, if you knew the month, but not the day and the year -
month and the year and not the day. Then, you would say "01" for month; "blank,
blank" for day; and 1918 for the year. Works just like MDS 2.0.
Race/ethnicity - the categories follow the common uniform language. I believe
this is mandated now by the OMB, and they're not used to determine any
eligibility for participation in any federal program. One thing that's left off
of this slide is that it's -- the race/ethnicity item is changed from MDS 2.0.
On MDS 2.0, you can only indicate one racial or ethnic group. On MDS 3.0, it
follows the new convention -- newer convention where you can indicate multiple
racial or ethnic categories, if appropriate.
A1100 is the language item and indicates whether or not the resident needs an
interpreter, and the reason that this is important is the inability to make
needs known and to engage in social interaction because the language barrier, of
course, causes problems for the resident. It can be frustrating and can lead to
isolation and depression, and language barriers can also interfere with
completing an accurate assessment, especially now that we have the interview
sections on the MDS. The need for an interpreter can be even more acute, and it
also -- ability to communicate or not have language barriers is necessary for
the consent process as well.
So, the purpose of 1100 is -- A1100 is to determine if an interpreter is needed.
You ask the resident if he or she needs or wants an interpreter. If they can't
answer, then you try to consult a family member or significant other or you
review the medical record if there's no other source of information available.
You ask for the preferred language, if needed, and a family member or
significant other can be used as an interpreter, if the resident is comfortable
with this and that person will translate exactly what the resident says without
providing their own interpretation. Ascertaining all this may be complex in some
cases, but coding the item is pretty straightforward. It's just a 0, 1 or 9: 0
meaning that an interpreter is not wanted or needed; a 1 - that the interpreter
is wanted, or is wanted or needed; or a 9 - that you're unable to determine. And
if you indicate that an interpreter is needed, then you should complete A1100B
where you actually indicate what preferred language is needed and there was one
note about this, about -- oh, yes, that an organized system of signing, such as
American sign language, can be reported as a preferred language if the resident
needs or wants to communicate that way.
A1200 is a fairly straightforward one. That's just marital status. I don't think
that's changed since MDS 2.0. A1300 has some optional resident items, and three
of these were on MDS 2.0. We have medical record number; the room number; and
the last one, lifetime occupation, were all on MDS 2.0. A preferred name is a
new one, and these are optional items and the only real difference in those
three that were on MDS 2.0, they've been collected together into a single place;
whereas, I think, on 2.0 they were spread in different places.
A1500, the PASRR overview - happily, someone who really knows something about
PASRR will be talking about it later this week, I understand. And Dan will --
I'm just repeating what I read here -- but, I can tell you that PASRR is the
pre-admission screening process. It applies to Medicaid units in a facility
only; residents who are on Medicaid units. A positive screen indicates that the
resident has a mental illness, mental retardation, or a related condition; and,
it documents whether a Level II PASRR screen determination has been issued. This
item is not really calling for you to make any sort of judgments at the time you
complete the item. It's just simply reporting what happened when you did the
PASRR screening. Okay? All individuals who are admitted to a Medicaid nursing
facility, I think that's to a Medicaid unit, must complete a Level I PASRR; and
then, if the Level I screen is positive, then you need to do a Level II
evaluation -- must be performed. Individuals who are suspected of having mental
illness or mental retardation or a later condition can't be admitted unless
they're approved through a Level II PASRR determination, and some of these
procedures vary from state to state, so you need to talk -- consult with your
state Medicaid agency for the details about the procedures.
The PASRR reporting, A1500, is required only on an admission assessment. If
you're completing a significant change in status for an MDS resident who is on a
Level II -- who have a Level II PASRR screen as positive -- then you're required
to notify the state mental health authority and mental retardation or
developmental disability authority -- this looks pretty repetitious. I think
this is the same -- and the coding, you indicate a no. A code of 0, if Level I
screening did not result in a referral. So, in other words, they were screened,
but they didn't need a referral. If a Level II screening determined that the
resident does not have a serious MI or MR condition - or there are a few cases
where PASRR screening is not required when the resident is admitted from the
hospital after an acute inpatient care - and they're receiving services for
conditions that received care for in the hospital and they certified before
admission to likely require less than 30 days of nursing home care. I hope Dan
talks about that in some more detail because I don't really know much more about
it than that. You code a yes if -- that's pretty straightforward - if the Level
II screening determined that the resident did have a serious condition of mental
illness or mental retardation condition, and a 9 if they're not on a
Medicaid-certified unit. Okay.
Then, A1550 is "Conditions Related to Mental Retardation or Developmental
Disabilities," and we've got a skip pattern in there based upon the age of the
resident. You're supposed to indicate in here whether the resident has any of
the conditions indicated, whether they had an onset before the age of 22. So, if
the resident is 22 years of age or older, that can't change. Either they had the
condition before they got to be 22 or they didn't. So, if they're 22 years of
age or older on the assessment date, then you only complete this item on an
admission assessment when A310A is equal to 01. If they're 21 years or younger
on the assessment date, then conceivably they could have - if it's a young
resident - a condition may not have been there before, but now it could be
there. So, the item needs to be completed, not just on an admission assessment,
but on all the comprehensives: on the annual; significant change in status; or
significant correction to a prior comprehensive. And the conditions are listed
here. You can see what they are. They're Down syndrome, autism, epilepsy, other
organic condition related to MR/DD, MR/DD with no organic condition, or none of
the above.
