Energize your MDS: Database
Accuracy and Analytical
Reports
PRESENTED BY
Leah Klusch, RN, BSN, FACHCA
Executive Director
The Alliance Training Center
Alliance, Ohio
330-821-7616
leahklusch@sbcglobal.net
Rules and Risk
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Every time the rules change the industry must respond
with careful action.
The entire assessment process has changed and this
impacts the documentation and the data base for every
facility in the country.
Some regulators have said this is just a minor change –
they are very wrong - either they do not understand the
scope of the process or they do not understand facility
operations.
THE CHANGE TO THE MDS 3.0 IS A BIG CHANGE !
New Data Base – New Timing
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All of the changes are going to impact the regulatory process
and the format of surveys in the future.
O
The data base that the surveyors and intermediaries are
using now is very rich and the was created to serve the
process both regulatory and payment.
O
Facilities must understand the data base and use
considerable operational energy to monitor their data as it
will continue to define the provider and create the payment
for Part A Medicare and Medicaid in many states.
New Data Base – New Timing
O
The timing of the assessment tasks, transmission and billing
for services are now more connected than ever before.
O
The big factor is the assessments and bills for Part A
Medicare services are going into the same server.
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Timelines for assessments and transmission have changed
and are more aggressive.
O
More assessments will be done in most facilities and more
data will be included in the facility data base in the federal
server.
FACT
CAREFUL OBSERVATIONS OF MDS
NURSES HAVE SHOWN THAT IT
TAKES AT LEAST 35% MORE TIME TO
COMPLETE THE MDS 3.0 –
CONTRARY TO THE STATEMENTS
FROM CMS IN THE SPRING OF 2010.
RULES ? What Rules?
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Two issues related to the rules and the regulatory process.
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Medicare plans to police the rules more carefully by using more
data analytics in their server to screen assessments and bills.
O
The rules for coverage of services are being addressed more
frequently in RAC Audits and other oversight activity.
O
Do you have a copy of the Medicare Benefit Policy Manual?
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Do you know what this reference is and who needs to read it?
RULES ? What Rules?
None of the regulatory tags have
changed but the type and intensity
of data flow has increased from the
2.0to the 3.0 process
However….The rules for data
collection – the timelines for data
collection, the definitions within the
manual, the types of assessments
and the requirements for doing and
transmitting the assessments are
very different , more detailed and
frequently require more staff time.
Regulatory Oversight
O
Regulatory oversight of the assessment process
and evaluation of compliance with the new data
collection processes and policies will be much
easier.
O
CMS will continue to roll out the QIS Survey process
throughout the country – which relies on the data
base to highlight issues with negative outcomes
and negative patterns of care. ( You may try to run
but you can not hide )
Ask yourself these questions…
Who is responsible for the data flow in our facility into the
assessment process and then into the federal data base?
Is the training and preparation of our team adequate ?
Where are the manuals ? Are they updated?
If our data base is wrong……..what is the risk?
Do our managers understand the importance of the assessment
process and its details ?
How about hardware and software?
New Style on Data
O Many of the data items on the MDS 3,0 data base are
outcome oriented and have more specific definitions
related to outcomes or specific scoring that shows
positive and negative outcomes over time.
O Now we are reporting interviews regularly related to
cognitive function, signs of depression and the resident’s
perception of pain.
O Two of these interviews create a numeric scores which
will be compared from assessment to assessment.
O The facility should be able to track the impact of the care
plan interventions in the data base over time.
REGULATORY STRATEGIES
O Know the rules – The regulatory TAGs and the structure
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and process of the assessment.
This will require resources – time and direction from
operations.
The MDS is not a nursing tool- It is a regulated
interdisciplinary functional assessment.
Have open discussions with all team members.
Clinical and operational leadership are essential.
Stay informed about the QIS implementation in your state
– or 3.0 data base use with the traditional survey.
The Focus on Outcomes
O Much of the data has implications for outcome reporting
or directly reports outcomes each time an assessment is
done.
O The MDS 3.0 has more measurements, comparisons and
data flow between assessments.
O The MDS 3.0 builds a more comprehensive data base at
the point of the admission and then points to the changes
with self reporting or specific reporting of changes from
assessment to assessment.
O The facility needs to monitor outcomes reported into the
data base…..so you need to know your data.
The Focus on Outcomes
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Outcomes can be measured in two ways in the new data
base.
O
Stated outcomes on the assessment - is the resident or
the issue the same – better or worse items.
