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Join the Nursing Facility Forum call for important HIPAA reminders, MDS 3.0 questions and answers, snippet training on quality indicators, and upcoming training announcements.
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Nursing FacilityForum Call Case Mix Team / Office of MaineCare Services November 2, 2017
Nursing Facility Forum Call 11/2/17 Welcome to the 4th Quarter Nursing Facility Forum call Department of Health and Human Services
Nursing Facility Forum Call 5/5/16 Nursing Facility Forum Call 11/2/17 Agenda • Welcome • HIPAA Reminders • Review of MDS 3.0 Questions and Answers • Snippet Training: Quality Indicators • Announcements • Upcoming Training • Questions Department of Health and Human Services
Nursing Facility Forum Call 5/5/16 Nursing Facility Forum Call 11/2/17 Department of Health and Human Services
Nursing Facility Forum Call 11/2/17 HIPAA Reminder: When sending email, please do not include any identifying information. This table developed by the Federal Department of Health and Human Services gives definitions of 18 examples of identifying information. Department of Health and Human Services
Nursing Facility Forum Call 11/2/17 If you need to send a portion of an MDS record: • Fax is preferred over email • If you must email, paste the document into an word document and apply a password. Do NOT send the password in the same email as the attached MDS document, OR Department of Health and Human Services
Nursing Facility Forum Call 11/2/17 • Black out all identifying information, such as name, social security number, DOB, etc. It is acceptable to refer to a resident as #1, #2, according to a list of residents left during a case mix review. • If you mail information, please label as confidential and identify the person to whom it is being sent. Department of Health and Human Services
Nursing Facility Forum Call 11/2/17 For more information: http://www.hhs.gov/ocr/privacy/hipaa/understanding/coveredentities/De-identification/guidance.html Department of Health and Human Services
Nursing Facility Forum Call 11/2/17 Questions, Questions, Questions … and Answers Department of Health and Human Services
Nursing Facility Forum Call 11/2/17 https://downloads.cms.gov/files/MDS-RAI-Users-Manual-Provider-Updates.pdf Department of Health and Human Services
Nursing Facility Forum Call 11/2/17 Section N I am looking for some clarification regarding the question on antipsychotic gradual dose reduction (GDR); if a resident was receiving an antipsychotic medication and then it was discontinued completely, does this count as a GDR? That is, if the medication was simply taken away, instead of a stepwise reduction? Department of Health and Human Services
Nursing Facility Forum Call 11/2/17 Here is the definition of GDR from the advanced copy of Appendix PP. I do not believe this definition has changed in any of the revisions. "Gradual Dose Reduction (GDR)" is the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose of medication can be discontinued.” Federal requirements regarding GDRs are found at 42 CFR §483.45(d) Unnecessary drugs and 483.45(e) Psychotropic drugs. Department of Health and Human Services
Nursing Facility Forum Call 8/3/17 Section N I’m looking for clarification regarding the coding of opioid administration related to transdermal administration, specifically for coding of a Fentanyl patch. Would we count only the days a new patch is placed (typically every three days), or since the medication is continuously administering, would we count all days on which the patch is in place? Department of Health and Human Services
Nursing Facility Forum Call 11/2/17 In the October 1, 2017 version of the RAI User’s Manual, page N-7, under Coding Tips and Special Populations,” the fourth bullet point addresses the coding of long-acting medications on the MDS. A Fentanyl patch is a transdermal system designed to release medication over a period of time (typically three days), therefore it would be considered a long-acting medication for the purpose of coding the MDS. Department of Health and Human Services
Nursing Facility Forum Call 11/2/17 The instructions on page N-7 direct the user to count long acting medications only if they are given during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). In the case of transdermal systems that are applied every few days, you would count the number of days the application of the patch occurred, not the number of days the patch is in place. Department of Health and Human Services
