Narrator: Hello, and welcome to the IRF
and LTCH training part one.
I'm Brenda Karkos and I'll be presenting
Section K: Swallowing/Nutritional Status
and Section H: Bowel and Bladder.
I'm a registered nurse with experience
in direct patient care,
education and nursing administration.
My experience includes inpatient care,
outpatient oncology, home health and hospice settings.
Currently I'm an associate nurse researcher
at Abt Associates in Cambridge Mass.
At the conclusion of this lesson,
you should be able to describe the new and revised
data elements in Section K, discuss the intent,
coding instructions and definitions for the Section K items
and explain the changes to coding instructions
for the Section H items
related to bowel and bladder continence.
Now let's take a closer look
at what's included in this section, nutritional approaches.
The data elements in this section are new to the IRF
and LTCH assessment instruments on admission and discharge.
These include parenteral/intravenous or IV feeding,
feeding tube, mechanically altered diet,
and therapeutic diet.
K0110, swallowing/nutritional status has now been removed
from the IRF-PAI.
The intent of K0520 is that there are many conditions
that can impact a patient's ability
to maintain adequate nutrition and hydration.
The items in this section are intended to assess this.
And here's the rationale for this item.
When patients must rely on mechanically altered food
or other or methods for their nutrition
such as feeding tubes,
this can diminish their sense of dignity and self worth.
And certainly the pleasure and enjoyment one gets
from eating real foods.
However, based on the patient's clinical condition,
they may benefit from various nutritional approaches
that are included in this section.
Here are just a few definitions to get us started.
While I won't read the entire definition
since most of you would be quite familiar with these,
I will just say the parenteral or IV feeding
is nutrition that avoids the GI tract,
while a feeding tube delivers nutrition
directly into the GI system.
And a few more definitions to differentiate
the therapeutic diet from a mechanically altered diet.
A therapeutic diet would be a prescribed diet
as part of a treatment for disease or condition.
For example, a low sodium diet.
And a mechanically altered diet is one that alters
the texture or the consistency of the food
to facilitate oral intake,
like pureed foods or thickened liquids.
And this is just a screenshot of this item.
You can see that on admission,
one would be assessing whether there
are any of these nutritional approaches being used.
On admission, you would check all that apply
for parenteral or IV feeding, feeding tube,
mechanically altered diet, therapeutic diet
or check Z for none of the above.
K0520 looks a little bit different on discharge.
While you are assessing these same elements,
you're going to check the first column labeled number four
for all that apply in the last seven days,
and the second column labeled number five
for all that apply at discharge.
And as with admission,
you would check Z if none of these apply for either column.
Now, let's look at some of the coding guidance
for this new item.
First, here's a list of some of the data sources
that can be used to complete these items.
These might include the medical record,
whether it be a paper or electronic health record,
for wherever the patient received care.
Other available documentation or notes from pharmacy,
nursing staff or the physician or physician designee,
or perhaps other clinical staff such as the dietician.
And you might also include discussions
with the hospital staff, the patient,
their family or perhaps other caregivers.
So here are the steps for assessment,
which I've already mentioned.
On admission, you're going to review the medical record
or available documentation
to determine if any of these apply.
And then at discharge, look to see if any were applicable
for the last seven days to complete column one
or a discharge for column two.
And here you can see all of the choices again for K0520.
And one difference of note in the coding guidance
for LTCH is that it states for the LCDS,
you will complete only if A0250 is 01 admission
And on discharge, you'll review all of these same choices
again for the last seven days.
And at discharge, just one note regarding the difference
in the coding guidance for LTCH.
For the LCDS, complete only if A0250 is 10 planned discharge
or 11, unplanned discharge.
Now let's just walk through a few specific coding tips.
If there is supporting documentation
indicating the need for additional fluid intake,
specifically to address a nutrition or hydration need,
the fluids mentioned here in the yellow box may be included.
IV fluids or hyperalimentation, including TPN,
whether continuous or intermittent.
Hypodermoclysis and subq ports for hydration,
and IV fluids if needed to prevent dehydration
if that additional fluid intake is specifically needed
for nutrition and hydration.