O
Comparison of data from one assessment to the next –
BIMS score from one assessment to the next etc.
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Item scoring that shows outcomes – continence tracking
, skin issues, or behavior coding by indicating the
frequency of occurrences.
Look at the proposed QI/QMs
O The theme is still outcomes.
O Now we have more data that more clearly defines
the progress of the resident.
O Customer satisfaction issues with the new data base
that will need to be defined.
O Monitor the progress of the resident in Rehab and or
skilled nursing programs.
O Definition of long and short stay populations.
Assessment Types and
Schedules
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Most managers do not understand the large changes in
this area.
O
Many more assessments are being done and if they are
not on time compliance and payment issues occur.
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It is important to monitor the number and types of
assessments being done weekly as well as validation
activity.
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Delayed assessments could be default rate or no
payment.
Question
Every time a resident
goes to the hospital and
is admitted and then
discharged back to the
facility……. How many
pages of assessments
are required to be
transmitted and
validated?
DOES THIS CHANGE IN
ASSESSMENT PROCESS
HAVE A LARGE IMPACT
ON THE EFFICIENCY
AND WORK LOAD OF
YOUR ASSESSMENT
TEAM? WHO MANAGES
THIS ACTIVITY ?
Be Aware..
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Be aware that this is a very complicated process.
IF YOU DO NOT BELIEVE THIS TRY TO READ CHAPTER 2
OF THE MDS MANUAL.
Some of the processes still need to be clarified by CMS
- the new system is complicated and very task intensive.
Scheduling is very important and must be
communicated to the entire IDT and then the staff so
everyone is focused on data collection and accuracy.
Problems with completion and transmission of
assessments will produce problems with payment.
MDS OFFICE EFFICIENCY
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Training needs to be on going and very complete.
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Competency is essential – Training with testing is
very important.
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Evaluate the location, supplies and software issues.
Monitor training quality from software vendors – sit
in on training and look for clear directions and
supporting written tools.
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Evaluate employee satisfaction - discuss the
problems – LISTEN TO THE STAFF.
ISSUES THAT IMPACT
PAYMENT
O The entire team needs to understand the payment
process changes from RUG III to RUG IV.
O RUG distribution is important - identifies the resident and
service types in the facility . The team must know the
MDS items that qualify cases for payment – Rehab and
Nursing.
O Payment levels per day for RUG groupings need to be
discussed by the IDT and at U.R. Meetings.
O Many teams do not utilize a variety of payment groupings
on Part A Medicare cases. RUG IV is not all about Rehab
only - Believe me!
Monitor Coverage Decisions
O Monitor coverage decisions – Remember the quote in the RAI
Manual Chapter 3, Section O page 14……..The physician, the
qualified therapist and nursing administration have the
responsibility to determine the quantity, duration and intensity
of therapy services.
O We now have a more flexible payment categories and payment
levels that more accurately cover skilled services.
O Accuracy of MDS and Universal Bills – result – no payment if
mismatched data
O Simple errors can stop payment of Part A Claims….quote from
RAI Manual chapter 6 p. 6-6.
Remember
O Remember all payment for Part A Medicare is the
responsibility of the facility – You must monitor your
contractors . Know the services they are delivering and
reporting through the MDS data base.
O Monitor all Medicare payments - follow up with any
delayed or denied payments or requests for information.
O Check that billing is using the correct billing manuals
and processes.
O ADL scores accuracy and influence on overall payment
levels – Biggest issue related to payment in most
facilities.
THEN WE HAVE ADL
SCORES!
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If you are tired of this discussion – Get over it.
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Fact – Every MDS data set creates an ADL score – which
is recorded in the data base and utilized to evaluate the
case, stay and payment.
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ADL tracking during the assessment reference period is
required and must be accurate –I am sure you have
heard this before…….
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It is true and must be addressed by operations because
of the risk to the facility from wrong scores.
SO WHAT HAS CHANGED ?
O The focus on ADL scores as a primary indicator of
functional decline is very strong..
O That means:
O What is the ADL score on admission for a Rehab case – It
must show functional loss.
O How does the ADL score change during the Part A stay with
Rehab services.
O Does the ADL score match the other functional performance
codes in the data set.
O Are ADL score values documented and discussed as part of
the Utilization Review Process.
There is more to the changes….
O ADL calculations have been changed and the value of
some self performance codes has been lowered in the
calculation .
O This means that self performance scores with a Limited
Assist code add less point value to the total ADL score
under RUG IV than RUG III.
