What Every Therapist should know About the MDS
A review of this essential documentation tool
By Pauline Watts, PT, MCSP, & Danna D. Mullins, PT, MHS
(Editor's note: See Medicare Advisor online at www.physical-therapy.advanceweb.com. A new column will be posted monthly. The authors will address questions sent in by readers. See the end of this article for contact information.)
Appreciation of the fundamentals of the Minimum Data Set (MDS) is essential for any member of the rehabilitation team providing care in skilled nursing facilities (SNFs). The MDS represents the resident's clinical status and as such is the source for determining Medicare reimbursement and assuring compliance with state and federal regulations. The Health Care Financing Administration (HCFA), in the Program Memorandum to Fiscal Intermediaries, Transmittal No. A-99-20, stated, "The methodology of review for Skilled Nursing Facilities must change under the prospective payment system (PPS) from a review of individualized services to a review of the beneficiary's clinical condition. Medical review decisions must be based on the observation and look back periods relevant to the MDS(s) for the billing period." Further, the state survey has become a focused quality review process, based on the quality indicators, which are a product of the information contained in the MDS(s).
Review of MDS 2.0
The nurses' and therapists' notes must corroborate the coding of the MDS. Incomplete supporting documentation leads to denial of claims as well as survey and audit problems. Therapists should understand that, when documentation discrepancies are uncovered during a Medicare Additional Development Request (ADR) or Medical Review (MR), the reviewer will most probably consider the information contained in the MDS and nursing notes to be the most accurate documentation of the resident's clinical condition. It is vital that therapists familiarize themselves with all of the sections of the MDS that may impact validation that therapy services were reasonable and necessary.
SECTION B: In this section, assessing cognitive patterns, therapists should be attentive to two subsections. B2. Memory, identifies the status of short-term and long-term memory. Identification of a short-term memory problem must eliminate from the treatment plan the expectation of learning and retaining new tasks. Therapists need to modify treatment goals accordingly. This deficit has the greatest effect on the utilization of assistive devices.
B4. Cognitive Skills for Daily Decision-Making, identifies the ability to make decisions regarding tasks of daily life. The instructions in the Resident Assessment Instrument (RAI) Users Manual give the example of "acknowledging need to use walker, and using it faithfully." If the coding of B4 is anything other than 0 "independent," this impacts on newly learned tasks or skills. Depending on the level of impairment identified, a medical review could question whether skilled services (rather than nursing rehabilitation) were reasonable and necessary for the duration of treatment.
SECTION C: This section deals with communication and hearing. C6. Ability to Understand Others, identifies "understanding verbal information content - however able." The RAI Users Manual explains the intent of this section "to describe the resident's ability to comprehend verbal information whether communicated to the resident orally, by writing, or in sign language or Braille. This item measures not only the resident's ability to hear messages but also to process and understand language."
When treating a resident with verbal comprehension difficulties, the therapist must consistently document what modified or alternative methods are being utilized to communicate with the resident and how the resident responds.
SECTION G: This section recognizes physical functioning and structural problems and should be one of the two sections of the MDS already familiar to therapists. G1. a-j, describes how the resident performs ADLs with regard to self-performance of activity and the level of assistance required. The intent is to identify the lowest level of performance and highest level of assistance required "over all shifts during last 7 days." Coding instructions for these subsections are very explicit. Section G should be completed by nursing personnel rather than by rehabilitation staff because rehabilitation services are never present during all shifts in a seven-day period and residents generally demonstrate peak ADL function during therapy sessions. By coding function according to a resident's performance with the therapist, the RUG level may be reduced, skilled therapy may not be substantiated and discrepancies may appear between the MDS, nursing notes and therapy notes.
Additionally, OBRA mandated a facility responsibility to maintain or improve a resident's functional ability. If the baseline functional level documented in Section G1 of the MDS is inappropriately high (because therapy assessments were utilized rather than nursing assessments), subsequent assessments may show a decline in function that, in fact, didn't occur.
