The (RAI) Resident Assessment Instrument offers guidance in completion of the MDS, but many times it is misinterpreted and thus coding errors occur. Section G0110 Activities of Daily Living of the MDS 3.0 is a prime example of where misinterpretation and miscoding can impact reimbursement. Question G0110 includes instructions for the Rule of 3:

Instructions for Rule of 3

• When an activity occurs three times at any one given level, code that level.
• When an activity occurs three times at multiple levels, code the most dependent, exceptions are total dependence (4), activity must require full assist every time, and activity did not occur (8), activity must not have occurred at all. Example, three times extensive assistance (3) and three times limited assistance (2), code extensive assistance (3).
• When an activity occurs at various levels, but not three times at any given level, apply the following:
  • When there is a combination of full staff performance, and extensive assistance, code extensive assistance.
  • When there is a combination of full staff performance, weight bearing assistance and/or non-weight bearing assistance code limited assistance (2).

If none of the above are met, code supervision.

Each ADL has two questions that must be answered: ADL Self-Performance and ADL Support Provided. These two questions are broken into two columns with completely different coding guidelines that often are the cause of confusion and errors in coding. A recommendation has been to code one column at a time to decrease potential for miscoding due to having to switch back and forth between the rules assigned to each column.

During your look-back period it is important that the staff be recording each episode during all shifts for each ADL, thus capturing all occurrences. Diligent recording will provide the information needed for proper coding at the appropriate level of the occurrences and support provided. Under-coding one ADL can cost almost $47 per day per assessment. Multiply $47 x 30 days x 25 assessments per month, and one is left with $35,250 in lost reimbursement.

Supervision is often miscoded. Supervision is one-on-one; they receive individualized supervision. As the RAI states, "General supervision of a dining room is not the same as individual supervision of a resident and is not captured in coding for Eating."

The key is education of not only the MDS staff tasked with properly coding the MDS, but also the floor staff. All staff assisting the resident must understand the coding rules for Self-Performance and Support Provided as well as the necessity for accurately gathering this information, thus increasing the opportunities for capturing all occurrences accurately.