Nursing Facility Forum Call 11/2/17 For example, during the 7-day look-back period a transdermal patch is applied on days 1, 4 and 7, N0410H (Opioid/0 would be coded 3, since the application occurred three days during the look-back period. This is the most recent guidance from CMS as of 10/16/17. This may change as further reviews are completed. Department of Health and Human Services
Nursing Facility Forum Call 11/2/17 Section N If an antipsychotic was discontinued and then a short time later restarted with physician note as clinically contraindicated with rationale documented within the look-back period, do we code “yes” to GDR and “yes” to being contraindicated? Department of Health and Human Services
Nursing Facility Forum Call 11/2/17 Department of Health and Human Services
Nursing Facility Forum Call 11/2/17 You would code both the GDR date at N0450B AND code N0450D as “yes,” the physician documented as clinically contraindicated, including the date of documentation at N0450E. There is not a skip pattern (to skip N0450D) if you answer “yes,” a GDR has been attempted at N0450B. While you will skip the GDR date if not attempted, you will still code N0450D if the physician documented clinically contraindicated, regardless of whether or not the GRD was attempted. Department of Health and Human Services
Nursing Facility Forum Call 11/2/17 Section O I am confused about how to code section O if pneumonia vaccine is “up to date.” If the resident only had a Pneumovax-23 vaccine and not the Prevnar-13 and resident is over 65, would it be considered up to date, or do they have to have both pneumococcal vaccines to be considered up to date as long as they are administered one year apart? Department of Health and Human Services
Nursing Facility Forum Call 11/2/17 Page O-13 tells us that "Up to date" in item O0300A means in accordance with current Advisory Committee on Immunization Practices (ACIP) recommendations. I have provided some information and links below: ACIP Pneumococcal Vaccine Recommendations | CDCThe ACIP pages lists "Current Pneumococcal Vaccine Recommendations." Be sure you are looking at the right recommendations for each resident, as the recommendation differ if older than 65, younger than 65, and other criteria. Department of Health and Human Services
Nursing Facility Forum Call 11/2/17 Intervals Between PCV13 and PPS23 Vaccines: Recommendations of the Advisory Committee on Immunization Practices: What is currently recommended? The Advisory Committee on Immunization Practices (ACIP) currently recommends that both 13-valent pneumococcal conjugate vaccine (PCV13) and 23-valent pneumococcal polysaccharide vaccine (PPSV23) be given to all immunocompetent adults aged ≥65 years. ACIP recommends that PCV13 be given first followed by PPSV23 6–12 months later. ACIP also recommends that adults aged ≥65 years who already received a dose of PPSV23, should also receive a dose of PCV13 ≥1 year after the dose of PPSV23. Department of Health and Human Services
Nursing Facility Forum Call 11/2/17 For immunocompetent adults who previously received PPSV23 when aged <65 years and for whom an additional dose of PPSV23 is indicated when aged ≥65 years, this subsequent PPSV23 dose should be given ≥1 year after PCV13 and ≥5 years after the most recent dose of PPSV23. For adults aged ≥65 years with immunocompromising conditions, functional or anatomic asplenia, cerebrospinal fluid leaks, or cochlear implants, the recommended interval between PCV13 followed by PPSV23 is ≥8 weeks. (underlined section was updated in an erratum) Department of Health and Human Services
Nursing Facility Forum Call 11/2/17 Why are the recommendations being modified now? To simplify the recommendations for PCV13 and PPSV23 use among immunocompetent adults aged ≥65 years, ACIP recommended harmonization of recommended intervals between PCV13 and PPSV23 regardless of the order in which the two vaccines are given. Department of Health and Human Services
Nursing Facility Forum Call 11/2/17 What are the new recommendations? ACIP recommends that both PCV13 and PPSV23 be given in series to adults aged ≥65 years. A dose of PCV13 should be given first followed by a dose of PPSV23 at least 1 year later to immunocompetent adults aged ≥65 years. The two vaccines should not be co-administered. If a dose of PPSV23 is inadvertently given earlier than the recommended interval, the dose need not be repeated. Department of Health and Human Services