Entry data - there's several items here that indicate the entry date, the type
of entry and where the resident entered from. And A2000, the discharge date. You
use that, obviously, to indicate the date that the resident leaves the facility.
Don't consider whether or not the resident's return is anticipated or not. In
either case, you still would enter the discharge date. When a resident is
discharged, the discharge date and the assessment reference date need to be
identical to one another, and that's a failed area. The record will be rejected
if that's not true. So, basically when the resident is discharged, you're
supposed to set the ARD date for that discharge date and answer the MDS with
reference to that discharge date. The discharge date can be later than the end
of the Medicare stay date if the resident is receiving services under SNF, Part
A, PPS. So, for example, Part A coverage could end. They could be there for a
few more days, or whatever, and then they could be discharged. Don't include
leaves of absence or if a resident is sent to the hospital for observation, but
not admitted. And the information for this can be obtained from medical
admissions or transfer records.
The discharge status -- and I believe these are unchanged from MDS 2.0 -- we've
got a number of options to indicate where the resident was discharged to: the
community; another nursing home or swing bed facility; acute hospital;
psychiatric hospital; inpatient rehabilitation facility; an MR/DD facility;
hospice; or they're deceased; or other.
Assessment reference dates, I think it was mentioned before that -- oh, well,
first of all, we have A2200 which is the previous assessment reference date
that's required for significant correction. This is required only on a
significant correction, and it's just to indicate what the assessment reference
date was of the assessment that you are -- you're correcting and then A2300 is
the assessment reference date. It's just comparable to the ARD date that is on
MDS 2.0 - designates the end of the look-back period. The look-back period
includes observations and events through midnight of the ARD, and anything that
happens after the ARD won't -- should not be -- won't be reflected on the MDS.
A2400 is the Medicare Stay items, and these are new items for MDS 3.0. They
identify when a resident is receiving services under SNF PPS, and they indicate
when a resident's Medicare Part A stay begins and ends. And the end date is used
to determine if the resident's stay qualifies for a short stay assessment. On
A2400A, you indicate whether the residents had a Medicare-covered stay since the
most recent entry. Okay, to go back to the definition of an entry, when they
came into the nursing home, however they came in, and what we're asking here is
whether they've had a stay since that date. So, if they had a Medicare stay,
they were discharged, came back in, but were not in a Medicare stay you wouldn't
answer this yes. It would only be if, in the current stay, they had some sort of
a Medicare coverage stay. And A2400 -- if A2400 is coded yes, then you indicate
the start and the end of the most recent Medicare stay. And the end date, if the
stay is on-going, then you fill those eight boxes with dashes to indicate that
the stay is on-going.
And here's a few guidelines for determining -- for filling out the end date. You
code whichever of these events occurs first: either the date the SNF benefits
were exhausted; the date of the last day covered, as recorded by the ABN - the
advanced beneficiary notice of...what's the other word? Yeah, okay. And then --
I forget that abbreviation -- and then or -- okay, we're talking of the earliest
of these dates, the date that the resident's payer source changes from Medicare
A to another payer; or the date that the resident was discharged from the
facility. So, you look at those four. If they apply, and we pick the earliest
one, and that would be the date you would put in the end date. If the resident
is returning from therapeutic leave of absence or hospital observation, that's a
continuation of the Medicare Part A Stay. This is all in keeping with the idea
that they haven't really been discharged. It's as if there's no interruption in
the stay under those two conditions, and as I said before, the end -- Medicare
end date -- stay end date can be earlier than the discharge date.
We've got a couple of scenarios here. I think there's three for us to talk
about. The first one: We have Mrs. G., and she began receiving services under
Medicare Part A on October 14th. She was in stable condition, able to manage her
medications and dressing changes and the facility determined that she no longer
qualified for Part A coverage -- SNF coverage -- and an ABN was issued with the
last day of coverage on November 23rd. And she was discharged from the facility
on November 24th. So, the question is, what would you put in for the start and
end dates? Well, first of all, you would say, yes. They had - well, you'd start
with the discharge date and code that as November 24th. That was the date she
was discharged. A2400A -- did they have a Medicare coverage day? Yes, she did.
And 2400B, what's the start date? That was the October 14th date. And what's the
end date? That would be the November 23rd, when the -- ABN date.
And, the second scenario: Mr. N. began receiving services under Medicare Part A
on December 11th. He was sent to the emergency room on December 19th at 8:30 and
was not admitted to the hospital; and he returned to the facility on December
20th, the following morning, and then - but less than 24 hours later. And the
facility completed his 14-day PPS assessment with an ARD of December 23rd. Okay,
so did he have a Part A stay? Yes, he did. It started on December 11th and even
though he went out, came back in without any discharge. So, he has an ongoing
stay. So, let's see if we got this right. Should be a yes, and then December 11,
and then ongoing. Yes, got that one right. Okay. Yeah, I do get one of these.
That's great.
So, we'll try number three now. Mr. R. began receiving services under Medicare
Part A on October 15th, and he was discharged return anticipated on October
20th. Yes, he had a Medicare stay and the stay started on the 15th and it ended
on the 20th. So, that one was a pretty straightforward one. So, that's it for
Section A.