»» Hopefully everyone got lunch? Yes.
»» Okay. Great. So we’re going to cover some dense material. A lot of this material,
some of it will be just repetitive to things that we’ve known and that we’ve trained on
back, all the way to 2010. But it’s important as we go through some of the item set issues
is, because it all feeds into the quality reporting and we want to make sure and levelset
and make sure that everyone knows what we’re talking about. So within my presentation,
we have a couple of activities. So at different points we’re taking a break, not physically
with you guys leaving the room, but I’ll stop the slide deck and give you all an opportunity
to work at your table and do some table activities. We’ve been doing trainings both we’ve done the LTCH training,
the inpatient rehab facility training, and now the skilled nursing. And what we have
found is some of these activities, having the opportunity to sit and discuss and debate
at your tables have been great learning experiences. And that’s the feedback that we’ve gotten.
So hopefully you will enjoy that. We have our objectives that we will define the following
associated with quality measures. By the time you are finished here you should be able to
understand the numerator, the denominators, a complete stay, what’s an incomplete stay,
what are the QM calculation algorithms and some of the risk adjustments which are very
helpful. We will also be able to describe the intent of Section M, explain the rationale
for the look-back periods and correct codings for sections, not the whole Section M, but
M0300 and M0800, and discuss how to code some of the associated items that are involved
in the risk adjustment to this item. So we’ll be looking at G0110A1, H0400, I0900 and I2900.
Then certainly be able to accurately code Section M. Let’s just jump into it. So we’ll
look at the percent of residents or patients with pressure ulcers that are new and worsening.
So this quality measure was adopted as a cross-setting measure to meet the requirements of the IMPACT
Act. We’ve heard a lot about that. And so, as we’ve gone along, we’ve been training in
these other settings, and it’s been interesting what we have found. When I’ve sat through
all of these trainings, SNFs are way ahead of everyone else. So we’re actually taking
a slightly different approach than some of the other settings. So when we’re teaching
and educating on these topics, we’ve got some deer in the headlights. We’ve got people upset
and concerned. And I am like alright. But the SNFs have gotten this down pat. So
this transition, for this particular setting, I think will be a little easier than the rest
of the other healthcare settings that are now having to do, and to complete, some of
these same item sets. The measuresto, is intended to encourage post-acute care providers to
prevent pressure ulcer development or worsening and to closely monitor and appropriately treat
interesting pressure ulcers. We know how critically important that is. When we look at the skilled
nursing facilities throughout the United States, and the years and the amount of effort and
time that’s been put into preventing pressure ulcers, and certainly if we get pressure ulcers
treating them, as quickly as possible, and improving the quality of life for the residents
and patients that we care for, this is something that’s near and dear to almost everyone’s
heart that’s sitting in this room and certainly who’s watching. So I applaud everyone for
the work that they’ve done in that. So we’re going the jump right in. You’ve just had lunch.
What happens when you’ve had lunch? I won’t make you do the hokiepokie. So instead of
the hokiepokie we’ll do a scavenger hunt. I don’t want to lose anyone so we’ll do the
scavenger hunt here. In this scavenger hunt, this is the opportunity for you to start exploring
and understanding where you can seek and find information once you leave here today. Because
you’re going to get so much information today and tomorrow that you’re going to go back
to your facilities, go back to your organizations and say, where did they say we could find
that? What was exactly that particular thing? You know, where do I seek the information?
So that’s part of what we’ll do today. Using your skilled nursing facility Quality Reporting
Program specifications for Quality Measures adopted through Fiscal Year 2016 Final Rule.
That’s the full title. Actually, there are binders on your table. There’s two binders
on every table, I think. So that, I’m looking at this table right in the center. If someone,
I don’t have a binder to hold up for you but the binders are there. Ok so grab… You’re
going to share. So that’s…The very back section…Ok so Jen is helping me out the
very back section of that manual. There’s a couple of ground rules. Here are the ground
rules…one we play nice, which means we share. Two, there within your folder on the right
hand side, there is,looks like a PowerPoint handout. That’s about three slides per page.
If you can pull that out, that’s the scavenger hunt document. I’m sorry. It’s small. I see
people doing this. They’re taking their glasses off and they are looking. Some people are
putting the glasses on. Sorry. The writing is a little small. But what I would like you
to do, if you can’t read it, pass it to someone at your table. Maybe they can read it for
you. This is a team sport. We want you to go through the slides and there are
some blanks in the slides. So, if you can go through and as a table work through and
answering , fill in the blanks, using your manual. There are nine blanks to fill in.
I’ll give you about ten minute to do this. But I will take a pulse of the room. If we’re
done before that, then we’ll stop. If it takes a little bit longer, that’s okay we have some flexibility. This is an opportunity for you to start exploring this manual, start using it.
It’s the last section. 1, 2, 3, go! (Begin table top exercises) Just so you know, it’s the very last section of the manual. And its got a green divider,
and from there behind. (Table top exercise) All right. We’ll give it another just two or three minutes and we’ll finish up
and then we’ll start going through the answers. Okay, if we can just wrap it up. Looks like
most people are done. (Pause)
Ok! Lot of energy after lunch. I’m thoroughly impressed. It was great. Everyone jumped right
into the activity. Hopefully this was a good activity, it allowed you to start to explore
the draft manual and sorry there was some feedback there and start to explore the manual
and and hopefully we were able to be successful in our scavenger hunt. As we go through the
next series of slides, there are some blanks in there. We’ll see how well, as a group you
did in answering the questions. Alright, let’s start with the first one, so the percent of
residents or patients with a pressure ulcer that are new or worsened. So the numerator,
the number of blank residents with a MDS 3.0 assessment during the selected time windows
who have had one or more Stage 2 – 4 pressure ulcers that are new or worsened over the denominator.
The number of short stay residents with one or more MDS assessments that are eligible
for a look-back scan, and of course except those that meet the exclusion criteria. Alright
so the number of what residents? You guys are so bright. Very good. So the number is
“short stay”. So the percent of residents or patients with a pressure ulcer that are
new or worsened, the new or worsened pressure ulcers are determined based on examination
of all assessments in a resident’s blank for reports of Stage 2-4 pressure ulcers that
were not present, or at a lesser stage on prior assessment as evidenced by. And of course
we have the coding for Stage 2, 3 or 4. What’s the blank in this one? Residents “episode.”
Correct. Episode. Awesome. So now, a blank is a review of all qualifying assessments
within a resident’s current episode to determine whether events occurred during the look-back
period. All assessments with a target date within the episode are examined to determine
whether the event or condition of interest occurred at the time during the episode. So
a… what’s that blank? Look-back scan. Exactly. And then it talks about the various different
types that are included. So a look-back scan. So the next one we have here. A SNF denominator
exclusion. Short stay residents are excluded if blank of the assessment that are included
in the look-back scan has a usable response for item indicating the presence of a new
or worsened Stage 2, 3, or 4 pressure ulcer since the prior assessment. This situation
is identified as followed: If the date on the new or worsened stage, 2, 3, or 4 pressure
ulcers are missing. If all the assessments that are eligible for the look-back scan are
discarded and there’s no usable assessments remaining then the resident is excluded from
the numerator. So what is the blank there? None. Right. And this makes sense. I don’t
think this is anything unusual for most people. The SNF denominator? We talked about the short
stay resident is excluded if there’s no initial assessment available to derive the data for
the risk adjustment. That makes sense right, because this is is a look-back scan. So we
need the initial assessment to set where that’s kind of the endpoint when we look back. If
there’s a death in the facility tracking record, then that person is also excluded from the
measure calculations. So these are important, as we go through these types of things, these
are the important things that when you sit down and say how did we get to this number?
