Therese: Welcome to the IRF and LTCH training
for Section N, medications new item and revisions.
Here are the objectives for the session today.
At the conclusion of this training, you should be able to:
describe the new assessment item in Section N,
explain the definitions for the Section N items,
and discuss the updates to the guidance
for the drug regimen review, DDR, items
N2001, N2003, and N2005.
We will start by taking a closer look
at the new assessment item in Section N,
N0415 high-risk drug classes use and indication.
Here is a screenshot of the new item in this section.
For the IRF-PAI and LCDS,
this data element will be collected
on admission and discharge.
The intent of this item is to record
whether the patient is taking any medications
in the specified drug classes
and whether the indication was noted
for taking the prescribed medications.
The item rationale stems from the fact
that we all know medications
are an integral part of the care provided to patients.
They are administered to try to achieve various outcomes
such as those listed here on the slide.
However, patients taking medications
in high-risk drug classes or categories
are at high risk for side effects
that can adversely affect their health, safety,
and quality of life.
So what do high-risk drug classes include?
They include combination medications
which should be coded in all the categories
and pharmacological classes that constitute the combination.
For example, if the patient takes a single tablet
that combines an antipsychotic and an antidepressant,
then both antipsychotic and antidepressant categories
should be coded.
They also include medications administered by any route.
You should include long-acting medications
only if they're taken at admission and discharge.
For this item, herbal and alternative medications
are not included.
These products are considered dietary supplements
by the FDA.
Now we will look at the item guidance for N0415.
We start with the data sources
one can use to complete this item.
These might include the medical record,
whether it be a paper or electronic health record
from wherever the patient received their care
that included treatments,
programs, procedures, and medications.
You can also include clinical communication or notes.
These might be notes from the pharmacy, nursing staff,
documentation from the physician or physician-designee,
and other clinical notes that might be applicable.
You might also include recent documents
such as the patient's history and physical,
a discharge summary, or any transfer documents.
And the last data source would be any discussions
with the hospital staff,
as well as with the patient, their family, or caregivers.
Here are the steps for assessment to complete the item
which are the same at admission and discharge.
For column one,
using the data sources on the previous slide,
you would determine if the patient is taking
any prescribed medications in any of the drug classes.
Next, if you check column one,
you need to determine from the data sources
if there is a documented indication
for all the checked medications.
Now let's go over some general coding tips.
Be sure to code medications
based on their therapeutic category or drug class
regardless of why the patient is taking it.
For example, if a patient is taking
an anti-anxiety medication for its hypnotic properties,
you would still code it as an anti-anxiety medication.
Remember to include medications
only taken once during the assessment period
and do not code antiplatelet medications
like extended release aspirin as anticoagulants.
Patients taking oral anticoagulants
that do not require lab testing
should still be coded as anticoagulants.
As we mentioned earlier, code dually classified medications
in all the categories and classes
regardless of how it is used.
We provide an example here.
Prochlorperazine is an antiemetic and an antipsychotic.
It would be coded as an antipsychotic.
Include medications by any route
and administered in any setting.
Be sure to include long-acting medications
that are given weekly or monthly
only if they are taken at admission or discharge.
Transdermal patches deliver medication
over three to five days
and are considered long-acting medications.
They should be counted if the patch is attached to the skin
during the assessment period.
Now we will review the definitions found in Section N.
We begin with an adverse drug reaction,
which is defined as any response to a drug
that is considered unexpected,
unintended, undesired, or excessive,
and requires discontinuing the drug,
therapeutic or diagnostic,
changing the drug therapy, or modifying the dose.
This does not include minor dose adjustments.
Or it necessitates an admission to a hospital,
prolongs a stay in a healthcare facility
or supportive treatment.
And finally, one that significantly complicates
the diagnosis, negatively affects the prognosis,
or results in temporary
or permanent harm, disability, or death.
Most of you are familiar with drug regimen review.
In post-acute care, the DRR is generally considered
to include medication reconciliation,
a review of all medications a patient is currently using,
and review the drug regimen to identify,
and if possible, prevent potentially
clinically significant medication issues.
The important note here
is unlike the new assessment item N0415,
the DRR includes all medications prescribed
and over-the-counter including nutritional supplements,
vitamins, and homeopathic and herbal products
administered by any route,
for example, oral, topical, inhalant, injections,
sublingual, parenteral, and by infusion.
The DRR also includes total parenteral nutrition and oxygen.
Clinically significant medication issue
is a potential or actual issue
that in the clinician's professional judgment
warrants physician or physician-designee communication
and completion of prescribed recommended actions
by midnight of the next calendar day at the latest.
Any circumstance that does not require
this immediate attention is not considered a potential
or actually clinically significant medication issue
for the purpose of the DRR items.
Medication follow-up is the process of contacting
a physician or physician-designee
to communicate the identified medication issue
and addressing all physician or physician-designee
prescribed or recommended actions
by midnight of the next calendar day at the latest.