The supporting documentation
would be defined by your facility policy
and should be noted in the patient's medical record.
Here are some items that would not be coded in K0520A.
IV medications, IV fluids used to reconstitute
or dilute medications for administration purposes,
IV fluids that are a routine part of an operative
or diagnostic procedure,
or IV fluids given just to flush the line.
You also would not include parenteral or IV fluids
given in conjunction with chemotherapy or dialysis.
Now, some tips for therapeutic diet.
You would code enteral feeding formulas
as a therapeutic diet only when used
to manage problematic health conditions such as diabetes.
Enteral feeding formulas are not coded
as a mechanically altered diet.
Another tip for therapeutic diets.
These diets provide specific nutritional requirement
to remedy a particular disease or clinical condition.
And one last coding tip for K052D.
A nutritional supplement
does not constitute a therapeutic diet,
but may be part of a therapeutic diet,
although it could be given as part of the treatment
for a disease or condition.
Supplements are only coded in here
if they're being taken as part of a therapeutic diet
to manage problematic health conditions.
One example might be a supplement
for a protein-calorie malnutrition.
Food elimination diets that are related to food allergies
can be coded as a therapeutic diet such as peanut allergy.
Okay, so here is an update for LTCH only
about K0200A height and K0200B weight.
These items do not exist in the IRF-PAI.
You can see the change noted in blue on this slide.
The coding instructions have been enhanced
to say only enter a height and weight
that has been directly measured by your facility staff.
Do not enter a height or weight that is self-reported
or derived from documentation from another provider setting.
And for K0200B weight, this should be measured in accordance
with the hospitals policies and procedures
which should reflect current standards of practice.
What has been added in blue and says for example,
in the morning after voiding with shoes off.
Now let's move to Section H, H0350 Bladder Continence
and H0400 Bowel Continence.
Here is a screenshot of an H0350 Bladder Continence item,
which is for a three day assessment period.
I'm sure this is familiar to you as this item is unchanged,
but there is some additional information
added to the coding instructions.
This slide notes the updated coding instructions
for the item.
These minor changes were for coding numbers two,
three and four, and were based on questions
being raised about exactly when to use these codes.
There were no changes to the other codes.
You can see the additional language that was added
to the coding instructions for these three codes
and this is highlighted in blue.
For code two, incontinent less than daily,
This now says if during the three day assessment period
the patient was incontinent of urine once or twice
and had at least one continent void
during the three day assessment period.
Code three, incontinent daily,
now says if during the three day assessment period
the patient was incontinent of urine at least once a day
and had at least one continent void
during the three assessment period.
And code four, always continent,
says if during the three day assessment period
the patient had no continent voids and no catheterization.
Now let's look at a few changes
to the bowel continence item on the next slide.
So here is a screenshot of H0400 Bowel Continence item,
which is also for a three day assessment period.
As with the bladder continence item,
the item itself is unchanged,
but there is now some additional information
added to the coding instructions for this item.
So these are the updated coding instructions for H0400.
These are minor changes.
You can see the additional language
that was added to the coding instructions
for two of these codes highlighted in blue.
No changes were made to the other codes.
For code one, occasionally incontinent,
states if during the three day assessment period
the patient was incontinent for bowel movement once
but also had at least one continent bowel movement.
This includes incontinence of any amount of stool
at any time.
The additional language is,
but also had at least one continent bowel movement.
And code nine, not rated,
states if during the three assessment period
the patient had an ostomy or another device
for bowel elimination,
or the patient did not have a bowel movement
during the entire three days.
The additional language here for bowel elimination
when referring to the ostomy or other device.
So just to summarize, we described K0520,
the new data element for Section K admission and discharge.
We also reviewed the intent and coding instructions
and some definitions for Section K.
And we learned about the changes to coding instructions
for Section H items.
In closing, if you'd like to submit a question
regarding this presentation, please send it
to the PACtraining@econometricainc.com by June third.
As a reminder, a practice coding workshop
will be held in June and we do encourage you to attend.
Select questions will be answered in a Q&A session
during this June 2022 virtual live event.
Thank you for reviewing this presentation
and we look forward to your attendance
at the coding workshop.