How do I go back into this? These are all of the pieces of information that you need
to understand that makes it helpful. So then we have a percent of residents or patients
with pressure ulcers that are new or worsened. The measure is risk-adjusted based on the
resident characteristics or covariants. So we’re going to spend some time for you to
understand what are the things that put the person at higher risk for developing or having
a worsened pressure ulcer. In residents with care characteristics or conditions that put
them at increased risk for skin breakdown or impact their ability to heal are treated
differently in the measure calculations. So that’s where we try to level-set and make
— not every patient is exactly the same. And we often say that. So what are those things
within the measures that we are looking at that says, if you have these or a series of
these covariants, they’re weighted at such a way that they’re at a higher risk? Ok, so
there usually a whole series of things we’re going to go through. They’ll say this person
as compared to someone without those risks has a greater chance of developing a pressure
ulcer. It doesn’t mean they should develop a pressure ulcer, it just means they’re at
high risk for doing it. The risk assessment is used to account for the medical and functional
complexity of our residents. And so that makes sense. As you see the measure, you’ll say,
oh, they make sense to me. So let’s — there’s a couple of blanks in this one. So let’s go
item by item. So an indicator of requiring limited or more assistance in blank self performance
dependence on the initial assessment. So these are some of the risk assessments, risk adjusted
assessments. So what did you think the first blank is? Bed mobility, right. This is someone
who has more than being totally dependent in bed mobility. That makes sense. Right,
if they need any kind of help moving in the bed it puts them at risk. Indicator of bowel
incontinence at least occasionally on the initial assessment. That makes sense, and
/ or the person has diabetes or blank on the initial assessment? Peripheral vascular disease.
Correct. And then an indicator of low body mass index or the BMI, based on their height
and their weight and someone actually talked a little bit earlier about that to make sure
we’re being accurate in calculating those two items in the MDS. All right. So, now we
get to go into the quality measure calculations. This is probably the driest material that
you’re going to get. Those people who love statistics and get into all of this, this
is the meat of what they wanted to understand. For everyone else you’re probably going the
glaze over, but that’s okay. (Laughter) But it is important just to at least hear it.
If you’re not doing the calculations, the biggest thing for the clinicians in the room
is to understand those things that put the person at highest risk. You know the bed mobility,
the incontinence, the diabetes, the peripheral vascular disease, those other things. You say okay, I understand
this puts my person at higher risk. So let’s go through this as a series of steps. Calculating
the facility observed score, so steps 1-3 we’ll go through them. Step, one we’ll be
calculating the denominator. So what we’re going to do is count the total number of short
stay residents with a selected targeted MDS 3.0 assessment in the time measurement window.
So they need to have a assessment there. Who do not need the exclusion criteria. So if you’re
not excluded, you’re included. That makes sense right? Okay. So if we don’t take you
out, then you’re in. Okay. That was a Phd that wrote that, guys. I’m only kidding. (Laughter)
I have to get you laughing. Come on. This is dry material. All right. Step 2, calculating
the numerator. So we have the denominator now. So it’s everyone that doesn’t meet the
exclusionary criteria is in our denominator. Now what’s in our numerator? It’s counted
total number of short stay residents in the denominator with a selected target of the
look-back assessment that indicates one or more new or worsened pressure ulcers. So now
we’re saying, okay. First blush is they need to be not excluded from the denominator. Okay.
Then we can consider them for the numerator. And then they need to meet this criteria that
they have one or more new or worsened pressure ulcers within the time frame. Then we’ll calculate
the facility-observed score. Right. That’s what we’re doing. And we’re going to divide
the facility numerator, count by its denominator count to obtain the facility’s observed score.
That is dividing the results of step 2 by the results of step 1. I think most people
here could do that. It gets more complicated as we go. I think that..It’s understanding
how this one is done, this observe rate. I think this is a relatively simple process.
Now we have our observed rate. Now we’re going to calculate the expected score for each patient
or resident. So the fourth step in the whole process is to determine the presence or absence
of the pressure ulcer covariant for each patient or resident. So we talked about some of those
covariants, they were bed mobility, incontinence, diabetes. Then we’ll use the resident level
covariants in a logistic regression model. How many people here know how to do a logistic
regression model? There is one, you can go see him.
(Laughter) This is when you need those advanced biostatistic
to do this. I’m working on my doctorate. I took advanced biostatistics, I can’t even
say the word. Yeah, I would hire someone to do that for me. (Laughter)
So it’s okay. But it is a series of words that you’ll hear. In the logistic regression
model to calculate a resident level expected quality measurement score and basically it’s a
probability that the resident will experience a ulcer given the presence or absence of the
risk characteristics measured by the covariants. It’s putting all these risks together and
saying, what is the probability if I have this, and this, and this, and that? It goes
through a whole series of things and puts them together. Don’t you love that explanation
of logistical regression.And I am sure my person over there would say it’s a little more complicated than that. But it’s looking at a series of things and putting them together and saying all right what is the probability of Ann Spenard developing a pressure ulcer?
So that’s the process. So then we go onto step 6. What’s an expected QM score has been
calculated for each resident? Calculate the mean facility level, blank, QM score by averaging
all the residents and patient levels expected scores. Expected. So we kind of gave you the
answer within that. So once you have the QM score for each resident, we’re going to calculate
the mean facility expected QM score. So now that we’re doing lots of math, let’s continue.
So now we’re going to calculate the national mean. So we are going to sign people up who
are going to do this. Who wants to volunteer? Okay. So calculating National Mean QM score,
that is the reason we have some very bright people who do that which is wonderful and they understand all
that. Calculate the denominator. Calculate the total number of patient stays/residents
retained after exclusion and some to derive the denominator count. That one makes sense
right. So again, it’s all those that are included that are not excluded. Then we look at step
8, calculating the numerator. Calculating the total number of patient stays or residents
that triggered the QM and some to derive the numerator count. So now these are ones that
are by triggered the quality measure. Then we have the denominator we’ve already been
through. Then we’re going to calculate the National mean observed QM Score. Then we’ll divide
the number count by the denominator count to obtain the National Mean Observe Score.
Then this is divide the results of steps 8 by the results of step 7. There’s a lot of
numerator, denominator, exclusions. We looked at the covariant, we have them the quality
measures, who triggered. Now we put this all together. Now in step 10, what do we have,
we calculate the facility level blank score, adjusted score. Right. So we’re looking at
the national mean to help us to do that. That was very, very dense information. And for
most of us here, it at least gives us a sense about how this whole process happens. But
we probably will not be doing any of these major calculations ourselves. But it is important
to know. I think again, clinically, is the biggest issue that we need to look at. I wanted
to just kind of introduce in your right-hand side of your folders there is a case study.
And lets see if I have my case study here. So there’s a case study. You should see it,
it’s a couple of pages, it says “skilled nursing facility quality reporting program training
case study.” And we actually changed up internally how we were going the present training. Section
GG was going to come first — Section M was going to come tomorrow, but because of scheduling
things changed. So anyway normally we would have had you kind of be introduced to Mrs.
J and had really read through this before we got to doing Section GG, before we got
to Section M. I just want you to take it out. Leave it off to the side. We will be doing
a case study. We will be taking a break again when we’re ready to score that. So just know
that that is there. We’ll give you some time to read the portions that are going to be
pertinent to what we’re doing. So this case study you’re going to use today and you’re
going to use that case study again tomorrow. So you may want to take the opportunity to
read through it tonight at some point. That’s your homework. There will be a test. All right.
So we’re going to meet Mrs. J. And we’ll be using her throughout Section GG and we’ll
be using her now in Section M. So let’s look at — we’re not going to go through all of
Section M. But it is important we want to level-set and make sure everyone understands
what is we’re looking for in Section M, and we’re going to cover certain items. In Section
M — actually the items that we’re going to be covering again — I’m sorry I’ll have you
go back if your folders. On your right side is a subset of the questions for Section M.
So you can pull those out. They’re going the use that for your case study. But in case
you want to refer to the item sets, you can look at them. You’ll see it’s not the full
section. But there are a couple of items on Section M. So what is the intent for Section
M in the MDS? It’s to look at the risk, presence, appearance and change of pressure ulcers.
It’s also notes other skin conditions, wounds, lesions, documents some treatment categories
related to skin and skin injuries. And it’s important to recognize and evaluate each resident’s
risk factors and certainly evaluate all the risks for constant pressure. Although we’re
not going to spend a lot of time talking about It, Section M, when you go back to your facilities
— we’ve been doing this in long-term care for a long time in skilled nursing. So it’s
important though to make sure whoever’s completing this section, do they really understand what
is a diabetic ulcer? What’s a peripheral vascular ulcer? Can they stage appropriately? I mean
–These are all going to be critical —These are just your general day-to-day operational
things that if you’re sitting in an office and you’re not out on the units, it’s amazing.