And what we mean by contact with physician
or physician-designee, this is all about the communication
to the physician or physician-designee
to convey an identified potential
or actually clinically significant medication issue
and a response from the physician or physician-designee
to convey prescribed recommended actions
in response to the medication issue.
This communication can be in-person,
by telephone, voicemail, electronic means such as facsimile,
or any other means that appropriately conveys
the message of patient status.
Communication can be directly
from the physician or physician designee
or indirectly through physician's office staff
on behalf of the physician or physician-designee
in accordance with the legal scope of practice.
Now, we are going to turn to a discussion of some updates
to the guidance for the drug regimen review items
N2001, N2003, and N2005.
Here is an overview of the revisions.
For N2001 drug regimen review,
we have expanded steps for assessment,
revisions to the coding instructions.
For N2003 medication follow-up,
we have some revisions to the item rationale
and coding instructions.
And finally, for N2005 medication intervention,
we have revisions to the item rationale
and steps for assessment.
We will start with the expanded steps
for assessment for N2001.
An additional step four was added to further clarify
what is meant by a potential
or actual clinically significant medication issue.
For example, a patient taking an excessive
as well as an inadequate dose of medication,
medication therapy that is ineffective,
such as analgesic which is not reducing
or controlling pain adequately.
Here are some more examples of potential
or actual clinically significant medication issues.
For example, the medication is missing
from the prescribed regimen.
A reminder, circumstances must require immediate attention
to be considered.
There have been some minor revisions
to the coding instructions.
The instructions for Code 0
reinforce the need for the clinician
to use professional judgment to identify a potential
or actual clinically significant medication issue.
The changes are highlighted here in blue text.
The instructions for Code 1 also reinforce the need
for the clinician to use professional judgment
to identify a potential
or actual clinically significant medication issue.
We provide an example on the next slide.
If patient medications are ineffective for the diagnosis
or symptoms for which they are prescribed,
the clinician could determine if there is a potential
or actually clinically significant medication issue.
Code 9 is the patient is not taking any medications.
Guidance has been clarified to include medications
by any route as noted by the blue text.
The coding language has been expanded
from just the clinician to include facility
that can determine whether there are potential
or actual clinically significant medication issues.
Let's look at N2003 now.
Once again, note the changes highlighted in the blue text.
We see the rationale has been updated
to include facility.
Physician or physician-designee
prescribed/recommended actions in response to identify
potential or actual clinically significant medication issues
must be completed by the facility
by midnight of the next calendar day at the latest
to reduce patient harm.
According to the steps for assessment for N2003
should be completed if the answer to N2001 is equal to one.
Again, two-way communication is now just the clinician,
but expanded to facility.
All actions prescribed/recommended by the physician
or the physician-designee
were completed by midnight of the next calendar day.
Now we'll take a look at the coding instructions for N2003.
For Code 0, the instructions now read
if the facility did not contact the physician
and completed the prescribed or recommended actions
in response to each potential
or actual clinically significant medication issue
by midnight of the next calendar day.
And for Code 1, yes, if the facility contacted the physician
and completed the prescribed or recommended actions
by midnight of the next calendar day after each potential
or actual clinically significant
medication issue was identified.
Now we turn to the updates for N2005.
The item rationale for N2005 has been revised.
It now says physician or physician-designee
prescribed or recommended actions
in response to identified potential
or actual clinically significant medication issues
must be completed by the facility
by midnight of the next calendar day
at the latest to reduce patient harm.
The guidance highlighted in pink on the slide
has been removed.
In the steps for assessment,
the time points for completion of N2005 are clearly defined.
The steps for assessment have been revised and updated
to be consistent with the other DRR items.
Using the clarified criteria,
you'll determine whether any potential
or actually clinically significant medication issues
were identified upon admission
or at any time during the patient's stay,
admission through discharge.
As with the other items,
the two-way communication is between the facility
and the physician or their designee.
All actions prescribed or recommended by the physician
or their designee were completed by midnight
of the next calendar day.
There are some revised coding tips for N2005 too.
Just another reminder, all references to clinician
have been expanded and changed to facility.
If the prescribed or recommended action
will take longer than midnight
of the next calendar day to complete,
Code 1, yes should still be entered
if by midnight of the next calendar day
the facility has taken whatever actions are possible
to comply with the recommended action.
Today, you learned about the new assessment item
in IRF and LTCH for Section N,
N0415 high-risk drug classes use and indication.
We also reviewed the definitions found in Section N.
And finally, we discuss the updates and revisions
to clarify or enhance the guidance for the DRR items
N2001, N2003, and N2005.
We welcome questions.
And if you would like to submit questions
you have about this presentation,
please send them to pactraining@econometricainc.com
by May 15th, 2022.
All questions submitted will be reviewed
and those that are most common
will be included in a Q&A document
published after the virtual event.
We invite you to attend the practice coding workshop
that would be held in June.
Based on the review of questions submitted,
select questions will also be discussed in a Q&A session
during the June 2022 virtual live event.
Thank you.