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Dave Nolley:
Welcome to the Centers for Medicare and Medicaid Services Post Acute Care
Provider Training Series. My name is Dave Nolley and I'm moderating today's
training session on MDS 3.0. Today's training will focus on specific items in
Section O: Special Treatments, Procedures, and Programs. Before we begin
discussing some of the items in this section of the MDS 3.0 I would like to
offer an important reminder. While the 2013 MDS 3.0 educational programs provide
great information about select sections or items of the MDS 3.0, it's critical
to remember that the RAI User's Manual, which is available at the CMS website
must be used routinely by assessors to ensure accuracy in coding the MDS 3.0.
Now Chapter Three of the RAI User's Manual is where intent rational and
step-by-step coding instructions can be found for each section and item in the
MDS 3.0. The goal of Chapter Three is to facilitate the accurate coding of the
MDS 3.0, and to provide assessors with the rational and resources to optimize
resident care and outcomes.
Before going any further I would to introduce our panelists for today. Joining
me today are Cheryl Wiseman and Rabia Khan. Hello ladies, and thank you for
joining us this morning.
Cheryl Wiseman:
Thank you very much.
Rabia Khan:
Hi, great to be here.
Dave Nolley:
Today, in addition to discussing the coding instructions for specific Section O
items, Cheryl and Rabia will be fielding some questions from the provider
community. Cheryl, would you share with our viewers the intent of Section O? In
other words, why is this an important part of the MDS 3.0 assessment?
Cheryl Wiseman:
Sure Dave, I'd be happy to discuss CMS's intent for Section O. According to the
MDS 3.0 RAI User's Manual, the items coded in Section O are to identify any
special treatments, procedures, and programs that the resident received during
the specified time periods. It goes on to say that these interventions can have
a profound effect on an individual's health status, self-image, dignity, and
quality of life.
Dave Nolley:
I've heard that some of these treatments, procedures and programs are difficult
to understand. Take Item O0100F, Ventilator or Respirator, for example. CMS has
received questions that speak to non-invasive vs. invasive ventilation. Cheryl,
are these really that different?
Cheryl Wiseman:
Yes, they are. There are quite a few facilities that have ventilator units and
several residents on these units may use non-invasive ventilation, NIV. The
difference between invasive and non-invasive ventilation is that residents on
non-invasive ventilation are not intubated but are instead supported through the
use of a facemask. Some residents need to be on this ventilation 24 hours a day;
however, there are some residents who are able to take periodic breaks from this
treatment to take medications and to eat meals. Invasive ventilation involves
ventilation through an endotracheal tube and these residents are not able to be
taken off this ventillary support.
Dave Nolley:
So, since there are residents that have different types of ventilation support,
can O0100F, Ventilator or Respirator, be coded for residents using a
non-invasive ventilator?
Cheryl Wiseman:
No. In order to code O0100F, ventilator or respirator, the resident must be
receiving ventilator support through an electrically or pneumatically powered
closed system mechanical ventilator support device that ensures adequate
ventilation in the resident who is or who may become unable to support his or
her own respiration. Residents receiving closed system ventilation will include
those residents receiving ventilation through an endotracheal tube, for example
nasally or orally intubated, or through a tracheostomy. If a resident is
receiving non-invasive ventilation and the treatment meets the definition for
item O0100G, by pap, c pap, this is the item that should
be coded.
Dave Nolley:
Thank you, Cheryl. So there is a place on the MDS to code for non-invasive
ventilation. Rabia, can you give us an example that illustrates a ventilator or
BIPAP/CPAP coding scenario?
Rabia Khan:
Sure, Dave. Here is an example: Mr. W was admitted ten days ago after being
hospitalized due to acute respiratory distress syndrome, ARDS. He was on a
ventilator in the hospital and was extubated two days before prior to being
admitted to the facility. Mr. W was started on post extubation non-invasive
positive pressure ventilation or NPPV through the use of nasal mask. The
assessment reference date, ARD of his admission assessment is today, the tenth
day of his stay.
Dave Nolley:
I heard you mention a type of non-invasive ventilation, so would the assessor
code this scenario in Section O under BIPAP/CPAP?
Rabia Khan:
Well partly Dave, the answer is a little complicated because of how item O0100
is constructed. Let's look at this for a minute, this item has two columns. For
column one you can see that the assessor will need to check all treatments,
procedures, and programs, received or performed by the resident prior to
admission, entry, or reentry to the facility and within the 14 day look-back
period. For column two, the assessor needs to check all treatments, procedures,
and programs received or performed by the resident after admission, entry or
reentry to the facility and within the 14 day look-back period. Since Mr. W used
both a ventilator and the non-invasive ventilation device before admission to
the facility and was within the 14-day look-back period, both conditions are
met. Therefore both O0100F, ventilator or respirator and O0100G by pap, c pap
should be checked in column one. In column two only O0100G by pap, c pap should
be check as only the non-invasive device has been used since admission to the
nursing home.