I’ve done a lot of chart review in my time, and you know, someone has staged an ulcer
as a Stage 2, but then they’ve done a really great job describing everything that they
see, and it’s a Stage 3. I mean they didn’t understand, because they did a beautiful job
describing. You know, this yellow kind of slough and what not. And it’s a stage 2. You
know based on what they described in fact it never was a 2, at least the point they
looked at it. It was a 3. So what would you do with that? It’s a learning opportunity,
right. Take the opportunity. Make sure you understand that people in your facilities
understand what they’re looking at related to a diabetic ulcer, peripheral ulcers. All
of these are really important. Because they’re going to impact these quality measures, right,
this quality reporting. And skin is one of them. Alright oh and and the other key thing,
there’s two words at the very end of this slide that I think are critically important,
“constant pressure.” So if you’re going to call something a pressure ulcer, what do you
think should happen that you need to be able to do? Relieve pressure, right. So if there’s
nothing pressing on whatever you want to call a pressure ulcer at anytime, you might be
hard pressed to call that a pressure ulcer. One of the ways you have to be able the do
is relieve the pressure as part of the identifying what’s a pressure ulcer. Okay. A complete
assessment of the skin is essential for certainly for prevention, for treatment, for monitoring
and hopefully healing our pressure ulcers. Be certain to include assessment process as
a holistic approach. So this is not just a nursing issue this. It Is a whole team. This
is your nursing assistants, your nurses, APRNs, your physicians, therapist, nutrition, dietary,
hydration. It’s everyone together working together to make sure we are keeping our patients
and residents healthy and well. It’s imperative to determine the ideology. We already talked
about that. That probably singularly was one of the biggest things that I’ve learned in
all the work that I’ve done in being out in facilities is staff not understanding or misidentifying
ulcers as pressure ulcers when they’re diabetic ulcers, peripheral vascular ulcers or something
else. And what happens with these especially with the peripheral vascular ulcers. Do they
heal like that? No. They don’t. So if someone’s calling something a pressure ulcer, and in fact it’s
not, it’s a peripheral vascular ulcer, some of these can be chronic for years. Right.
So we wanna be sure right again it’s like anything, garbage in, garbage out. We want
to make sure that to the best of our knowledge what we’re putting on the MDS is accurate. It’s accurate because not
only do we want the MDS to be correct, and everything else that goes into that, but we
want to make sure that our care plan is correct, and that our whole treatment plan that we’ve
put into place is looking at the right type of ulcers. Different ulcers are treated different
ways. All right. So step 1, determining the deepest anatomical stage. For each pressure
ulcer determine the stage. Don’t reverse or backstage. We’re going to talk about that.
Why? Who was around when we did MDS 2.0. What did we do? We back staged. The wonderful people
that we are. We all reverse staged everything. So if you’re an old nurse like me, you might
want to reverse stage. But seriously, as we go forward, think about this from the perspective
of new admissions to your unit and what you’re seeing is a stage — what would be equivalent
to a Stage 3? But what’s important to know would be the … The history right. What was
that? It would have been a stage 4. It’s a healing stage 4. But it still is a stage 4.
It is what it’s deepest component was. So that is really…again think about it from
a training perspective. I know we’ve been doing this forever, but let’s take the opportunity
to get reenergized. When we go back to our organizations and say, hey, how are we doing
this? Are we consistently doing this? Does everyone who’s going to be touching the MDS
coding this are nurses? Because then you get all kinds of conflicting information. We have
something from the discharge paperwork from the hospital that says one thing, the nursing
home records say something else, the lawyers come in, what do they want to do? I won’t
say anymore. (Laughter) So you just want to make sure — it’s about having appropriate
documentation, appropriate assessment, appropriate care planning. So when you want to look at
the wound, you want to palpate the base of any identified pressure ulcer to determine the anatomical
death — depth, not death. Hopefully we’re not killing people. (Laughter) — of the soft
tissue and damage. Can we see tendon? Can we see bone? Can we palpate it? What are we
dealing with? It’s going to help us to determine. So it should be based on the ulcer’s deepest
anatomical soft tissue that’s visible and palpable. If you have it up obscured so the
depth soft tissue can not be observed it is considered unstagable. This is those ones
that are eschar or slough throughout. But what happens if we have a wound that has 75% slough,
but that 25% that we can see, we can see bone, would you still stage that? Would you be confident
that your nurses on your unit can do that? They would say I see slough, unstageable.
Unstageable. That’s what you told me, has slough, its unstageable. But if you can see
bone on that 25%? It’s a stage 4. It’s a stage 4. Again another opportunity to teach and
educate. So you want to certainly — again, this is another caveat. Review the history
of each pressure ulcer in the medical record in your medical record, in the discharge record
from the hospital, or whatever way that you can get information. Find out again if it’s
in that exact spot? What was it’s deepest stage? Because that’s what it is. And that
again is a caveat that some people don’t even go back and read the full discharge summary
from the hospital. Some of these discharge paperwork right, I don’t know. There’s some
hospitals in Connecticut, I mean, you’re getting this amount, like a ream of paper. And to
read through it all and some little spot you know, in the midst of page 20 of 40 pages
that they’ve sent to you gives you the stage of the pressure ulcer. Others do a really
great job and put it right up front so. That would be really important. It should continue
to be classified at the higher numeric stage. Then you can certainly carefully document and track the pressure ulcer to be able to more accurately code and to be able to treat the pressure ulcer. Those
are a couple of what we call action steps or thoughts that you want to do when you go
back to your facilities. Okay. So we want to continue. We want the identify unstageable
pressure ulcers. We want to visualization of the wound bed. It necessary to accurately
stage. So if it’s a 100% covered with slough, then you can’t stage it. Right. If it’s got
eschar across the whole wound, then we can’t stage it. It is unstageable. So we talked
about that, eschar can be tan, black or brown. Slough is yellow, tan, gray, green or brown,
usually stringy. Isn’t that great to think about right after lunch. Alright, tissue presence
such as the anatomical depth of soft tissue damage can not be visualized. So if in that
example where I gave you that wound 75% of it is covered in slough, but 25% was clean
enough to get down and visualize, then we can probably stage that ulcer. But if we can’t
really get a good sense about what the base is in that ulcer, then it’s going to be unstageable
for us. Okay and so we talked about that. So now a pressure ulcer with intact skin, that is suspected deep tissue injury
should not be coded as a Stage 1 pressure ulcer. It should be coded as unstageable.
I think we know that pretty well in our area. But we want to make sure that staff understand
what is suspected deep tissue injury looks like compared to a Stage 1. And pressure ulcers
covered by a non-removable dressing or device like a primary surgical dressing or a cast
where you know there was a pressure ulcer underneath it should be coded as unstageable.