G8. outlines the resident's ADL functional rehabilitation potential and as such does much to substantiate the need for skilled services. Care must be taken to complete this section appropriately. G8.b., which indicates that the direct care staff believe the resident is capable of increased independence in at least some ADLs, should almost always be checked when a resident is receiving skill therapy services. G8.c. "Resident able to perform tasks/activity but is very slow," if checked, may indicate that a nursing rehabilitation program is indicated rather than skilled intervention unless the specific tasks/activities that this coding refers to are identified within other nursing notes as well as therapy documentation.
Claims for skilled therapy provided when G8.e., none of the above, is checked may be rejected as unnecessary, unless the therapy is directed at improving a resident's quality of life rather than functional ability (e.g., wound care or contracture management). G9. Change in ADL Function should almost always indicate 2 - "Deteriorated" on the Medicare 5 Day Assessment, coding 0 - " No change" for the resident's ADL self-performance status compared to 90 days ago usually indicates that a resident is not a candidate for rehabilitation.
SECTION I: Identifies disease diagnoses and should contain at least one disease or diagnosis justifying therapy intervention when a resident is undergoing skilled rehabilitation. Medicare does not acknowledge the treatment of generalized deconditioning such as "generalized weakness" as a diagnosis justifying the use of physical therapy; rather, Medicare expects treatment to be directed at specific neurological, muscular and skeletal problems. Reimbursement for therapy can be withheld if service is not indicated by a resident's ICD-9 profile.
SECTION J: Identifies health conditions and in J1, Problem Conditions, has included several conditions that can impact physical therapy. If J1.f. Dizziness/Vertigo, or J1.l. Shortness of Breath, is checked on the MDS, the therapists' notes need to identify this problem and when applicable indicate its relevance to the response of the resident during treatment. If the resident is complaining about these problems during therapy treatment only, the therapist needs to relate this information to nursing for both follow up and identification on the MDS.
J1.n. Unsteady Gait, should always be checked when gait training is being provided to the resident. J2 and J3 deal with pain symptoms and pain sites. Communication to nursing of a resident's pain level during treatment is essential to ensure correct coding as frequently the resident will experience the highest level of pain during their therapy session. At this time, identification of pain does not trigger a Resident Assessment Protocol (RAP) but it is anticipated that this will be rectified in the new MDS 3.0 that will be implemented in the near future.
SECTION P: Special Treatments and Procedures, subsection P1.a. (r) Training in Skills Required to Return to the Community, has a look-back period of 14 days, not the normal seven, and checking this is essential when there is expectation of discharge into the community and retraining in ADL skills is occurring.
The accuracy of section P1.b. Therapies, is fundamental to the appropriate reimbursement for the provision of therapy services under PPS. Rehab RUG levels must be based on only post-admission therapies. The Assessment Reference Date (ARD) utilized for Rehab RUG determination can fall on day five through eight. To maximize Rehab RUG classification, the ARD used for Rehab RUG determination should usually fall on day seven. In rare situations, the ARD can be extended to day eight for those residents whose medical condition temporarily precluded them from participating in therapies just after admission.
During the assessment period, continuous communication between nursing and rehabilitation services regarding expected RUG levels helps focus the MDS coordinator on correct therapy days and minutes. The rehabilitation team should be responsible for double checking the total number of days per discipline and total number of care minutes entered in Section P1.b. prior to locking the MDS.
Only actual therapy days and minutes must be utilized in the calculation of Section P1.b. Medicare regulations allow sufficient time between the ARD and the lock date to review the MDS for complete accuracy. However, if facility policy dictates that an MDS be locked on the ARD for a rehabilitation patient and predicted treatment time is used in the tabulation, and that treatment does not occur, the MDS is incorrect, and the resident may be placed in a higher Rehab RUG level than is actually achieved.
SECTION Q: The therapist needs to be aware of documentation in the subsection Q1. Discharge Potential, especially if time on premise is limited and/or the therapist does not have the benefit of frequent communication with social services. There may be occasions when the therapist has the understanding that the resident is to be discharged home and continues treating the resident with this goal in mind when actual circumstances have made this either impossible or noticeably delayed.
SECTION R: If therapists have reviewed any sections of the MDS for accuracy, they must sign their name, title and date reviewed and identify sections checked for accuracy on the hard copy of the MDS. The date must not precede the Assessment Reference Date or fall after date identified in Section R2.b.