Dave Nolley:
Thank you, Rabia. It does seem like this can be a little tricky to figure out,
but that example was very clear. We often receive questions from providers
regarding Section O. We have a question from Nebraska who is wondering how to
code respiratory services. I work in a small rural facility and we tend to get
residents who are admitted to our facility due to the chemicals they previously
used on many of the farms here. Mrs. R. has been with us for a year now and has
a diagnosis of Chronic Obstructive Pulmonary Disease, or COPD. She receives
respiratory therapy services Sunday through Thursday for ten minutes each day.
Rabia, how would this scenario be coded in Section O?
Rabia Khan:
The assessor would enter 0050 in item O0400D1 because there were five days of
therapy for ten minutes per day, five times ten equals 50. The resident received
services for five days, Sunday through Thursday. CMS wants facilities to count
and enter the number of days in item O0400D2, that the therapy was administered
for at least 15 minutes a day in the last seven days. So since there were not
any days that respiratory therapy was provided for at least 15 minutes a day in
the last seven days, O0400D2 should be coded with a zero.
Dave Nolley:
I can definitely see why this section requires quite a bit of attention to
detail. I think we have time for one more question. This question comes from
Maine. Mrs. J. has been in our facility several years now. In her medical
record, it shows that she had a CVA less than a year ago resulting in a
left-sided hemiplegia and that she has a strong desire to participate in her own
care. Mrs. J. has said that although she cannot dress herself independently, she
knows she is capable of participating in the dressing activity and wants to
pursue her overall goal of being able to complete as many ADLs as she can, as
independently as possible. After talking with Mrs. J. and working with the
restorative nursing program staff, an individualized care plan has been
developed that should help Mrs. J. reach her goals. Right now, our staff is
concentrating on assisting Mrs. J. to maintain the ability to put on and take
off her blouse with little to no physical assistance from the staff. To this
end, all of her blouses have been adapted for front closure with a hook and
loop-type fastener. The restorative nursing assistants have been instructed in
how to verbally guide Mrs. J. as she puts on and takes off her blouse to enhance
her efficiency and maintain her level of function. It took approximately 20
minutes per day for Mrs. J. to complete this task on each day of the week. This
information is documented by the staff that are providing this intervention and
our nursing staff oversees the program to ensure that things are going in the
right direction. How is item O0500, Restorative Nursing Programs coded in this
scenario? Cheryl?
Cheryl Wiseman:
There's a lot of information in this scenario and it is very helpful in
determining what needs to be coded in item O0500, restorative nursing programs.
There are several criteria that must be met in order to code for restorative
nursing programs. There have to be measurable objectives and interventions must
be documented in the care plan and in the medical record. There has to be
evidence of periodic evaluation by a licensed nurse in the resident's medical
record. When not contra [spelled phonetically] indicated by state practice act
provisions, a progress note written by the restorative aid and counter signed by
a licensed nurse is sufficient to document the restorative nursing program once
the purpose and objectives of treatment have been established. Nursing
assistance aids must be trained in the techniques that promote resident
involvement in the activity. A registered nurse or a licensed practical
vocational nurse must supervise the activities in a restorative nursing program.
Sometimes under license or supervision other staff and volunteers will be
assigned to work with specific residents. An important thing to remember is that
restorative nursing does not require a physician's order. Nursing homes by elect
to have licensed rehabilitation professionals perform repetitive exercises and
other maintenance treatments or to supervise aids performing these maintenance
services. In these situations, the services may not be coded as therapy in item
O0400 therapies because the specific interventions are considered restorative
nursing services. The therapist time, actually providing the maintenance service
can be included when counting restorative nursing minutes. Although therapists
may participate, members of the nursing staff are still responsible for overall
coordination and supervision of restorative nursing programs. Also restorative
nursing does not include groups with more than four residents per supervising
helper or caregiver.
From the scenario presented, it seems as those these criteria are being met.
When you look at the number of days and the minutes of training and skill
practice that were provided and documented, it should lead the assessor to code
O0500G, dressing and/or grooming with a seven because this was the number of
calendar days that restorative nursing training and skill practice for dressing
was provided for a total of at least 15 minutes each day for the last seven
days.
Dave Nolley:
Thank you, Cheryl. We have covered a lot of information in today's training and
answered some great questions from the provider community. I would like to thank
our presenters, Cheryl and Rabia for joining us today and you for your time and
attention. We hope that you found this training on Section O to be helpful.
Ensuring MDS 3.0 accuracy is critical to ensuring accurate care plans, quality
measures and much more. If you have additional questions regarding Section O
please refer to the MDS 3.0 RAI User's Manual. If you still have a question
after viewing this training and referring to the RAI User's Manual, please feel
free to contact your state RAI coordinator. There's a list of state RAI
coordinator in appendix B of the MDS 3.0 RAI User's Manual. Remember: the work
that you do is important to ensure that the best possible care and quality of
life is afforded to the residents of America's nursing homes.
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To all of you taking part in this educational activity I again thank you for
your time and attention on behalf of myself, Cheryl, Rabia, and CMS.
CMS: Section O 1 3/12/14
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