Understanding RAI Manual Coding Updates and Avoiding Common Coding Errors

October 1, 2016 brought forth some significant changes to the Resident Assessment Instrument (RAI) Manual used by minimum data set (MDS) nurses throughout the country.

The RAI Manual is essentially an MDS nurse’s bible. It explains how to code and provides the rational for coding every single item on the MDS. If you have a question, it has the answer. My manual has never been far from me and the many notes and dog eared pages throughout it are a testament to that.

Today, the manual can be referenced online, so there is no need to carry the five inch binder around (although I still keep mine in the trunk of my car just in case). While the online version is a much better travel companion, I feel like we are not able to really dig our heels in and read it. For that reason, some items are much more likely to be miscoded in this new era of technology. Here are some of the most common areas I've found in which miscoding occurs:

Section E: Rejection of care E 0800 can be difficult to code at times, especially if the resident is cognitively impaired and cannot express their desires. It is important to differentiate between rejection of care and the resident’s choice. The RAI User’s Manual defines rejection of care as “…behavior that interrupts or interferes with the delivery or receipt of care.”

The manual states, "rejection of care is not based on what the facility staff has established as their own goals for the resident; rather, staff should seek to ascertain what the resident’s goals are for his or her own well-being, health, functional status and life satisfaction. These goals help define an acceptable quality of life for each individual resident.”

The RAI User’s Manual instructions indicate that as long as a behavior is considered a rejection of the resident’s own goals for him or herself, and it occurred during the seven day look-back period on subsequent MDS assessments, it should continue to be coded as rejection of care, even if it has been thoroughly addressed in the care plan.

Section GG: This was a brand-new section last October, and has its own rules to follow. This section will be completed Start of Medicare A Stay and End of Medicare A Stay. Both assessments have a three-day look-back. It is imperative that you are able to 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. The way we will code this section is also different. This should include the resident’s “usual performance” for mid-loss activities of daily living (ADLs). These are assigned numbers from one to six, six being the most independent.

Section H: In order to code H0200 as “yes,” the toileting program must include a specific approach that is organized, planned, documented, monitored, evaluated and consistent with the facility’s policies, procedures and current standards of practice. The resident’s chart must meet the following requirements:

• Implementation of an individualized, resident-specific toileting program that was based on an assessment of the resident’s unique voiding pattern
• Evidence that the individualized program was communicated to staff and the resident (as appropriate) verbally and through a care plan, flow records and a written report
• Notations of the resident’s response to the toileting program and subsequent evaluations, as needed

Section I: Section I is intended to be a complete list of active diagnoses only. Active diagnoses are those that have a direct relationship during the seven day look-back period to the resident’s functional status, cognitive status, mood, behavior, medical treatments, nursing monitoring or risk of death. Any diagnosis for resolved conditions should not be included in this section.

Diagnosis by physician must have been entered in the chart within 60 days. This can include new diagnosis and monthly recap of orders if the diagnosis is included in the orders. Diagnosis must still meet the  seven day lookback requirements to be considered active.

The only exception to this rule is for urinary tract infections, which have a 30 day look-back window.

Section J: There has been recent clarification regarding the coding of injuries directly related to falls: “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.”

Section K: In order to check K0510A for Parenteral/IV feeding, the fluids must be specifically for a nutrition or hydration need:

• IV fluids or hyperalimentation, including total parenteral nutrition (TPN), administered continuously or intermittently
• IV fluids running at KVO (Keep Vein Open)
• IV fluids contained in IV Piggybacks
• Hypodermoclysis and subcutaneous ports in hydration therapy
• IV fluids can be coded in K0510** if needed to prevent dehydration, or if the additional fluid intake is specifically needed for nutrition and hydration. Prevention of dehydration should be clinically indicated and supporting documentation should be provided in the medical record.

** The following are NOT to be coded in K0510A: IV Medication, IV fluids used to reconstitute and/or dilute medications for IV administration, IV fluids administered as a routine part of an operative or diagnostic procedure or recovery room stay, IV fluids administered solely as flushes, parenteral/IV fluids administered in conjunction with chemotherapy or dialysis.

Section M: This includes changes that 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.

Section N: The common coding error for this section is that often times the reviewer codes medications for their use rather than class.

                Example 1:  Mrs. Jones receives 25mg of diphenhydramine every night at bedtime to help her sleep. Should this be coded as a sedative/hypnotic? You first must determine the class of the medication. In this case the medication is a histamine-blocker, therefore it does not meet the criteria set forth in Section N.

                Example 2: Mr. Jones is receiving reglan10 mg three times a day for diabetic gastroparesis. Should this be coded in Section N? Again we need to determine the classification of the medication. In this case, reglan or metoclopramide is an antipsychotic, and therefore would be included in Section N.

Section P: Restraint coding has been one of the most common mistakes to date. The key terms used when discussing restraints are “remove easily” and “freedom movement.” Let’s start out with these definitions:

• Remove easily: the resident should be able to remove the device in the same manner in which it was applied, considering the resident’s functional abilities
• Freedom of movement: any change in place or position for the body or any part of the body that the person is physically able to control or access

It is also important to evaluate every possible restraint and document your findings once determined.

Section V: We have recently seen an increase in the focus of Care Area Assessments (CAAs) by surveyors. One of the most common mistakes in this section is that departments complete their CAAs prior to the MDS being completed in its entirety.  This is problematic because there is substantial crossover in the CAAs. There are items that trigger CAAs throughout all sections of the MDS, not just the correlating area(s). If the dietician completed their section K on the MDS, he/she must wait until all other sections of the MDS are complete before moving on to the CAAs.

Section Z: Item Z0500A is the location of the RN Assessment Coordinator’s signature, which verifies assessment completion. Often times, I see this signature by someone who is not an RN. This item in the RAI Manual very specifically states this is to be an RN. The date that goes with this signature is to be the date the pen touches the paper or the date the actual electronic signature is applied. This signature and date is attesting to the completeness of the assessment, therefore will be added after the competition of the MDS in its entirety.

While the RAI Manual is more easily accessible online, it is important to still remember to fully abide by it. I hope my tips and tricks to avoid these common errors will help you achieve success.  

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