#5. Coding for the Resident Mood Interview (PHQ-9) MDS Section D0200
It’s critical to have your team members educated and competent in both the process and the timing of the Mood Interview. After reviewing medical documentation of the patient, the PDPMpros are finding that often the PHQ-9 is not capturing the patients true affect, and this may be for a few reasons. Possibly the interviewee is not asking the questions correctly, or perhaps, the interviewee has not yet established a rapport with the patient, so therefore, the patient does not provide accurate answers. The PHQ-9 asks very “private” questions, so it is important that the person performing the interview has developed some trust with the resident. Another key point- the patient is supposed to recall how they felt over the last 14 days per the RAI manual. This is important to remember, and if the resident responds with noncommittal responses such as “not really,” we should be exploring that further with neutral questions like “What do you mean? Give me an example or Please be more specific.”
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#4. Coding for IV Fluids: Section K0510A
One of the rare areas of PDPM payment that comes directly from treatment outside of the SNF is capturing IV Fluids in section K0510A. In the PDPMPro audits, we are finding that this is one area that is commonly missed. Provided they were administered for nutrition or hydration purposes, all nutrition and hydration received by the resident in the last 7 days either at the nursing home, at the hospital as an outpatient or an inpatient is able to be captured in this section.
The PDPMpro’s advise you to follow the RAI guidelines that states - The following fluids may be included when there is supporting documentation that reflects the need for additional fluid intake specifically addressing a nutrition or hydration need. This supporting documentation should be noted in the resident's medical record according to State and/or internal facility policy.
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#3. Coding MDS Section GG
One of the most common areas of discrepancies that the PDPMPros are finding it a clear lack of training with how Section GG is supposed to be coded. It is critical for payment that GG areas are assessed based on the rules of the RAI manual. These rules should be educated to all interdisciplinary team members who collect the data for this section. Here are the facts per the RAI manual:
1. Code the resident’s usual performance for each activity based on observation or assessment. Do not record the best performance, do not code the worst performance, but the “usual” performance over the 3-day assessment period.
2. Functional performance should be assessed by the interdisciplinary team based on direct observation during the 3-day look-back period.
3. If the activity was not attempted, code the reason. Only use these codes if the activity did not occur, that is the resident did not perform the activity and a helper did not perform that activity for the resident.
4. Resident should complete the activity as independently as possible, as long as safe, without benefiting from any treatment interventions. They may use assistive devices to complete the activity which do not impact coding.
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#2. Coding for Isolation- MDS Section O0100
Since the start of the pandemic, the PDPMPros have been finding both missed opportunities as well as misuse of the coding for an active infection / isolation. The missed opportunity- not capturing this code when the patient is in isolation due to Covid-19 (or other active infections with highly transmissible or epidemiologically significant pathogens). The misuse- coding this when the patient is in isolation for a routine quarantine due to the pandemic. Without the “active infectious disease,” you cannot capture isolation in the MDS.
According to the RAI User’s Manual, Page O-5, to code for “single room isolation” all the following conditions must be met:
1. The resident has active infection with highly transmissible or epidemiologically significant pathogens that have been acquired by physical contact or airborne or droplet transmission.
2. Precautions are over and above standard precautions. That is, transmission based precautions (contact, droplet, and/or airborne) must be in effect.
3. The resident is in a room alone because of active infection and cannot have a roommate. This means that the resident must be in the room alone and not cohorted with a roommate regardless of whether the roommate has a similar active infection that requires isolation.
4. The resident must remain in his/her room. This requires that all services be brought to the resident (e.g. rehabilitation, activities, dining, etc.).
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#1. Active Diagnosis in the past 7 days – MDS Section I
In order to capture a diagnosis for PDPM, per the RAI, the diagnosis must be considered active. The RAI states the conditions in this section require “a physician-documented diagnosis (or by a nurse practitioner, physician assistant, or clinician nurse specialist if allowable under state licensure laws) in the last 60 days.” Furthermore, they should have a “direct relationship to the resident’s current functional status, cognitive status, mood or behavior, medical treatments, nursing monitoring or risk of death during the 7-day look-back period.”
The PDPMpros advise you to always confirm that there is supportive documentation in the medical record for the diagnosis as stated above. Since so many of our residents have long lists of diagnoses, it is critical to have your Physician and Non-Physician Practitioners keeping an active list of “all” diagnoses. We commonly see monthly visit summaries only skimming the surface.
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