Nursing Facility Forum Call 11/2/17 Resident Interviews Is a resident interview able to be used for two separate MDSs? The RAI manual has one reference in Ch. 2, pg. 2-59: When coding a standalone Change of Therapy (COT), a standalone End of Therapy (EOT), or a standalone Start of Therapy (SOT), the interview items may be coded using the responses provided by the resident on a previous assessment only if the DATE of the interview responses from the previous assessment (as documented in item Z0400) were obtained no more than 14 days prior to the DATE of completion for the interview items on the unscheduled assessment (as documented in item Z0400) for which those responses will be used Department of Health and Human Services
Nursing Facility Forum Call 11/2/17 The manual references unscheduled standalone COT, EOT and SOT utilizing prior interviews completed (at Z0400) within 14 days of the Z0400 date of the current assessment. There is no other reference that would allow utilizing prior interviews for any other type of assessment. Department of Health and Human Services
Nursing Facility Forum Call 11/2/17 Resident Interviews Where the manual specifically references OMRAs and being able to use an interview coded on a previous MDS, what about reusing an interview for a different item set? For example (OBRA): Med A patient had 14 day on 2/22. • Pain, BIMS, and PHQ9 interviews done on 2/22 • Signed onto hospice on 2/23 • Sig Change ARD is set for 2/23 Department of Health and Human Services
Nursing Facility Forum Call 11/2/17 It’s not clear, but the 14-day assessment might have been able to be completed, using grace days, on 2/23 to combine the 14-day and a significant change. There is no allowance for utilizing interviews completed with prior scheduled PPS or OBRA assessments other than SOT, COT, and EOT, as described above. Department of Health and Human Services
Nursing Facility Forum Call 11/2/17 Resident Interviews A Medicare/PPS Example: • Med A patient had a COT on day 56. • Interviews were all completed on day 56 • The 60 day is scheduled for day 57 Department of Health and Human Services
Nursing Facility Forum Call 11/2/17 These two assessment could have been combined. RAI Manual, page 2-65: When the OBRA and Medicare assessment time frames coincide, one assessment may be used to satisfy both requirements. PPS and OBRA assessments may be combined when the ARD windows overlap allowing for a common assessment reference date. When combining the OBRA and Medicare assessments, the most stringent requirements for ARD, item set, and CAA completion requirements must be met. Department of Health and Human Services
Nursing Facility Forum Call 11/2/17 Section N It’s my understanding that the GDR questions concern psychoACTIVE medications. When I re-read N0450, it asks if the resident received any ANTIPSYCHOTIC meds. Above, in N0410 A-D, psychoactives are broken down & antipsychotics are just one sub-group. If a resident receives an antidepressant, I code that under N0410-C. Am I also coding it under N0450 -- the antipsychotic review -- as an "antipsychotic"?? Department of Health and Human Services
Nursing Facility Forum Call 11/2/17 Item N0450 is specific to GDR of "antipsychotics", so, as with N0410, you should go by the "pharmacological classification" of the medication, not how it is being used. An antipsychotic being used to treat depression would still place the resident at risk for the "adverse outcomes that can affect health, safely, and quality of life." (Manual, page N-11 through N-13. Department of Health and Human Services
Nursing Facility Forum Call 11/2/17 Must residents who have Medicare as a payer comply with the 100-day rule? We are getting authorizations from UHC to approve the patient for past what we thought was 100 days. Not really an MDS question. You could talk with the MAC for Maine, National Government Services, Inc. https://www.cms.gov/Medicare/Medicare-Contracting/Medicare-Administrative-Contractors/Who-are-the-MACs.html Department of Health and Human Services
Nursing Facility Forum Call 11/2/17 Department of Health and Human Services
Nursing Facility Forum Call 11/2/17 Section N Is Tramadol considered an opioid under section N? According to the website http://www.druglib.com/drugindex/category/, Tramadol (Ultram) is classified as an Opioid Analgesic. This link came from the RAI Manual, page N-11. I have also heard some conflicting reports of categorization of this drug. Department of Health and Human Services
