- Good morning.
I'm going to kind of move from side to side,
because I don't think you can see me
if I stand behind the podium. So, right.
As Mark mentioned, I'm going to talk about Section B.
Our objectives this morning are to define that section
which happens to be on hearing, speech, and vision.
I'm going to explain the new items
in the LTCH Care Data Set version 3.00,
explaining the intent of this particular section,
talk about coding instructions
and needed information for items.
And then we are going to code some scenarios.
And I would like for you to use those numbers and letters
and I'll let you know when I'm ready for that.
Okay. So the new items and changes to this section B,
B0100 is on the planned discharge assessment.
Currently the B0100 is an item on the version 2.0
admission assessment.
And then BB0700 is on both the admission
and planned discharge assessments,
and BB0800 is also on the admission
and planned discharge assessments.
So the intent of this section
is to document the patient's ability
to understand and to communicate with others.
There's a few definitions.
We have comatose, which is a pathological state
in which neither arousal nor awareness exists;
persistent vegetative state
where the patient may regain wakefulness
but no evidence of any purposeful behavior or cognition
with extensive damage to both cerebral hemispheres;
the expression of ideas and wants,
both verbal and non-verbal expression,
and it excludes any kind of language barriers
and understanding verbal content with hearing aid or device,
again excluding any language barriers.
So here is a screenshot of the item.
B0100 comatose, and it applies again,
to admission and planned discharge assessments.
And for coding, you would use code 0, if the answer is no,
meaning a diagnosis of coma or persistent vegetative state
is not present at the time of admission or discharge.
And you would use code one, yes,
if the record indicates that either a physician,
a physician assistant, a nurse practitioner,
a clinical nurse specialist has documented diagnosis
of coma or persistent vegetative state
that is applicable either at the admission assessment
or discharge.
For the screenshot for BB0700,
for expression of ideas or wants,
we have four codes here,
again for admission and discharge planning assessments,
code four expresses without difficulty.
So the patient expresses complex messages without difficulty,
and with speech that is clear, and easy to understand.
Code three expresses with some difficulty,
if the patient exhibits some difficulty
with expressing needs and ideas
or the speech is not clear.
Your code two is frequently exhibits
difficulty with expression,
if the patient frequently exhibits difficulty
with expressing needs and ideas,
and code one is rarely or never expresses themselves.
And the last item, BB0800, understanding verbal content,
again we have four codes here,
understands that the patient has clear comprehension
without cues or instructions.
Code three, usually understands;
if the patient understands most conversations,
but misses some or part of the message or requires cues.
Code two is sometimes understands,
if the patient understands only basic conversation,
or simple direct phrases,
or if the patient frequently requires cues.
And then code one, rarely or never understands.
So I would like to do some of those scenarios.
So if you have your numbers and items out,
we'll do some over here.
So the first coding scenario for B0100 is,
Mrs. F has arrived at the LTCH,
and she's comatose due to traumatic brain injury.
Mrs. F's medical record includes the diagnosis
of persistent vegetative state.
So, how would you code B0100?
So, why don't you raise what you think?
Okay.
I got a couple of ones over here, got some more ones.
Okay, I got lots of ones, all right. Good.
And the answer is, one. So very good.
And the reason behind that is documented in the medical record
that Mrs. F was in a persistent vegetative state
when she arrived.
Our second scenario,
Ms. T underwent surgery for glioblastoma,
and is now admitted to the LTCH for further treatments.
When she needs to go to the bathroom,
she uses the call light.
When the certified nursing assistant arrives,
Ms. T points to the bathroom and with garbled speech says, "Go".
The certified nursing assistant reports to the nurse
that she often has difficulty understanding Ms. T.
So how would you code BB0700?
I see some twos.
I see some threes.
Some more two, more threes.
All right. So the answer is two,
frequently exhibits difficulty with expressing needs and ideas.
Ms. T gets her point across
regarding the need to go to the bathroom,
but the staff does often have difficulty understanding her.
