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The problem with nurses’ notes - page 7 / 12





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November 2009

PPS Alert for Long-Term Care

Page 7

Consistency is crucial

structions and procedures to follow when assessing and coding each section of the MDS 2.0.

Assessing another person’s cognitive functions can be subjective. To prevent inconsistent or inaccurate coding of Section B, SNFs should ensure that staff members follow the same procedures and guidelines for inter- preting, measuring, and coding cognitive functions in residents.

“Nursing facilities can help prevent inaccurate or incon- sistent coding in Section B by making sure their staff fol- low the guidelines included in the manual,” Riggin says.

“The RAI User’s Manual is an excellent resource, and I can’t stress how important it is for everyone, even the most sea- soned nurses, to read and reread it on a regular basis.”

“When this information is not gathered from a new resident’s family, these indicators of delirium are often coded as a 2, meaning new onset or different from usual functioning,” Riggin says. “But in actuality, the behavior

is not new to the resident, but new to the facility.”

“Two mistakes facilities often make with Section B is that they don’t involve staff members from all shifts or they don’t make sure all staff members are on the same page,” Riggin says.

Fortunately, the RAI User’s Manual provides specific in-

Capturing preadmission IV medications

Steps to help your SNF get the necessary documentation

IV medications provided during a resident’s acute care stay can be significant sources of revenue for SNFs. As long as IV medications were provided within the 14-day

Fortunately, there are steps SNFs can take to solve this

problem and receive reimbursement for IV medications provided in the acute care stay while they still can.

look-back period, they can be coded on the MDS 2.0 and counted toward resource utilization group (RUG) place- ment, which determines the reimbursement rate for a particular resident.

However, to code these IV medications on the MDS, fa- cilities must get supporting documentation from the acute care provider, which can be quite a challenge for SNFs.

“Capturing IV medications on the MDS is more im- portant than ever because once RUG-IV is implemented in 2010, services provided prior to SNF admission will

no longer contribute to a resident’s RUG score and reim- bursement rate,” says Maureen McCarthy, president of Celtic Consulting in Goshen, CT. “Until then, it is in our best interest to make sure we are capturing these IV medications on the MDS.”

So what happens if a SNF is unable to get supporting documentation from the acute care provider?

“Without the supporting documentation from the hospital, SNFs can’t code for the IV medications and, therefore, lose that reimbursement,” McCarthy says.

Documentation requirements

There are myriad reasons why it can be difficult to get supporting documentation from acute care providers, such as tight budgets or busy medical records departments. Re- gardless of the reason, SNFs should understand exactly

what documentation is required from the hospital before taking matters into their own hands.

The documentation from the hospital must indicate the last date the resident received IV medications. If a SNF does not know when the IV medications were last pro- vided, it cannot determine whether the date falls within the 14-day look-back period and, therefore, cannot code

these IV medications on the MDS. Facilities should make sure the documentation from the hospital includes the last date the resident received the IV medications.

“One of the biggest problems is that SNFs sometimes get medication reconciliation forms, which typically do

not list the last day the medication was received,” says

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    continued on p. 8

© 2009 HCPro, Inc.

For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at www.copyright.com or 978/750-8400.

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