MDS 3.0: Three Things You Need to Know Now

The MDS – Minimum Data Set – is an important tool for implementing standardized assessment and for facilitating care management in nursing homes. The Centers for Medicare and Medicaid Services (CMS) has said that the revisions in MDS 3.0, which goes into effect October 1st, will impact residents, families, providers, researchers, and policymakers.

Several years in the making, MDS 3.0 was declared almost finished in mid-July 2010, and training materials were posted on the CMS website in almost-final form.

According to the CMS website, “MDS 3.0 has been designed to improve the reliability, accuracy, and usefulness of the MDS, to include the resident in the assessment process, and to use standard protocols used in other settings. These improvements have profound implications for NH and SB care and public policy. Enhanced accuracy supports the primary legislative intent that MDS be a tool to improve clinical assessment and supports the credibility of programs that rely on MDS.”

The long-awaited revisions to MDS 2.0, which was last updated in 2002, have sparked everything from outrage to guarded optimism in the healthcare sector.

Whether you’re looking forward to the changes (and some are) or you anticipate disaster (as some do), knowing a few key facts will help you get ready to embark on the October odyssey.

1. The Deadline for Compliance Is October 1st 
   
      No really – this time they mean it.

Yes, we know the original implementation was supposed to take place in October of 2009. We know the training materials were revised, were supposed to be finalized in May, and didn’t actually near completion until July, with less than 3 months left before the deadline. But the long wait is over and things are finally settling down: The latest and last major training material update – posted on CMS’s Skilled Nursing Facilities/Long-Term Care Open Door Forum July 19 – read as follows: 

MDS 3.0 RAI Manual V1.02 July 15, 2010 – Note: This update includes the following revisions of the RAI Manual: Appendix A and H (the item sets in Appendix H have not changed since they were last published in November 2009). The revised manual is now complete with the exception of Appendix F which is forthcoming.

So, the great majority of the MDS 3.0 training materials are now final, and the federal government has no plans to extend the October 1st deadline.  Since the MDS drives almost everything the entire interdisciplinary team does in long term care –surveys, reimbursement, quality measures, and information that will be available to the public – it behooves providers and staff to be ready for full compliance October 1st, since reimbursement can be withheld starting October 2 for those who cannot prove compliance. There is no grace period or learning curve allowance!

The Living Deadline – Rug-IV
Believe it or not, whether or not Resource Utilization Groups, Version 4 (RUGS IV) billing goes effect this October or next is still up in the air. A partial delay of RUGS IV was signed into law on March 23, 2010, when President Obama signed the healthcare reform bill.  But a repeal of that delay was slipped into H.R. 5712 – the Veterans', Seniors', and Children's Health Technical Corrections Act of 2010 – which was introduced on July 13th and passed the House July 14th. If it passes the Senate – still unknown at press time – the delay would be repealed, and CMS will implement RUG-IV in full this October.  You can read more about H.R. 5712 at http://www.gop.gov/bill/111/2/hr5712 and http://www.mcknights.com/house-repeals-rug-iv-delay-doc-fix-extended-to-dec-1/article/176292/.

Hang on to your hats!

2. Interviewing Required as Part of Resident Assessment

One of CMS’s major goals in MDS 3.0 was to gives residents and their families a more active voice in their care. Thus, new interviewing processes are in place in MDS 3.0 to help caregivers extract quality, accurate information from patients with efficient, focused questions. Appendix D of the RAI manual discusses interviewing techniques – so give it a read before the deadline!

Parts of MDS 3.0 that include resident interviews are:

Section C - Cognitive Patterns
Section D - Mood
Section F - Preferences for Customary Routine & Activities
Section J - Pain - in Health Conditions
Section Q - Return to Community/Overall Goals

The Brief Interview for Mental Status (BIMS) replaces the MDS 2.0 staff assessment for cognition in patients who can be understood. You can find the content of the interview in Chapter 3, Section C, page C-2 of the MDS 3.0 RAI Manual.