Nothing has changed in that. So the next thing we want to do is determine is it present upon
admission. For each pressure ulcer determine if the pressure ulcer was present at the time
of admission or entry, or reentry, and not acquired while the resident was in the care
of the nursing home. Consider current and historic levels of tissue involvement when
you’re doing this. You want to review your medical records for history of ulcer and review for
location and the stage at the time of admission/entry or reentry. We want to make sure that we understand
was it there and what stage was it? This is where it gets convoluted especially between 2’s and 3’s
with your general nursing staff on your unit coding pressure ulcers. If the pressure ulcer
was present on admission or reentry and subsequently increased in number, stage during the resident’s
stay, the pressure ulcer is coded at the higher stage, and the higher stage should not be
considered as present upon admission. Does that make sense to everyone? Okay. So they
came in with a Stage 2. So it’s present upon admission. During the stay it worsened to
a Stage 3. Now you understand why it’s so important to understand upon admission is
it a Stage 2 or is it a Stage 3. Otherwise you are saying that if we truly went by that nurse saying it’s a Stage 2, now it’s a Stage 3, it could have happened that way. And that’s fine. Then we
want to code it as on admission as a Stage 2. Now when it gets coded to a Stage 3, it’s
not considered present upon admission, because it’s worsened. If the pressure ulcer was unstageable
on admission but becomes numerically stageable later, it should be considered still
present upon admission. Does that make sense to folks? It came in as unstageable. We didn’t
know what it was. We knew something was there. But we didn’t know what it was. Now we chemically debrided it, surgically debride it whatever we’re doing, we now can stage the ulcer. Now it is a stage a 3. Now it’s a stage 4, whatever it is. Now that we stage it, once we’re able to stage it, we say it was present upon admission. Because it
was there. We just didn’t know what it was until it told us what it was once we cleared
the eschar or the slough away. Hopefully that’s no confusion for you with your staff. But
that’s an important point. So if a resident who has a pressure ulcer was originally acquired
in the facility is hospitalized and returned with a pressure ulcer at the same numerical
stage the pressure ulcer should not be coded as present upon admission. So they went, they
had a Stage 2 they developed in your facility. They went out to the hospital. They came back
with a Stage 2. Some people will say, now it present upon admission they came back from
the hospital. No. But they had a 2 when they left. They had a 2 when they came back. It’s
the same. You owned it. You grew that one. You don’t get to the pawn that one off. Ok
that’s yours. You own that particular ulcer. If a resident who had a pressure ulcer that
was present upon admission, not acquired in the facility, ok so they came in with a pressure
ulcer, is hospitalized and returned with that pressure ulcer at the same numerical stage,
the pressure ulcer is still coded as present upon admission. So they came to you with a
3. They went out to the hospital. They came back in with a 3. It’s still present upon
admission. Right so that’s an important piece. Because it was originally acquired outside
of the facility and not changed in staging. So that’s an important point for you to remember.
And I think that’s a little bit of a change or a caveat in the clarification in the manual.
So determine the present upon admission — if the resident who has a pressure ulcer is hospitalized and
the ulcer increases in number stage during the hospitalization, it should be coded as
present upon admission at the higher stage upon reentry. So that doesn’t make sense to
me. Person who has a pressure ulcer is hospitalized and the ulcer increases in numerical stage… okay,
yes, I’m sorry. It’s after lunch for me too. They left your facility with a Stage 2. They
went to the hospital because the person was really sick or whatever happened. Now it is
a Stage 3 when they come back in. So it increased in size while they were in the hospital. Now
we code that increase in stage as a present upon admission. So think about this and who’s
completing these assessments in your facilities. Do they understand all of these little caveats?
Because this is going to be critically important for having accurate assessments. Alright So
let’s look at a case study. So Ms. K is admitted to your facility without a pressure ulcer.
And during the stay she develops a Stage 2 pressure ulcer. This is a facility-acquired
pressure ulcer. And was not present upon admission. Ms. K’s was hospitalized and return to the
facility with the same Stage 2 pressure ulcer. The pressure ulcer was originally acquired
in the nursing home and should not be considered present upon admission when she returns from
the hospital. Does that make sense to everyone? Yeah. Okay. So Mr. J is a new admission to
the facility, he’s admitted with a Stage 2 pressure ulcer. The pressure ulcer is considered
present upon admission, because he came in with it. It was not acquired in the facility.
He’s hospitalized and returns with the same Stage 2. And it’s unchanged from the prior
admission or entry. This pressure ulcer is still considered present upon admission. Because
he went out with a 2. Came back with a 2. He had it before he came into the facility.
Because it was originally acquired outside. That makes sense. Alright so in this section
we’ll try to go through pretty quickly. These have not changed. These are the standard definitions
that we’ve been using for Stage 1 pressure ulcers. This is M0300A. So that’s asking you
to say is this intact skin with nonblanchable redness or localization, usually over bony
prominence, darkly pigmented skin may not have visible blanching and dark skin tones
only may too be appeared as bluish and/or purplish because of the dark skin pigment.
It was interesting going back to the MDS 2.0 but when we did the day two study and we looked at this, It was interesting when we looked at people with very dark skin pigments, often facilities
were picking up at Stage 2. They missed the stage 1, they really just weren’t picking
up the Stage 1s. So if that’s your population that you’re serving, it’s really important
to make sure that you’re assessing the skin, that it’s well lit. Have a little flashlight,
whatever it takes so you can really do a good assessment. And hopefully pick up something
that’s at a Stage 1. Relieve the pressure and never allow it to get to allow it to get
to the point of 2 or greater. We have an obligation for that. For me, I’m Irish. I’m very pale.
You would pick up my redness very easily. And so I’m easy to pick that up on okay. But
if you’re thinking of someone who has you know very dark skin pigment, it’s going to
be really — it can be really hard. And again lighting is the key there. And being sensitive
to that. So there’s been some great education that’s been done around people with dark pigmented
skin. So again making sure that your staff understands that and can do a good observation.
Ok. So an observed pressure ulcer alteration of the intact skin whose indicator as compared
to an adjacent or opposite area to the body may include change to one or more of the following.
We go through the various things. And we talk about darker skin tones being an issue. Stage
2 pressure ulcers, partial thickness, loss of the dermis, has a shallow open ulcer with
a red or pink wound bed without slough, and may also present as an intact or open or ruptured
blister. Partial thickness, loss of dermis, presenting with a shallow open ulcer with
pink or red, can have intact or open ruptured blister. Those are important things to make sure your
staff has. The biggest trouble is between 2s and 3s is what I find out clinically. Stage
3 is full thickness tissue loss, subcutaneous fat may be visible, but bone tendon or muscle are not be exposed. At that point you would be at a stage 4 Slough may be present but not obscure the
depth of the tissue loss. I think probably the main thing to say to staff when they’re
struggling with this is it a two or a three is that one thing. If you’re really struggling
and there’s slough, it’s automatically a three. If that’s one caveat that you can give to
your staff that’s going to be really helpful. It may include undermining or tunneling in a
stage 3. Then your stage 4 pressure ulcers, those are the most devastating of the ulcers.
Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be
present on some parts of the wound bed, and often including undermining and tunneling. One thing I want to get into a little bit is when you’re staging these, when we’re talking bony
prominences, we’re talking ischialtuberosity and what are not. But where else can you get
pressure ulcers? You can get pressure ulcers from right back from the ears to the ears
from oxygen tubing. I actually, my husband was in the hospital for an extended period
of time with a surgical belly, and had a NG tube that was too tight on how it was done.
He actually ended up with a stage 4 pressure ulcer in the nose. And now has a little divet
in his nose because of that. So it has it can be any of these things, if you think about,
you know, the outer part of your ankle, there’s not a whole lot right. You don’t have a lot
of fat. So you very quickly can get to bone on some of these ulcers. So just make sure
that you’re looking at all of these areas and then appropriately staging. Let’s talk
about unstageable pressure ulcers related to non-removable dressings. It can be a primary
surgical dressing that can’t be removed, aorthopedic devise, a cast, something that you can’t remove but you know there’s a pressure ulcer underneath that. So we have unstageable pressure ulcer
related to slough or eschar, we really have killed this. We already know what it is. It’s
non-viable tissue, the slough and the eschar, the idea is we have the full wound bed. We
can’t see the base of it. So we can’t code this. So we would say it’s unstageable due
to slough or eschar. And then we have the unstageable pressure ulcer related to suspected
deep tissue injuries. And purple or maroon areas of discolored intact skin due to damage
of underlying soft tissue. The area may be preceded by tissue that’s painful, firm, mushy,
boggy warm or cool. So it could be anything. Because these all countermand each other as
compared to adjacent tissue. Those of us clinicians who have worked any extended period of time,
we’re pretty good at picking up a suspected deep tissue injury. And the idea behind the
suspected deep tissue injury as to why it is unstageable. Until it goes through it lifecycle
and reveals itself, we don’t know what it going to be. Some of these can, you know,
open up and be right to the bone. Some of these can just dry up, especially on the heel,
that blister just kind of dries up. You get this hard scab over it. When everything’s
said and done you have intact skin underneath. But we don’t know what it is. So we have a
polling scenario. Do we have our polling devices? There’s one on each table. I’m going to ask
you a couple of questions about this case. So let’s go through the case. And then there
will be a series of three questions we’ll ask afterwards. So Mrs. N was admitted with
a pressure ulcer on her right ischium on March 3, 2016. The ulcer was obscured with slough
on admission. The physician debrided the ulcer on March 14 and a full-thickness ulcer without
exposed bone tendon or muscle was revealed. Everyone have that case down? We’re going
to ask a couple of questions about it all right. So here’s our first polling question.
