An informa onal bulle n brought to you by polaris group cms released a draft copy of the minimum data set mds 3. Term care facility resident assessment instrument users manual, mds 3. Mds coding of pressure ulcers and other skin conditions stacey bryan rn, bsn, rac. This is the same material as the item above, except there are separate files for each chapter or subchapter. The items in this section are intended to code diseases that have a direct relationship to the residents current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death. Mdsrai changes and pdpm policy updates for october 1, 2019. Rai manual rehabilitation manual section s snf policies and procedures survey mds 3. Mdsrai changes and pdpm policy updates for october 1.
To ensure accurate formatting, use a current version of adobe acrobat reader to view this pdf. Planning for care orders for insulin may have to change depending on the residents condition e. Department of health and human service, centers for medicare and medicaid services cms. Once you are on this page, scroll down to the download section. The mds item sets and data submission specifications are available for download from the cms mds 3. On may 20th the centers for medicare and medicaid services cms issued an. Longterm care facility resident assessment instrument 3. A sliding scale dosage schedule that is written to cover different dosages depending on lab values does not count as an order change simply because a different dose is administered based on the sliding scale guidelines. Record the number of days a hypnotic medication was received by the resident at any time during the 7day lookback period or since admissionentry or. Please note this early release is being provided in response to stakeholder feedback. Coding tips mouth or facial pain coded for this item should also be coded in section j, items j0100 through j0850, in any items in which the coding requirements of section j are met.
Functional abilities and goals, the new part a pps discharge assessment, and clarifications to existing. Cms has released replacement pages for the rai manual with changes in three key sections of the mds. Speak with the treatment nurse and direct care staff on all. Ask the resident and his or her family or significant other about any surgical procedures in the 100 days prior to admission. Rai manual chapter 4 care area assessment process and. On august 26, 2016 the centers for medicare and medicaid services cms released the final revisions to the mds 3. Special treatments, procedures, and programs intent. The medical record documented that the resident did not receive scheduled pain medication during the 5day lookback period.
Department of health and human service, centers for medicare and medicaid services cms site. Rai manual chapter 2 chapter 2obra instructions there are no significant changes to the obra sections 2. The rai panel is a group of experienced rai coordinators who assist cms and other state rai coordinators in answering mds related questions. Caa resources april 2012 appendix c3 care area specific resources the specific resources or tools contained on the next several pages are provided by care area. An example of an established pressure ulcer risk tool is the braden scale for predicting pressure sore risk. This manual provides information about the electronic submission of mds 3. Ct state rai coordinator fall provider meeting 2019 identify the wound types coded on the mds. This video from the august 2019 skilled nursing facility snf quality reporting program qrp provider training held on august and 14. Cms publications referenced during this presentation.
Cms released a draft copy of the minimum data set mds 3. Review the medical record, including skin care flow sheets or other skin tracking forms, nurses notes, and pressure ulcer risk assessments. This training is current as of the date of this recording. Minimum data set training department of health and human. However, the coding instructions on pages n5 and n6, instruct providers to enter checkmarks instead of days. New rai manual still on hold news mcknights long term. Describe the characteristics the rai manual lists for each type of wound including.
The flowchart adl selfperformance algorithm, which describes the algorithm for adl function items in chapter 3 section g page g7, and the accompanying change table coding. The intent of the items in this section is to document a number of health conditions that impact the residents functional status and quality of life. Coding tips and special populations for sliding scale orders. Rai manual chapter 4 care area assessment process and care. Resident assessment instrument rai october 2017 page 18 3 how the assessment information is documented while remaining in compliance with the. This webpage includes the current version of the mds 3. Planning for care reevaluation of special treatments and procedures the resident received or performed, or programs that the resident was involved in during the 14day lookback period is important. Review the residents medical record to determine whether the resident had major.
Appendix d provides an overview of various interviewing. Care area assessment caa process and care planning this chapter provides information about the caas, care area triggers cats. The intent of the items in this section is to identify any special treatments, procedures, and programs that. The textbook associated with this course is required solely for the course taker to learn the underlying principles which they will apply in taking a casestudy based exam. H0200a, trial of a toileting program the lookback period for this item is since the most recent admissionentry or reentry or since urinary incontinence was first noted within the facility. Questions and answers for coding opiods in section. The april 2012 mds item set instructs providers to enter the number of days each of the medications listed were received in the last 7 days in item n0410, as does the screen shot of item n0410 on page n4 of the mds 3. In addition to the manual changes, there are changes to the. If the medical record reveals that the resident currently has a pressure ulcerinjury, a scar over a bony prominence, or a nonremovable dressing or. Providers, consultants, and industry associations who have mds questions should always first contact their state rai coordinator, who will then forward questions to the rai panel, if needed.
1456 341 1020 56 1189 229 80 1674 334 576 859 925 528 569 321 471 479 1285 776 809 880 1681 181 1530 965 1238 266 1397 187 1218 34 1557 1145 1364 1769 1137 1700 957 288