The Patient Health Questionnaire (PHQ 9; Resident Mood Interview) replaces staff observations for patients who are capable of reporting mood symptoms, and the Staff Assessment of Resident Mood (PHQ-9-OV) replaces old staff assessment and is only used for patients who cannot self report.. Guidelines about whether to administer the interviews and the interviews themselves are covered in Chapter 3, Section D of the MDS 3.0 RAI Manual.

The Interview for Daily Preferences is covered in full in Chapter 3, Section F, as is the Interview for Activity Preferences and the Staff Assessment of Daily and Activity Preferences – along with guidelines for administering each.

As you might guess, the remaining interviews are located in Chapter 3, Sections J and Q of the MDS 3.0 Manual, and you can learn what they are by looking those sections up. The best advice, other than any courses your facility is providing, for learning how to interview effectively? Practice, practice, practice!

3. Now You See It, Now You Don’t: Concurrent Therapy and Look-backs

Concurrent Therapy: Under the MDS 2.0 and RUG-III, concurrent therapy minutes could be counted as one-on-one therapy minutes. That meant that a therapist who provided 90 minutes of therapy to three residents who were all doing different exercises could “capture” (read: bill) 90 minutes for each resident...for a total of 280 minutes, which the facility could bill at the higher individual rate.

MDS 3.0 imposes significant limitations on CT. It includes three distinct entries for therapy: “Concurrent,” “Group,” or “Individual.” The bottom line is that the number of revenue-generating treatment minutes may no longer exceed actual therapist treatment time (with limited exceptions for Group therapy). In addition, CT is limited to two patients per session, no matter who the payer is, and the therapist must exercise his/her professional judgment to divide concurrent therapy minutes evenly.  Basically, Medicare Part A is enforcing a “one-on-one” treatment model. Facilities that billed a lot of concurrent therapy may have to scramble to add therapy time – perhaps by extending the hours therapy is performed or adding extra days or weekends – to avoid the loss of significant revenue. On the other hand, facilities that rarely used concurrent therapy may see an increase in revenue.

The MDS 3.0 RAI Manual, Section O, Special Treatments and Procedures, p. O-14, describes CT coding instructions thus:

“Concurrent minutes—Enter the total number of minutes of therapy that was provided on a concurrent basis in the last 7 days. Enter 0 if none were provided. Concurrent therapy is defined as the treatment of 2 residents at the same time, when the residents are performing two different activities, regardless of payer source, both of whom must be in line-of-sight of the treating therapist or assistant for Medicare Part A. For Part B, residents may not be treated concurrently: a therapist may treat one resident at a time, and the minutes during the day when the resident is treated individually are added, even if the therapist provides that treatment intermittently (first to one resident and then to another).”

Look Back:  Under MDS 2.0 and RUG-III, clinical staff could “look back” into a resident’s hospital stay for intravenous medications/fluids to capture a high revenue Rehab + Extensive Services RUG. Two separate changes will disallow this practice under MDS 3.0 and RUG-IV. RUG-IV does not recognize most services residents receive “While not a resident” of the facility, and IV medications/fluids will no longer be Extensive Services qualifiers (IV medications provided in-house will qualify for Clinically Complex).

Under RUG-IV, Extensive Services qualifiers include only ventilator and tracheotomy care (while a resident) and isolation due to active infection. If you do not provide this level of care, you won’t capture an “X/L” category.

Conclusion

These three steps are by no means anything other than the tip of the iceberg for care providers – but one thing all experts seem to agree upon is that the way to ensure this iceberg doesn’t sink your facility lies with training and preparation.

Overall, MDS 3.0 is the carefully thought out and critically needed culmination of years of research into elder care. We’re sure that despite the inevitable glitches and momentary pain of transition, the very thing that made you choose care giving as a career will see you through: The desire to provide for others the kind of quality care you’d want for yourself and your family.