SECTION T: Therapy Supplement for Medicare PPS is probably the one section that has caused most confusion for therapists. Subsections T.1b., c., and d., are only completed on the Medicare five day or Medicare readmission/return assessment.
Subsection T1.b., Ordered Therapies, must always be checked when there is a physician order for therapy to begin any time within the first 14 days of stay. Subsections T.1.c. and T.1.d. ask for an estimation of "the number of days when at least 1 therapy service can be expected to have been delivered" and "the number of the therapy minutes (across the therapies) that can be expected to be delivered." Completion instructions specifically direct that these predictions be made through day 15. The most common error made here is to estimate through day 14 only, as this coincides with the first Medicare reimbursement period. Predicting through this extra day may raise the legitimate RUG level for many patients during the first reimbursement period.
Subsection T2, Walking, when most self-sufficient, must be completed on every MDS when the resident is receiving gait training from physical therapy. There may be occasions when the electronic MDS will not accept this information. This is due to an MDS computer program feature that will eliminate this information if the resident does not meet other criteria in Section G. It is important, however, for the therapist to develop a regular routine of communicating this information to the MDS coordinator. The information required in this section is entirely the opposite of all other required information in respect that the best single effort of the resident in the past seven days is to be recorded.
The intent of Section T is described fully in the RAI Users Manual and we strongly recommend that therapists read this section. In brief review, "It is important to monitor the gait pattern and walking progress for the resident and how functional walking is integrated into the resident's activities of daily living on the nursing unit." Also, "Assessment of the resident's ability to walk using these four components should be viewed in combination with information in Section G, Section I and Section J (Unsteady Gait)," and "Discussions between the physical therapist working with the resident on walking and the RN Assessment Coordinator regarding these differences should lead to better coordination of care and foster continuity of physical therapy treatment for the resident on the nursing unit."
Accurate knowledge of the MDS is important for any rehabilitation professional in long-term care. The MDS is used to assess an individual resident's care, determine reimbursement under PPS and develop the quality indicators. The checklist can be used when therapists are reviewing the portion of the MDS associated with skilled therapy intervention.
* For more information, see a related article by the authors, "Rehabilitating the MDS," which appeared on www.advance forPT.com. It can be obtained by clicking on "Search Articles" on the Web site; specify issue 10/11/99. This article describes some of the most common errors impacting Rehab RUG levels and affecting substantiation of skilled therapy. We invite you to share this article with other rehabilitation staff members and your MDS coordinator.
* If you have a question about Medicare reimbursement you would like the authors to address in "Medicare Advisor," send your question and contact information to Linda Jones, Medicare Advisor, ADVANCE for PTs & PTAs, 2900 Horizon Dr., King of Prussia, PA 19803; fax (610) 278-1425; firstname.lastname@example.org.
Pauline Watts and Danna D. Mullins are the co-founders of Encompass Education, Inc. in Palm Harbor, FL. Contact the authors at encompassedu @netscape.net.
MDS Checklist for Therapists
Prior to Locking All MDSs:
___ Section G1.a-j coded by nursing staff only
___ Sections G1.a-j coding does not show greater ability than current therapy documentation
___ Section G8.b is checked when resident is receiving ADLs in therapy
___ Section I lists a diagnosis for which therapy is indicated
___ Section J1.n is checked if therapy is providing gait training
___ Section P1.b contains therapy days and minutes actually provided
___ Section P1.b is checked by therapy for mathematical accuracy
___ Section P1.a[r] is checked if ADLs are directed at returning to community
___ Section T2 is completed if resident receiving gait training in therapy
On All MDS Hard Copies:
___ Section R2 therapist signs name, title, and date and indicates sections checked for accuracy
For 5 Day Assessments or Readmission/Return Assessment:
___ Assessment Reference Date (ARD) is day 5, 6, or 7
___ Section G9 is coded "2" (deteriorated) if resident is receiving ADLs
___ Section T1.b. is checked if therapy is to begin within first 14 days of stay
___ Section T1.c estimates days of therapy for days1 through 15
___ Section T1.d estimates total therapy time for days 1 through 15
--© 2000 Encompass Education, Inc.