Nursing Facility Forum Call 11/2/17 Section N Do we need to have a resident’s POA/ next of kin sign a consent form for use of Psychoactive medications that are needed for end of life care? Department of Health and Human Services
Nursing Facility Forum Call 11/2/17 Section N Do we need to have a resident’s POA or next of kin sign a consent form for use of Psychoactive medications that are needed for end of life care? Department of Health and Human Services
Nursing Facility Forum Call 11/2/17 There are no specific regulations around having a POA/NOK sign a consent form. There is language that the resident and family must be informed of the treatment, side effects, etc. It then becomes up to your facility policy as to how you are meeting those requirements. There is a 6-page document briefly outlining references in Appendix PP and State Licensing rules around restraints, unnecessary medications, resident rights/informed consent, and hospice ( under files to download, below). I thought those topics would adequately address your questions. There is a link to Appendix PP in the notes, if you have additional questions. Appendix PP is 739 pages! Department of Health and Human Services
Nursing Facility Forum Call 11/2/17 Section O Can we code a virtual physician assessment through a machine that connects to the patient reads vital signs and the physician can see and can communicate with staff and the patient… Can we call this a visit?? The doctor is not in the building.... but is at bedside through this machine called Triple care. This is a new service we added recently in our facility. Department of Health and Human Services
Nursing Facility Forum Call 11/2/17 RAI Manual, page O-44: Coding Tips and Special Populations • Includes medical doctors, doctors of osteopathy, podiatrists, dentists, and authorized physician assistants, nurse practitioners, or clinical nurse specialists working in collaboration with the physician as allowable by state law. • Examination (partial or full) can occur in the facility or in the physician’s office. Included in this item are telehealth visits as long as the requirements are met for physician/practitioner type as defined above and whether it qualifies as a telehealth billable visit. For eligibility requirements and additional information about Medicare telehealth services refer to: — Chapter 15 of the Medicare Benefit Policy Manual (Pub. 100-2) and Chapter 12 of the Medicare Claims Processing Manual (Pub. 100-4) may be accessed at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-OnlyManuals-IOMs.html . Department of Health and Human Services
Nursing Facility Forum Call 11/2/17 Section O CMS does not require questions O0600 and O0700, but it may be required by individual states. Does Maine require these? Department of Health and Human Services
Nursing Facility Forum Call 11/2/17 Maine will continue to require O0600 and O0700 as they may be payment items for clinically complex RUG groups. If you leave this item blank, that would be an invalid value and CMS would reject the assessment. If enter a dash, as recommended by CMS, it would be a valid value but would count as a zero (0) and would not contribute towards clinically complex RUG scoring. Check your final validation report to confirm it was submitted the way you wanted it to be filled out. Department of Health and Human Services
Nursing Facility Forum Call 11/2/17 Section O What is the requirement with regards to restorative programs and nursing oversight. Specifically, I would like clarification of the frequency of a nurse’s note for a restorative plan and what are the requirements for our MDS Coordinator with regards to notes. Department of Health and Human Services
Nursing Facility Forum Call 11/2/17 Documentation requirements Quarterly care review Periodic evaluation All plans must be overseen by nurse, not therapist. Department of Health and Human Services
Nursing Facility Forum Call 11/2/17 Section N What is the look back period for the new items in section N? For example, "Has a gradual dose reduction (GDR) been attempted?" Does the GDR have to be in the look back period or "since admission/entry or reentry or the prior OBRA assessment, whichever is more recent?" Department of Health and Human Services
Nursing Facility Forum Call 11/2/17 Department of Health and Human Services
Nursing Facility Forum Call 11/2/17 Department of Health and Human Services
Nursing Facility Forum Call 11/2/17 Department of Health and Human Services
Nursing Facility Forum Call 11/2/17 Department of Health and Human Services
