The latest update to the Minimum Data Set addresses a major concern for providers facing state case-mid audits and medical reviews, which often demand additional or conflicting documentation.
But these updates by the Centers for Medicare and Medicaid Services (CMS) to the MDS 3.0 Resident Assessment Instrument (RAI) manual, which are due to be implemented on Oct. 1, have left other areas conspicuously absent, most notably a change in discharge definition, according to Joel Van Eaton, master teacher and EVP of PAC regulatory affairs and education at Broad River Rehab.
That said, Jessie McGill, senior curriculum development specialist at the American Association of Post-Acute Care Nursing (AAPACN) was still impressed with a lot of the updates made, and she said that AAPACN was working with CMS to convey a lot of the challenges operators had with different audits and medical reviews.
“CMS listened to our member feedback, and they made some changes that clarified some of the items that have been a major challenge for providers over the last couple of years,” said McGill. “One of the major changes, which was a huge celebration for the entire industry, is the clarification that states and other payers cannot supersede the RAI guidance.”
A lot of recent state case mix programs have required documentation above and beyond what the RAI requires. State programs were telling operators that their MDS coding wasn’t accurate enough, compared to what the state wanted.
“The added guidance clearly says that states do not have that authority,” said McGill. “They can’t change the guidance for all the items that are used for the federal [Omnibus Budget Reconciliation Act] OBRA assessments. That’s important because that data is used for quality measurements.”
The update is a boon for MDS coordinators that have found themselves at odds with states or auditing agencies, Van Eaton said, especially those that have developed coding directives that go beyond or contradict the RAI manual.
“This is most prolific where the state has developed coding guidance in addition to the RAI manual,” said Van Eaton. “Failure to pass these audits often has negative financial implications for the facility. This guidance will also become more impactful in situations where managed care organizations require aberrant coding requirements.”
MDS assessments will be required to be submitted to CMS for these payers starting in 2029, he said.
And if one state is coding differently than others, that skews national data, McGill added.
Moving forward, states can have requirements that go above and beyond the MDS, but they have to be implemented on the back end, with billing edits. States can’t ask a nursing home to modify the MDS, with clinicians signing off on accuracy, and that accuracy is based on RAI guidance.
Operators and associations like AAPACN, are “anxiously awaiting” state and contractor response to the clarification.
“When [providers] have a case mix auditor or a medical review saying that they want additional documentation, the provider now has a statement in the manual that says no, I have to follow this guidance and nothing else,” said McGill.
For Van Eaton, the “elephant in the room” remains a lack of clarification following CMS’ change to the OBRA discharge definition.
CMS’s proposal in May requires admission and discharge assessments for all residents, rather than only traditional Medicare Part A stays, and would force facilities to evaluate every resident to determine whether they meet the criteria for skilled care.
And in a separate “mock-up” document, CMS is proposing to add two new assessment types under the PPS assessment names: the “Other Skilled Care Admission Assessment” and the “Other Skilled Care Discharge Assessment.”
“This will be an ongoing conversation to be sure,” said Van Eaton. “In my opinion, there remains contradictory guidance in the RAI manual related to this issue … that CMS will need to revise for consistency with the recently released guidance.”
Changes in respiratory therapy, PHQ-9
In addition to the guidance on state requirements versus RAI updates, McGill said nursing homes should pay attention to changes to respiratory therapy coding.
If nursing homes provides at least 15 minutes of therapy per day for seven days in a row, it needs to be skilled therapy, or a service that requires the skill and knowledge of a nurse or respiratory therapist in order to administer the treatment.
“I believe the manual has changed this because of a trend in capturing more and more respiratory therapy, and providers trying to establish programs within their facility for spirometry and other respiratory therapy,” said McGill.
This change could reduce the number of residents who are captured on respiratory therapy and decrease the reimbursement for Medicaid case mix states and Medicare, with the prophylactic treatment missing of those with chronic or long-term respiratory conditions.
Another MDS update that affects reimbursement involves the PHQ-9, a questionnaire which screens for depression. Medical reviews were known to question depression coding from the questionnaire of the resident didn’t have a diagnosis of depression or any depression treatment, because the PHQ-9 only dealt with the signs and symptoms of depression.
CMS added signs and symptoms of depression in chapter six of the MDS to remove any confusion or misconceptions, McGill said.
“Even though it was just a misunderstanding of the reviewers, CMS added that clarification. That should help future reviewers so that providers don’t have to spend their time appealing these types of medical reviews just because the language didn’t exactly match,” said McGill.
Preparing for MDS and RAI changes
Revised guidance in depression screenings, respiratory therapy and other areas have implications related to care planning, added Van Eaton.
“We are now in an ‘audit crazy’ environment and coding accuracy is paramount. The recently released [Program for Evaluating Payment Patterns Electronic Report] PEPPER reports are certainly a reminder that CMS is looking at these things,” said Van Eaton.
As operators take in these updates, McGill suggests they focus on underlying documentation for any of the items that have changed and sharpen clinical practices for assessing respiratory therapy and shortness of breath to support how the MAC applies the new rules and codes MDS accurately.
Van Eaton suggested staff prepare by reviewing revisions together as an interdisciplinary team, and that it’s not just the purview of the MDS coordinator. Teams need to have a good understanding across the board, so coding is in line with revisions come Oct. 1.
“CMS didn’t give us a significant amount of time to prepare but we must be ready nonetheless,” said Van Eaton. “Thankfully there were no revisions to the data set this year so at least we don’t have that in addition to the coding revisions and clarifications.”
Companies featured in this article:
AAPACN, Broad River Rehab, Centers for Medicare & Medicaid Services, CMS