M0301. How will the pressure ulcer stage be reflected on the M0300 on the combined admissions 5-day
PPS assessment with an assessment reference date of March 10? Does everyone have their
devices? All right, we’re going to start the timer.
(Pause while people participate) If you put in the wrong answer and you want
to change your answer, just go put the new answer in, and it will cancel out your other
answer. Okay. Everyone done? All right. So let’s see what we have here . All right. So
the majority, 94% of the folks got answer C, which is unstageable related to slough
or eschar. March 10th. Okay Mrs. N was admitted with a pressure ulcer on the right ischium
on March 3. It was unstageable due the slough. The physician debrided the ulcer on March
14 and a full-thickness ulcer without exposed bone tendon or muscle was revealed. That should
be C. I don’t know who did the questions. It should be C, I’m sorry. Unstageable. So
that check mark got to the wrong answer. So, C, is the answer on that. It is unstageable.
Because why? She didn’t have the debridement yet, so we didn’t know what it was. We’ll
have to correct that slide. Hopefully someone’s keeping track of that one. Let’s go onto the
next question. Following the debridement how will the pressure ulcer be reflected in M0300?
You all should get this one correctly. Let’s go ahead and answer this one. Now we’ve had the
All right. We ready to see everyone answered? Okay. We have 91% said, B, which is hopefully
this is correct. That is correct in the polling. But no matter, that was the correct answer.
So now we had it was unstageable due the slough. We debrided it. After the time of the debridement,
now we’re able to stage it as a Stage 3. Not sure we had about 6% of the people still say
it was unstageable.I think it was probably just the caveat of reading the question that
it now had been debrided and we were able the stage it. Alright we have one more question
related to this scenario. Following debridement will the pressure ulcer be considered present
on admission in M0300? Let’s go ahead, I’ll give you time to answer that one.
(Pause while people participate) All right does everyone have one? This one’s
an easy one. All right. I think we’ve answered it. All right. So we have 97% of the group
saying, A, which means yes. And it is correct. And why would that be? Well when the pressure
ulcer was unstageable upon admission but becomes numerically stageable later it should be considered
as present upon admission at the stage that now the slough is removed or the unremovable
dress — you know, non-removable dressing, everything comes off. Now you’re able to stage
it. Now you’re able the see it. They still came in with it. It’s still counted as present
upon admission. But good job. All right. So let’s start get a little bit into worsening
in pressure ulcering status since the prior assessment. I have to tell you, this is a
section was new for long term care hospitals and the IRFS and they struggled
a little bit with this and it would have been nice to have a bunch of SNF folks in there
because I think you would do a great job in educating them. Alright worsening in
pressure ulcers. Here we’re saying it worsening in pressure ulcer since the prior assessment
or the last admission or reentry. So we have stages 2s, 3s, and 4s here. All right so.
The item rationale. This item documents whether skin status overall has worsened since the
last assessment. We track increasing skin damage that documents the number in new
pressure ulcers and whether any pressure ulcers have worsened or increased in the numeric
staging since the last assessment. So really the better title for this would be “new or worsening
assessments.” It’s important that if you didn’t have an ulcer that was indicated before and
now you have it, or it’s gotten worse you want to track it here. And then of course
tracking a pressure ulcer is consistent with good clinical practice and we know that here.
The Interdisciplinary Care Plan should be reevaluated to ensure that we have the appropriate
prevention measures in place and treatment measures and management. And we want to do
everything that we can, within our power, and within our abilities to not let a pressure
ulcer worsen. But we know sometimes that does happen due to some of the clinical reasons.
But I think we’ve done generally a very good job at-large in the nursing home setting around
pressure ulcers. So let’s talk about M0800 again. Pressure ulcers worsening is defined
as a pressure ulcer that has progressed to a deeper level of tissue damage and is therefore
staged at a higher number using the numeric scale of 1-4. And on the assessment, as compared
to the previous assessment — So this is where it’s going to be really important, again,
that on that admission assessment or that initial assessment, that we understand how
to code. Because if you have Nancy Nurse coding something as a Stage 2, and then I come in
as the wound care nurse, you know, a week later or two weeks later, now I’m staging
it a 3, what do we have? We have worsening, right. And yet in fact, sometimes nurses do
even though they code it incorrectly they do that great job of describing it. In fact probably that was initially always a Stage 3. So in fact it wouldn’t have been worsened. For the
purpose of identifying the absence of pressure ulcers, zero pressure ulcers is used when
there is no skin breakdown or evidence of damage. So that’s always nice thing to be
able to say, there is none. Look-back period for this item is back to the assessment reference
date of the prior assessment. So whatever that assessment was. If there was no prior
assessment, meaning this is the first over or scheduled PPS assessment, do not complete
this item and skip to M01030 number of venous and arterial ulcers. That makes sese right
because it says to code this you have a previous assessment. So again this is just logic. If
you don’t a previous assessment, you can’t code this particular item. So, what do we
want to do? We want to review the history of each current pressure ulcer. Specifically
compare the current stage to past stages. Determine whether the pressure ulcer on the
current assessment is new. So they didn’t have it before. This is the first time we’re
seeing it, or an increased numerical stage when compared to the last MDS assessment. So this allows for a more accurate assessment is simply comparing the total counts of the current
and prior MDS assessment. So we’re evaluating or saying it’s worse, or we have new ulcers.
For each of the current stages count the number of current pressure ulcers that are new or increased
in numerical stage since the last MDS assessment. Then you’re going to do that for Stage 2,
for Stage 3, and Stage 4 ulcers. And we’re actually going to have an activity that we’re
going to talk about that. So we’re going to enter the number of pressure ulcers that were
not present, or were not present or were at a lesser numerical stage on the prior assessment.
Then we’re going to Code 0, if like I just said, if they didn’t have any pressure ulcers
in that particular stage, new or worsening, then we put a 0 in. Let’s see. Some coding
tips, code this item will be easier for nursing homes that document and follow pressure ulcer
status on a routine basis. I’d be hard pressed — I guess there are some nursing homes that
don’t do this. I have to say this is usually one the areas that can I go into almost any
nursing home and they have a pretty robust program, some better than others. But if you’re
routinely monitoring, rounding, measuring, competency to your staff to make sure they understand how to stage, this is going to be a fairly easy item for you to be able to code. And you should
feel confident in being able to code that. If a numerical staged pressure ulcer increases
in numerical staging, it is considered worsening. So again that’s negative for us. We don’t
want thing to worsen. Sometimes they happen. But man we do our darndest to make sure we
don’t have something to get worse. That it either stays the same as someone gets healthier,
nutrition, and get to the point that we can ultimately heal the ulcers. So if a pressure
ulcer was unstageable upon admission or re-entry, do not consider it to be worsened on the first
assessment that was able to numerically stage it. Let’s talk about that. They came in. It’s
unstageable. Now it’s a Stage 3. Would we code M0800 as worsening? No. No. Why? Because
it’s not worse right? We didn’t know what it was. But now that we’ve cleared off the
slough, we know now it’s a Stage 3. It is what it is. From that point forward, now we
can determine whether it’s going to get worse or not. So we would not consider that as worsening.