O The ADL levels that change payment rates within the
RUG categories are now different and the IDT must
monitor functional changes so that the reported ADL
values are accurate.
2.0 to 3.0 ADL Score Calculation
MDS 2.0 ADL Calculation
MDS 3.0 ADL Calculation
Bed Mobility
2
2
ADL Pts 3
Bed Mobility 2
2
ADL Pts 1
Transfer
2
2
ADL Pts 3
Transfer
2
2
ADL Pts 1
Eating
1
1
ADL Pts 1
Eating
1
1
ADL Pts 0
Toilet Use
2
2
ADL Pts 3
Toilet Use
2
2
ADL Pts 1
Total ADL Score = 10!
Total ADL Score = 3!
2.0 to 3.0 ADL Score Calculation
MDS 2.0 ADL Calculation
MDS 3.0 ADL Calculation
Bed Mobility
3
2
ADL Pts 4
Bed Mobility 3
2
ADL Pts 2
Transfer
3
2
ADL Pts 4
Transfer
3
2
ADL Pts 2
Eating
1
2
ADL Pts 1
Eating
1
2
ADL Pts 2
Toilet Use
3
2
ADL Pts 4
Toilet Use
3
2
ADL Pts 2
Total ADL Score = 13!
Total ADL Score = 8!
2.0 to 3.0 ADL Score Calculation
MDS 2.0 ADL Calculation
MDS 3.0 ADL Calculation
Bed
Mobility
3
3
ADL Pts 5
Bed
Mobility
3
3
ADL Pts 4
Transfer
3
3
ADL Pts 5
Transfer
3
3
ADL Pts 4
Eating
1
1
ADL Pts 1
Eating
1
1
ADL Pts 0
Toilet Use
3
2
ADL Pts 4
Toilet Use
3
2
ADL Pts 2
Total ADL Score = 15!
Total ADL Score = 10!
Some ADL Rules That Work
O On admission to Skilled Rehab the elder must exhibit
functional decline – An ADL score of 10 or more on
the admission assessment is very safe for most
situations.
O ADL coding must be scored from 24 hours of staff
documentation during the assessment reference
period – usually 7 days.
O ADL documentation from the front line staff must
become part of the medical record to substantiate
the ADL score in the MDS data base.
ADLs
O As the elder progresses in the Rehab program
changes in the ADL score should be correlated with
the gains in strength and skill.
O ADL scores should be reported and discussed at
Utilization Review Meetings.
O Staff learn about ADL definitions and coding formats
in orientation programs at the time of hire.
O IDT members need to know the impact of ADL scores
on payment groupings and the $ value of payment
levels.
Changes in Payment
O Importance of RUG distribution reports with ADL
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scores.
Report of RUG and ADL for an individual case
Report of all Medicare Part A cases for the entire
facility
Report of RUG distribution for the total census of the
facility.
Track RUGs by the week, month and quarter looking
for trends and outcome documentation.
Be careful to……..
O Do Mood interview according to the steps in the RAI
manual so the scores are relative and valid – MSS of
10 or over will have positive impact on Nursing RUGs
payment.
O Only code infections if they qualify in the 2007 CDC
Guidelines – Manual page 0-4 for reference.
O Monitor ADL scores during the assessment reference
period - Low scores on 5 and 14 day assessments
could be a problem.
Make Certain..
O Make certain that the team doing admissions
understand the new qualifiers into the nursing RUGs
– this is a very rich area for coverage and services for
a broad population.
O Track each Part A admission and be sure that the
team understands about the possibility of doing
more than one RUG during the stay.
O Look for weight bearing assist for tracking ADL
activity. Focus on evening and night shift
documentation.
Audit Rehab Services
O Audit rehab services between assessment reference
periods to document consistent delivery – if rehab
services or intensity of services change then the plan
and the Dr.s order needs to change as well.
O Follow the Rehab documentation rules in the MDS
manual – Chapter 3, Section O, page 15 to 30.
O Check that billing is using the same data for the
Universal Bill as the MDS has documented –
problem area – focus on Dx. Dates and services.
Training – Live & Online
O Continue to provide training to your MDS office staff
and members of the IDT.
O Live training is very helpful but check out the session
before you attend to confirm that the material has
updated accurate information.
O On line training is very practical and flexible for
facility staff – suggest Redilearning.com as a
resource.
Questions?
Thank You!
For more information on
Leah’s online MDS 3.0
program, go to:
redilearning.com
http://redilearning.com/skill
ed-nursing-mds-30.asp