The newest update from the Centers for Medicare and Medicaid Services (CMS) was just released in August and I want to share some specifics about the upcoming changes to the Resident Assessment Instrument (RAI) Manual. The RAI Manual changes are effective for October 1, 2016. Most of us have heard about the new section GG, but there are some other notable changes as well:

Notable Changes to the Resident Assessment Instrument Manual

1. The Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) will begin collecting data from Minimum Data Set (MDS) assessments beginning October 1, 2016. SNF’s that do not submit the required quality measures data may receive a two percent reduction to their annual payment update for the applicable payment year.

• You may also be subject to a two percent reduction in reimbursement for failure to report if your MDS’ are not submitted properly. This includes submitted, validated, and accepted. Lastly, if you use a significant number of dashes, the assessments become invalidated. This will also be monitored and can ultimately lead to a two percent reduction under failure to report.
• If you are cited for failure to report, you may receive a 2567 in the mail for a level violation and this will be included in the calculation of your Five Star rating, weighted as a substantiated complaint survey.

2. Section C will have a new question, C1310D, related to altered level of consciousness, including vigilant, lethargic, stuporous and comatose.

3. Section J brings to us clarification regarding the coding of injuries directly related to a fall. “Any documented injury that occurred as a result of, or was recognized within a short period of time (e.g., hours to a few days) after the fall and attributed to the fall.”

• “If the level of injury directly related to a fall that occurred during the look-back period is identified after the ARD and is at a different injury level than what was originally coded on an assessment that was submitted to QIES ASAP, the assessment must be modified to update the level of injury that occurred with that fall.”

4. Section M changes specify the use of present on admission (POA) and its use when coding pressure ulcers, M0300.

• For each pressure ulcer, determine if the pressure ulcer was present at the time of admission/entry or reentry and not acquired while the resident was in the care of the nursing home. Consider current and historical levels of tissue involvement.
• Review the medical record for the history of the ulcer.
• Review for location and stage at the time of admission/entry or reentry.
• If the pressure ulcer was present on admission/entry or reentry and subsequently increased in numerical stage during the resident’s stay, the pressure ulcer is coded at that higher stage, and that higher stage should not be considered as “present on admission.”
• If the pressure ulcer was unstageable on admission/entry or reentry, but becomes numerically stageable later, it should be considered as “present on admission” at the stage at which it first becomes numerically stageable. If it subsequently increases in numerical stage, that higher stage should not be considered “present on admission.”
• If a resident who has a pressure ulcer that was originally acquired in the facility is hospitalized and returns with that pressure ulcer at the same numerical stage, the pressure ulcer should not be coded as “present on admission” because it was present and acquired at the facility prior to the hospitalization.
• If a resident who has a pressure ulcer that was “present on admission” (not acquired in the facility) is hospitalized and returns with that pressure ulcer at the same numerical stage, the pressure ulcer is still coded as “present on admission” because it was originally acquired outside the facility and has not changed in stage.
• If a resident who has a pressure ulcer is hospitalized and the ulcer increases in numerical stage during the hospitalization, it should be coded as “present on admission” at that higher stage upon reentry.

5. Section GG is a brand new section will have its own rules to follow as well as some new Medicare Part A assessments.

• The new assessments are Start of Medicare A Stay and End of Medicare A Stay. Both assessments have a 3 day look back. It is imperative that you have supporting documentation available for the first three days of the Medicare stay and the last three days of the Medicare stay. This means you will need a process in place to obtain documentation from off shift and on weekends and holidays.
• “During a Medicare Part A SNF stay, residents may have self-care limitations on admission. In addition, residents may be at risk of further functional decline during their stay in the SNF.”
• “For the purposes of completing Section GG, a “helper” is defined as facility staff who are direct employees and facility-contracted employees (e.g., rehabilitation staff, nursing agency staff). Thus, does not include individuals hired, compensated or not, by individuals outside of the facility's management and administration such as hospice staff, nursing/certified nursing assistant students, etc. Therefore, when helper assistance is required because a resident’s performance is unsafe or of poor quality, only consider facility staff when scoring according to amount of assistance provided.”
• Admission or Discharge Performance Coding Instructions: 
  • Code 06, Independent: if the resident completes the activity by him/herself with no assistance from a helper.
  • Code 05, Setup or clean-up assistance: if the helper SETS UP or CLEANS UP; resident completes activity. Helper assists only prior to or following the activity, but not during the activity. For example, the resident requires assistance cutting up food or opening container, or requires setup of hygiene item(s) or assistive device(s).
  • Code 04, Supervision or touching assistance: if the helper provides VERBAL CUES or TOUCHING/ STEADYING assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. For example, the resident requires verbal cueing, coaxing, or general supervision for safety to complete activity; or resident may require only incidental help such as contact guard or steadying assist during the activity.
  • Code 03, Partial/moderate assistance: if the helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort.
  • Code 02, Substantial/maximal assistance: if the helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.
  • Code 01, Dependent: if the helper does ALL of the effort. Resident does none of the effort to complete the activity; or the assistance of two or more helpers is required for the resident to complete the activity.
  • Code 07, Resident refused: if the resident refused to complete the activity.
  • Code 09, Not applicable: if the resident did not perform this activity prior to the current illness, exacerbation, or injury.
  • Code 88, Not attempted due to medical condition or safety concerns: if the activity was not attempted due to medical condition or safety concerns.

It is more important than ever to not only understand all of the changes, but also understand how they affect Case Mix, Quality Measures, and Five Star Rating. For more information about these changes, subscribe to the Richter Sharesource Blog.