So if a numerically staged ulcer becomes worsened, the only way to determine if the pressure
ulcer is worsened is to remove enough slough or eschar so that the wound bed can become
visible. And then once you can do that, then it can be restaged and you can determine if
it’s worsened. Meaning, if you had it staged as a 3 and then it had slough and now you
cleared out the slough now it’s stage 4 we knew, we had a 3, we had slough, we clear
it, now it’s a stage 4, it’s worsened. If a pressure ulcer was numerically staged and
becomes unstageable and subsequently debrided sufficiently to become numerically staged
compare its stages. So again, 3, it was totally covered with slough, and it’s 3 after the
slough is removed do we have it worsened? No. Right it’s the same. It was a 3. It got
sloughed. We cleaned it. It stayed a 3. It’s not worsened. If it had gone to a 4 then it
would say it’s worsened. If two pressure ulcers merge, do not code as worsened although two
merged pressure ulcers might increase certainly in their surface area. There would need to
be an increase in numeric stage in order for it to be considered worsened. So only if it
went from, you know two ulcers that were bridged near each other, that bridge opens up now
we have one ulcer. Okay. The only way to say it’s worsened is to say now, if it went from
a Stage 2 to a Stage 3. But the total number of ulcers would go from 2 ulcers to 1 ulcer,
right? Because they merged together. So if a pressure ulcer is acquired during a hospital
admission, its stage should be coded on the admission and be considered as present upon
admission. And it’s not included or coded in this item. If the pressure ulcer increased
in numeric stage during the hospital admission, its stage should be coded on admission and
is considered present upon admission. And we talked about that earlier. So they went
out with a stage 2 they came back with a Stage 3. It’s now present upon admission. It’s important
to recognize clinically on reentry that the resident’s overall skin status deteriorated
while in the hospital. In this case the pressure ulcer deteriorated or increased in numeric
stage. The subsequent MDS assessment would be considered as worsened and would be coded on that item.
All right. So we have a coding scenario. And this is where we’re going to do our case study.
Some whatwhat I’d like to do. I think we’re going to take a break at 3:15. So we have
— let’s do 10 or 15 minutes, let’s see how things go. I’ll say break, we’ll take a break, I think Mark
will come up. We’ll take a break and after the break we’ll come back with our coding of our
coding scenario, then I’ll finish up a few of my slides then we’ll do Q&A, kind of a
wrap-up Q&A for a day. The team’s been working on answering the questions that have been
submitted. So what you need to do your case study is, you need your case study that I
had you pull out earlier. You need your Section M questions. And you can quickly read through,
there’s a lot of information here that will be used for Section GG tomorrow. So you kind
of want to ferret out what information that you’re going to need in this study to answer
your questions. So work at your table. And we’re going to code your questions, and then
we’re going to review them all. (Pause)
Alright, so let’s if we can hopefully everyone has their scoring sheets let’s go through
and look at our case study. Alright so lets go through and we are going to look at how
we would code M0300 in this case study. So how would you code M0300 current number of
unhealed pressure ulcers at each stage on Mrs. J’s discharge assessment? Ok discharge assessment. I think this is a coding question ok why don’t you
take your little coding devices, I think the yellow tells me its coding question , so if
you have your devices at the table let’s answer the number of stage one pressure ulcers?
I guess it is not, nevermind it is not a coding one. SORRY that was just a joke. Alright I
am glad I did not have to push through all of the questions. But you said it correctly
for those who are watching live streaming the group said zero. Ok the number stage two
pressure ulcers? Ok I am hearing mixed review some are saying zeros and we are hearing some
ones so again this me M0300 current number of unhealed pressure ulcers at each stage
on her discharge assessment. So the answer is zero. Ok alright so she, again on discharge,
so number of stage three pressure ulcers? On discharge? One correct. This is such a
smart group. Number of stage four pressure ulcers? She had none right, zero. Ok good,
so how about number of unstageable pressure ulcers with non-removable dressings? She did
not have any of those correct. Ok how about unstageable due to slough or eschar? Zero
is correct. And number of unstageable pressure ulcers due to deep tissue? Zero good. Ok that
was not too difficult was it? Alright so lets go through, is/are the ulcer considered present
on admission on Mrs. J’s discharge assessment and yes you are correct I would expect nothing
less. If the pressure ulcer was unstageable on admission entry or reentry but becomes
numerically stageable later it should be considered present on admission at the
stage in which it first becomes numerically staged. And so we are able to code that as present upon admission. Very good. Alright let’s look at this one how will M0800 worsening in pressure ulcer status since prior assessment OBRA or scheduled
PPS or last admission entry or reenty be coded on Mrs. J’s discharge assessment? So again
this is worsening ok so how about stage two? Zero is correct. How about stage three? Zero
is correct ok how about stage four? Zero is correct ok. Ok so she went from unstageable
to stagable and then it became present upon admission so it was not worsing. Ok great
job. So we are just, were winding down to the last bit of the presentation that I have
to do. And then we’ll get the team together. They’re answering and just going through the
questions that we can answer today. Usually there’s one or two questions that end up being
a policy or need clarification. But the team will talk about that. So we’re going to spend
a few minutes going through some of the covariant items. Remember we talked at the very beginning,
this is a test short-term memory, we do not do the BIMs interview. But we’ll say, do you
remember from an hour ago when I started talking or so? Some of those things that add or covariants that say
they’re at greater risk. We’re going to go through those items and where they’re pulled from, from the
MDS. These are item answers that are pulled from the MDS that feed into this, that add
to that wonderful logistical regression to help us figure out how we’re doing. These are some covariant
items. We talked about this, right, bed mobility. G0100A is a covariant. And really in this
particular item what it’s asking for is how the resident moves to and from a lying position,
turns side to side and positions body while in bed, or sleeps in the furniture. The coding
for this, we’re looking at self performance. We’re looking at coding 0 for independent.
Code 1 for supervision, limited assistance, or 3 extensive assistance. We’ll go through
all the codes. I am not going to read these. You would shoot me if I read them to you.
(Laughter). We know these. We use these. For those who maybe are new to MDS, these are
your best friends. So get to know them, and know their definitions. But code 3 extensive
assistance. Total dependence. Activity did not occur or only occurred once or twice which
is code 7. Or code 8, activity did not occur at all. So in the covariant component of this,
what’s going to happen in this situation is — let me just go back a couple of slides.
Oops. They told me I would do that. All right. So what we talked about here is that someone
needed limited assistance or greater okay. So they needed anything, they needed to move,
that would help to be a covariant in this. All right. Does anyone have tomatoes? (Laughter).
Don’t throw them, or eggs. I think we’re way past that. Who loves the Rule of 3? No one?
Come on. Rule of 3, probably one the hardest concepts to teach anyone in doing the MDS.
So we’re going to talk a little bit about the Rule of 3. And we’re going to just make
sure that everyone’s on the same page, because this is important when we are coding. So it’s
a method that was developed to frustrate you. No, I’m sorry. (Laughter) To help determine
the appropriate code to document in the ADL self performance on the MDS. Now for many
of you who have known me, I’ve been working on the MDS in some various capacities on a
variety of contracts sense, oh, gosh, well, I think 2005, if not a little sooner. And
so I’ve been involved with a lot of the conversations around this. And you would think we could
make it very easy. But it got complicated as we moved along to make it work. But it
is what it is. I think we’ve lived with it long enough now that the industry is doing
a pretty good job. As a new MDS person coming in, this can be like, where they on drugs
when they did this? Because, you know — and people just, they want to go to the last chapter
the book instead of reading it. They don’t want to spot at different points. They just
want to keep applying the Rule of 3 to its Nth degree. So it’s a matter of practicing
this. So if you’re training new folks or educating them, this is an area where they’ve got to
spend some time. It’s very important that staff completing this section fully understand
the components of each ADL, the ADL self performance coding definitions and the Rule of 3. To be
able to apply the Rule of 3 the facility must note what ADL activity occurred, how many
times the ADL activity occurred, what type and what level of support was required? Over
the entire 7-day look-back period. So those are your basics that you must include. So
the following ADL self performance coding levels are expected to the Rule of 3. So independent,
code only if the resident completed the ADL activity with no help or oversight, every time that
that activity was done during the 7-day look-back period. Every time we code them a 0 independent.
So this would be excluded, right. So we’re talking about some exclusions. So if they
are totally independent. We’re not going to be applying the Rule of 3. Code 4, totally
dependent. Now, we’re taking them from totally independent to totally dependent means. Code only
if the resident requires full staff performance of the ADL activity every time that the ADL
activity occurred during the 7-day look-back period. We’ll code it as a 7, means the activity
occurred only once or twice during that 7-day look-back period. And code 8, activity did
not occur. And we do this, code this if it did not occur or the family or non-facility
staff provided the care 100% of the time for the activity over the entire 7-day period
of time. Now let’s get into the Rule of 3. So when the ADL activity has occurred three
or more times apply the steps of the Rule of 3. Keep the ADL coding level definitions
and above exceptions in mind. I actually would say actually keep them on a piece of paper alongside
you. Never mind in your mind because you’ll get confused if you keep them all up here but — over time obviously you can apply these very easily.