For BB0700, Mr. B had a stroke several weeks ago,
and has a diagnosis of expressive aphasia.
The certified nursing assistant asks Mr. B,
if he needs help with bathing,
and he looks at the certified nursing assistant,
he smiles, but he doesn't respond verbally.
The CNA reports to the nurse
that she's not been able to determine
Mr. B's preferences and needs
with any of his activities of daily living
since he was admitted the day before.
The nurse interacts with Mr. B
and determines he rarely expresses himself.
The nurse plans to collaborate
with the speech language pathologist
and other care team members and Mr. B,
to increase Mr. B's ability to express himself.
So how would you code BB0700?
I see lots of ones.
All right. The answer is, one,
rarely or never expresses self
or speech is very difficult to understand.
And this is because Mr. B's expressive aphasia,
he's unable to verbally express his needs.
So for BB0800, we have a coding scenario.
Mr. K has been participating in physical therapy
to improve his bad mobility skills.
The physical therapist reports that Mr. K occasionally requires
repetition of simple instructions during therapy.
The nurse also reports
that she had to repeat information once yesterday
to reinforce her verbal communication with Mr. K.
So how are you going to code BB0800?
I see some twos.
I see some threes.
More twos.
The answer is three,
usually understands.
He understands most conversation,
but misses some or part of the intent of the message
and requires cues at times to understand.
The rationale being that Mr. K requires cues at times
to understand instructions,
both from the physical therapist,
as well as the nurse.
Our second scenario for BB0800.
Ms. H recently had a cancerous brain tumor removed,
and it affected her ability to comprehend others.
The certified nursing assistant asked Ms. H
if she's ready to bathe,
Ms. H nods and reaches for the washcloth.
When the CNA tell Ms. H to be careful
not to get her head bandages wet,
Ms. H continues to bring the washcloth towards her head,
and she looks puzzled and asks why.
The CNA explains to Ms. H that she had surgery,
but Ms. H doesn't understand
until the certified nursing assistant
shows her a reflection of her head in the mirror.
The nurse notes that cues and repetition
are frequently required for Ms. H to understand.
So how would you code BB0800?
I see some twos.
I see more twos.
Maybe a three.
It is two,
sometimes understands.
Understands only basic conversations
or simple direct phrases,
frequently requires cues to understand.
And the rationale being that Ms. H understands
only basic conversation,
and does need repetition or cues to understand.
So, in summary, Section B documents the patient's ability
to understand and communicate with others.
Patients who are in a coma, or persistent vegetative state
are at a risk for complications of immobility,
including skin breakdown and joint contractures.
B0100 is a new item
on the planned discharge assessment.
BB0700 and BB0800 are new items on the admission
and planned discharge assessments.
Unaddressed communication problems
can be inappropriately mistaken for confusion
or cognitive impairment,
and they lead to patient frustration,
social isolation, mood and behavior disorders.
The inability to understand
direct person-to-person communication
can severely limit association with other people
and inhibit the individual's ability to follow instructions
that can affect health and safety.
There are a few coding tips for you.
You want to look for documentation
of a neurological diagnosis
of comatose or persistent vegetative state.
You want to be sure the patient can hear you,
or has access to his or her preferred method
for communication, including the preferred language.
If the patient seems unable to communicate,
you can offer alternatives --
things such as electronic devices,
smart phones, tablets, laptop, et cetera,
writing, pointing, nodding, or using some type of cue card.
You want to observe his or her interactions with others
in different locations, and circumstances.
And consult with the direct care staff over all shifts,
and if available, talk with the patient's family
and their speech language pathologist.
As Charles mentioned, you have in your packet an action plan,
things you can write down for you to do
when you get back to your institutions
to help with the rest of the staff to learn this.
Evaluate your current documentation to ensure
the terminology aligns with the items
in the new LTCH Care Data Set version 3.00,
and you want to give practice coding a variety of scenarios
with your staff.