Significant Changes to High-Risk Drugs’ Coding in MDS Will Require Training at Nursing Homes

The Centers for Medicare & Medicaid Services (CMS) has introduced significant changes regarding medication coding related to certain high-risk drugs that will go into effect on Oct. 1 with the updates to the Minimum Data Set.

These changes to MDS are focusing on specific medications, including antipsychotics, anti-anxiety medications, antidepressants, hypnotics, anticoagulant antibiotics and opioids. And, the new modifications will require training of nurses and a shift in methods used to record, for example, indications of use for these medications, according to experts and nurses affiliated with nursing homes. Some clinical staff even recommend templates for verifying the medication order details to avoid scrutiny by surveyors.

CMS will now require evidence in the records, emphasizing the importance of understanding the indication — the diagnosis or symptom the medication is treating. The implications of these changes extend to various assessments like the Behavioral Intervention Minimum Data Set (BIM) and Patient Health Questionnaire (PHQ) interviews, which will now be structured differently, necessitating proper education for conducting these interviews effectively.

Previously, coding involved counting the number of days residents received medication based on logical classifications. However, now the process requires ensuring clear indications for medication administration.

“Sometimes the resident may have been on that particular medication for quite a long time, and that may have gotten lost in the shuffle from one provider to another, but it’s very important to dig in now,” Wendy Strain, Director of Consulting Services at Polaris Group told Skilled Nursing News. “One of the first things we recommend our outsource MDS Coordinators do now and not wait until the last minute is for those because we’re investing in communication with the provider.”

Implications and preparations for the updated CMS guidelines

The updated CMS guidelines include an extensive amount of new information within the Resident Assessment Instrument (RAI) manual. Although the final version remains pending, the draft version already presents numerous shifts in approaches. Strain said these changes demand thorough training for staff members, enabling them to approach medication management with a fresh perspective, and that new processes must be implemented to align with the updated requirements.

Strain said that to ensure smooth compliance with the new CMS coding and documentation requirements, preparation and proactive actions are vital. She recommended that rather than scrambling at the last minute, facilities should begin audits and verification of indications for medications well ahead of time.

“There’s no reason we can’t audit, or do an audit on all of those medications and ensure that the indications are already evident in the documentation in the physician’s orders so that we can get a head start on that,” she said.

Instead of recording the number of days, caregivers simply check a positive or negative box to indicate whether the resident received the medication during the seven-day look-back period.

Amy Stewart, VP of education and certification strategy for the American Association of Post-Acute Care Nursing (AAPACN), told Skilled Nursing News that the major modification lies in the requirement to check for indications noted for all medications within that classification during the seven-day period with consistency.

“You’re going to want to ensure that you have that indication for use during the look-back period,” she said. “You want to be consistently saying ‘yes’  we have an indication for [the resident]. If you don’t have an indication for use in the medical record, now it’s going to be on the MDS. So it’s going to be clear to the surveyor. You’re going to be questioned, most likely, well, why don’t you have an indication for use? And what are you doing to get one?”

These changes, while impacting the coding process, do not affect other elements of the MDS, she said.

Adherence to new requirements and ensuring accurate documentation

Quality measures related to medications, such as antipsychotic and anti-anxiety drugs, are still triggered based on whether or not the resident received the medication, and this remains unchanged with the checkbox system. However, the major modification lies in the requirement to check for indications noted for all medications within that classification during the seven-day period.

“There’s no kind of overflowing impact on quality measures with the changes to Section N. But the major change was that we have to check if there’s an indication noted for all medications within that classification that the resident received during the seven-day look-back period,” Jessie McGill, RN and curriculum development specialist at AAPACN told Skilled Nursing News.

McGill said that while many facilities may already have processes in place for this, it is crucial for MDS nurses to carefully evaluate and verify indications. Caregivers should not blindly accept any indication connected to a medication if it lacks logical sense or lacks direct physician documentation, especially if it involves off-label usage.

This thorough investigation ensures appropriate and accurate documentation for all medications administered to residents, leading to improved quality of care and regulatory compliance.

“We want to make sure that we’re not just signing saying yes, they have an indication based on documentation that may not make sense but investigating that further to make sure we do have appropriate documentation and an appropriate indication for all medications that the resident receives,” she said.

McGill said that for facilities with a weaker system in place, it is advisable to start with the basics and introduce a template that nurses can use for new medication orders. This template should include checkboxes for verifying the order details, such as medication, dosage, route, frequency, and indication of use.

Additionally, she recommends offering training to nurses on how to appropriately query the physician to obtain the indication of use if it was not initially provided with the order. Ensuring this information is documented and accessible will enhance the accuracy and compliance of medication coding.

“I would say, when looking at your process for nurses receiving new orders, follow up with the physician right away if the indication of use was not received with the order,” she said. “Also, provide education to the nurses that, despite their clinical judgment, it is essential to obtain documentation from the physician regarding the purpose of medication administration.”