But for a new person they need to have that in front of them. To determine the code to
enter into column 1, ADL self performance, these steps must be used in sequence. I think
that’s the biggest mistake that people make, they’re not sequential in how they applied
the Rule of 3 and use the first instruction encountered that meets the coding scenario.
If number one applies, stop and code at that level. And we’re going to go through some
examples. So when an activity occurs three or more times at any one level, code that level.
Stop! Okay. So, if it’s happening, if you have three or more at any one level, then
you’re going to code that level. When the activity occurs three or more times at multiple
levels code the most dependent level. So if I have someone coded at three times or four
times at limited and four times at extensive, what am I going to code them at? Extensive.
Right. Because they went to the higher level there. Okay. So when the activity occurs three
or more times and at multiple levels, but not three times at any one level, apply the
following. And this is when it starts to get a little muddy in the water. You want to convert
episodes of full staff performance to weight bearing assistance when applying the third
Rule of 3. Now, in that last scenario, when I did limited and extensive, would I start
applying some of these rules? No, because we haven’t gotten that step yet. The biggest
thing is, again, sequentially once you hit that three at one level, stop. Never mind
the rest of the Rules of 3. You don’t need to consider them. As long as the full staff
performance episode did not occur every time the ADL was performed in the last seven days.
If they had four straight across, we wouldn’t convert them to extensive right. Because it
was totally dependent. The total dependence can be coded — so remember that weight bearing
episodes that occur three or more times or full staff performance that is provided three
or more times during part but not all of the last seven days are included in the ADL
self performance for extensive assistance. So when there’s a combination of full staff
performance and weight bearing assistance that total three or more times, then at
that point you’ll code them as extensive and stop. When there’s a combination full staff
performance, weight-bearing assistance, or non-weight bearing assistance, a total of
3 or more times, code limited. If none of the above, you’re going to code supervision. Let’s
go through some coding scenarios. All right. Use the correct code for G0110 column 1. So
the resident ADL documentation demonstrates the following, they have supervision was provided
nine times. Limited assistance was provided twice. Extensive assistance was provided once.
And total assistance was provided twice. So if you were going to answer this question,
what would you think the answer would be? Oh, I guess this is a coding question. I guess
you get to push your button, sorry. You all said 3. So let’s go right there. All right.
Okay. So what do you think? So A. 89% of you said supervision. Why did you say supervision?
Right, at least three, right, at one level. Okay. So hopefully that’s clarifying for folks.
So that coding 1, supervision for this patient is correct. So 11% of you coded 3, extensive
assistance. Now why did that happen? People jumped right to applying the Rule of 3 right?
Oh, wait a minute. I can combine total assistance and extensive assistance. That’s true if we
had gotten to that step. So of those people that 11% of people that coded that, if we
had gotten down and missed the first couple of steps, they would have been correct. C
would have been the right answer. But we stopped at supervision there where we had three or
more at one level. Okay. So that met the first rules before we went down the way. Let’s look
at another scenario. This is a polling one. So if you can get your little devices out.
So I missed that critical word in the question that said “polling.” But it is the end of
the day so hopefully you will give me a little slack on that. Okay so choose the correct
code for G0110. The resident’s ADL documentation demonstrates supervision– we just did that
one. No, it’s different alright. Sorry. Sorry. Okay. Sorry. Supervision was provided
nine times. Limited assistance was provided three times. Extensive assistance was provided
once. And total assistance was provided twice. Okay. Let’s do the timer here. Okay. Everyone got
this one? Everyone locked in your answers? It’s for a million dollars and the answer is — (Laughter).
Okay. Limited. Very good. 96% of people got this one correct at 96. And why is it limited?
Let’s talk about that? They had nine times at supervision, why wouldn’t we do that one?
Right. So the answer is, everyone had it here. We’re saying it holler out limited assistance
was provided three times. So when we have two levels, providing at least three times
at each level we go for the higher level. Just for those 4% that got that one not correct.
Okay. So that’s the reason we went ahead and coded that one. All right. We have another
polling question. So the resident’s ADL documentation demonstrates supervision was provided one
time. Limit assistance was provided two times. Extensive assistance was provided once. And
total assistance was provided twice. So this is a polling question. Get your device out.
The answers are starting to come in. Okay. I think most people have locked in. We’re
getting there. Everyone, you’ve put your answer in. Okay. Let’s see what we have here. Wow!
So we have some points to discuss here. All right. So we have 4% of the group saying answer
A, supervision. 21% coding, 2, limited assistance. 75% said coding 3, extensive assistance. And
no one coded it as a 4. So let’s look at the answer here. So the majority of you got it
correct at 75%, extensive assistance. So why is this extensive assistance? Well we have
total assistance twice, and extensive assistance once. Okay. And we look prior to that supervision
was only one time that doesn’t meet — there’s not three times, right. Limited assistance
happened how many times? Twice. So that doesn’t meet it. So we’re like, okay. Well it’s not
supervision or limited. So is it extensive? That’s what we’re looking for next. We have
extensive once and total twice. We know that the totals, as long as it’s not every single
time, drop down to be weight bearing assistance and are fact coded as extensive assistance.
So now we have three times at extensive assistance. Hopefully that helps. All right. We’re almost
done folks. So we have a resident ADL documentation supervision was two times. Limited was provided
two times. Extensive was provided one time. Total assistance was provided one time. So
let’s answer this one. Let’s start the clock. A little more complex. I’ll give another minute
or so for people to continue answering. Talk this one through your table. Let’s come up
with some consensus. Okay. I think we have the majority of the people answering. So let’s
see what we have here. All right. So again, we have some varying answers. We have 15%
answering A. 76% answered B, limited. And 9% saying it was extensive. And no one said
it was totally dependant. So let’s look at the answer. Limited assistance. And why is
it limited assistance? Okay. So let’s look at this. Total assistance was not provided.
First off, we have nothing at any level at three times. So okay, we’re moving
on. Then we say, all right, well we have extensive assistance one time and limited assistance
two. Combine those together. And then we have our answer at limited assistance. All right.
Great job on that. Bowel continence, all right. So this is another covariant. We know that
bowel incontinence, or the absence of bowel incontinence can put us at higher risk for pressure
ulcers. So this is H0400. So it’s a covariant. We want to look at this. We’ll say, well,
if they’re always continent-during the 7-day look-back period, the resident has been continent
of bowel on all occasions, code them as 0. 1, occasionally incontinent if during look back
period, the resident was incontinent of stool once. This includes incontinence of
any amount of stool day or night. Then code two 2, frequently incontinent, they had incontinence
of the bowel more than once, but at least had one continent bowel movement anytime day or
night. And then always incontinent is that the resident was incontinent of bowel or all
bowel movements and had no continent bowel movements. Those are our definitions that
we’re working with. We have a Code 9, not rated. That would be if during the look-back
period the resident had a ostomy, that would be included in incontinence. Or they didn’t
have a bowel movement. We’ll have a quality issue for most people if they haven’t had a
bowel movement in seven days. Could it happen? I guess, I’d be concerned
but we probably want to be looking at if that’s happening in your facility frequently. That would be hopefully a documentation issue
versus an actual care issue. So we have a polling question here. We have Mr. J had loose
stool one day and was incontinent three times that day. Then he was continent of stool all
the other days during his look-back period. How would you code H0400 for Mr. J? This is
a polling question. Take your device out, and we’ll go ahead and code this. You can
discuss it at your table. I hope everyone locks in. We’re almost there. Okay. So again
we have kind of some mixed results here. 36% of the people said, B, which was occasionally
incontinent. 64% said, frequently incontinent. So there was a split between those two. We
have to look at the definition of what’s the right answer. Frequently incontinent. Why
is this person in this particular scenario frequently incontinent is two or more episodes
of bowel incontinent, but at least one continent bowel movement? So it says here “it was
only one day”. Might have had a bug or something like that. But he had three times, he had
incontinent episodes of his bowel, and then was continent the rest of his time. In fact,
that meets the definition of frequently incontinent. It is important when answering these questions
if you have any questions, look at your manual. Look at your guiding criteria for that. I’m
sorry? Okay. So we’re almost done here. This is the last bit. So Section I, active diagnoses.
So we’ll be calling out and looking at two areas here. I0900 peripheral vascular disease
or peripheral arterial disease, and I 2900 diabetes. These again are covariants. So we want to make sure we’re looking at this. This is from the active diagnoses section. Remember the caveat that was put in place for Section
I. There are two look-back periods, the diagnosis identification and the 60-day look-back period.
Was this diagnoses available? And then is it active? So do we have the diagnoses in
the last 60 days? And then is it active or inactive in the 7-day look-back period, except
for I2300 UTI which does not use the 7-day, it actually has a 30-day look-back period.
So did they have the diagnoses in the last 60 days and have a direct relationship to
the resident’s current functional status, cognitive status, mood or behavior status,
medical treatments, nursing monitoring or risk of death during the 7-day look-back period?
And certainly we would then to make sure that — so they have it, and then it’s active.
And I think we’ve been doing this for a long time. I think you know about that. But you
want to make sure when you’re looking at those covariants and areas that are putting someone
at high risk this is it. This is the last section, the last covariants that affect this
measure, K0200 height and weight. We record the height to the nearest whole inch. And you should probably –believe
it or not, this is a silly one, but this is where you need to have a policy in place how
do you manage somebody who’s missing both limbs? There’s a whole variety of things that
came through when we were rolling out the original MDS 3.0. And a lot of the Q&As came
back. Basically you have to have a policy in place on how you’re measuring height. So
that’s important. Use mathematical rounding for the height. I think you understand the
math behind that. This is not super math. Then use mathematical rounding if the weight
is again for pounds. And if the resident cannot be weighed for example because of extreme
pain and mobility, or risk of fracture, use a standard no information dash code for this
particular one. But these should be few and far between. We should be able to have the
weight. All right. So as we know height and weight someone’s underweight, they’re certainly
at risk for having an issue with pressure ulcers. So we covered a lot, or I covered
a lot today in just my section. I will take just a couple of minutes if there’s any questions
related to this section, otherwise we’re going to get right to the summary questions that
were submitted today. If you have any questions for my section, you can just come up to the
mic, if not we’ll move on. (Q&A)
»» Hi, I’m Carol Mayor from Handson Hunter. I’m the one that asked the question before
about is it Medicare admissions on or after October 1st or the ARD. So for these pressure
ulcers, it’s only for residents admitted after October 1st?
»» For this particular quality reporting — I’m looking to the back table, right. October 1st. I’m getting from Stacy, yes admission October 1st.
»» It says short stay. But the last one said long stay, and it wasn’t really long
stay. Is this one the typical nursing home short stay the way we think of it, being in
the facility 100 days or less all together? Or is this from Medicare admission/readmission?
Just calling everybody on Medicare short stay? »» Right. So you have to remember, there’s
a difference between — so I think that’s actually a question that has come up that
we’re going the address in the frequently asked questions here. But there’s the quality
reporting, which is one piece. Quality measurement public reporting, that’s one piece and then
this — Be my guest. I’m digging it deep. (Laughter) The statute requires, or the law
requires that the program be in relation to the Medicare SNF Prospective Payment System
population. It’s not an all payer data collection. We have to go through regulation to propose
the use of all payer data. The short stay measure, because it uses residents in the
nursing home could be any payer, right. Its built off the over … system not just a SNF
PPS payments, so that’s sort of the difference. So yeah, we answered another question. So
that’s the sort of nuance that exists through law, not through CMS.
»» So if I have a long stay resident who goes to the hospital for three days and comes
back on Medicare, would they be in this measure? »» Yes.
»» Okay. So it’s not really the short stay that we know, even though it’s saying 100
days or less in your document. It really is Medicare?
»» The 100 days is based on the Medicare Coverage Program, right. So, I mean it could
be — they could be in there and discharged from the SNF PPS system on Day 100, but not
leave the nursing home, right. Because that’s where they live. Right. And so that’s where
that SNF PPS Part A discharge comes in. It’s the covered stay. So that’s when that would
happen. And I know it gets confusing with the terminologies as far was the measures are called. I think that Roberta touched on it. That’s simply the measure name, it has “long
stay” because that’s what originally the measure was developed for.
»» This resident could trigger again and again?
»» If the resident — »» If they go back to the hospital and come
back again? »» Yeah, I think it’s — an important distinction is in
the Nursing Home Quality Initiative Program it’s sort of resident-based. When we’re talking
about the Quality Reporting Programs as a whole, you know, whether an individual goes
into the hospital every time and gets a pressure ulcer every time, or goes into the hospital
and falls and has a major injury every time, we’re trying to draw an analogy that oh, yeah,
that matters. That’s quality. Does it matter if it the same person or three different people
in three different stays? It’s still happening. It’s really unfortunate if it’s always you.
But you know — so those are some important distinctions.
»» Right. So when we talked about episode in our filling in the blank. It’s different
than the traditional quality measure episode that’s over multiple stays. This is basically
per stay of Medicare? »» Yeah, because you could be in an episode
right, and come in and out of the SNF PPS. Think of it like this, when they’re under
the SNF PPS and they get discharged — so let’s say they fall and have a major injury.
I know that would not happen with any of these providers. They go into the hospital. Now
they’re under the hospital IQR Program, HAC, Value-based Purchasing, Inpatient Quality
Reporting Program. Now, they’re under that program, under the IPPS system. That’s the
Inpatient Prospective Payment System. And they come back to you, they get readmitted
under a SNF PPS, right. So there’s another stay. You want to almost erase the name, you
know. Those are stays in the PPS system, kind of period.
»» So it’s stays, not really “episodes” the way we think of episodes.
»» Right. Right. And when you’re looking at an individual and tracking for quality
initiative stuff for that resident you know what you need to be doing for that person.
Maybe that’s just a different way of looking at the data. But anyway, for the purposes
of the SNF program, the SNF Quality Reporting Program, it’s stay based.
»» The look back scan also means something different. Because the look-back scan for
CASPER, is look-back a whole year for major injuries even though it didn’t happen right
now. But this is basically saying, since admission, or since the most recent PPS assessment they’ve
had a fall with major injury? »» Yeah. I think that’s how —
»» Okay, so it’s not look-back scan for a year, it’s look-back scan during this stay?
»» Did they have a fall or major injury while covered under —
»» With Medicare. »» Perfect. Thank you.
»» You’re welcome. Does that help? »» That did. Yes.
»» That was helpful for me. »» I’m sort of tagging on with her question
as well for further clarity. When I look at the Quality Reporting Program Manual when
you look at the numerator denominator information, its very clear that it says Part A residents
for fall and for GG. But for wounds it doesn’t necessarily say that. So that’s where I’m still– that’s where it’s not clicking that I could have a Medicaid payer come in, and admission assessment shows a pressure
ulcer, will that be included. »» Yeah. So if they come in — if they come
with present on admission? »» Yeah, any payer? Any payer that comes
in and has a other than Medicare, if they have a pressure ulcer, are they included?
If they’re not a Part A. »» We have to go through rulemaking through
regulation to allow the measure to be calculated with payer sources other than SNF PPS.
»» So what are you — »» So the answer is, no.
»» They are not included? »» Not right now.
»» So when we teach this for the upcoming reporting program, it’s only applying to SNF
PPS – »» The measure is calculated. Whoever you’re
required to collect the data on may be a different story. You may have OBRA.
»» Yeah we collect the data on OBRAs, the quality. I’m saying are they calculated in
the measure? »» The measure will be calculated now using
Part A stays. Yep. And we’ll probably be issuing some additional guidance surrounding that
in our postings. And actually, if you think that it’s important to expand to all payer,
I would — that would be great information for us to have.