Section A, I, J,  and O Updates

Section A, I, J, and O Updates

September 14, 2019 0 By Ewald Bahringer


»» Good morning everybody. So we’re going to go over the changes in A,
I, J and O this morning. I just want to reiterate a little bit of what
Brigitte said which is if you take out handout Number 3, those are your acronym lists. Handout Number 4 is your Action Plan. And handout Number 13 is one that Brigitte
did not mention, but it is the practice scenarios that we’ll be going over during this presentation. So you might want to have those handy as we
go through some of the Slido questions. So as always, we start with a couple of slides
of the acronyms that are going to be used in the presentation. So this is the first set of acronyms. And this is the second set. And now we’ll move on to our objectives. So after participating in this session, you
should be able to describe the changes that have occurred in sections A, I, J and O and
knowing enough to be able to answer some of the practice coding scenarios. And actually, some of the information that
you’ll learn during this presentation will also help you in the PDPM Case Study that
John and Jen are going to be leading you on this afternoon. So let’s start right off with Section A. So
the intent of Section A is to obtain key information to uniquely identify each resident, the home
in which he or she resides and the reasons for the assessment. So facility provider numbers had a couple
of changes here. And it was mostly for clarification. Item A0100B, the CMS Certification Number,
the addition here is that if A0410 equals 3, which is the federally required assessment,
the CCN number must be there. It cannot be blank. And for item A0100C, the State Survey Agency
was actually added to this bullet, just to let you know that it is the state survey agency
that assigns this number. You probably already knew that, but it was
just for clarification. So the next item is A0300 and that is the
Optional State Assessment. This slide shows you the two different item
set snapshots. If you remember from yesterday morning’s presentation,
the top snapshot of A0300 is what you’ll see on every other item set except the OSA. The second snapshot that’s on that slide,
the bigger one, allows you to identify the type of assessment that you are completing
for the state. So you’ll only see that item on the OSA. And also, as I mentioned yesterday, the OSA
is State optional. It’s not federally required. And it was created to allow providers the
ability to collect data required for the state payment reimbursement. It’s important to note that the OSA is a standalone
and it cannot be combined with any other assessment. So the coding instructions are very straightforward
for the OSA, if your state requires you to complete the OSA, you’re going to enter, yes,
which is 1. And if not, you’re going to enter 0, which
is no. And when you enter all of the information
into the OSA, what it’s going to do is it’s going to help calculate the HIPPS code for
state payment purposes. If you don’t know if your State is going to
be using the OSA, you might want to talk to your State agency. If you already know that your State is going
to be using the OSA, you need to contact them to talk to them about the completion requirements
for the OSA. So the other thing that was mentioned at the
last training was that you are going to be able to submit the OSA to QIES ASAP. And it will also give you a Validation Report. So you’ll have that. We had some folks asking, well, that doesn’t
really make sense, why would we send that to QIES ASAP? So that’s kind of how it works now. (Laughter) So when you send your assessments
into QIES ASAP they accept all of the assessments, and then they push out a State file. So it’s kind of what happens now. And that’s also one of the reasons why CMS
doesn’t like you to submit Medicare Advantage plan information, because all of it goes into
that MDS file that gets pushed out to States and the States can’t have that, and actually
CMS can’t have that information. So A0310, Type of Assessment. And this will look familiar to you from yesterday,
basically, the changes here of course are in the PPS area, which is A0310B, quite a
few of the assessment types have been removed and we know why. It’s because they’re not needed on the PDPM. And this slide just highlights for you that
section itself. So what we’re left with are just those three
response codes for the 5-day PPS which is 01, the IPA which is 08, and 99 which is none
of the above. The coding instructions were also updated
to accommodate the new IPA, which again, you learned about yesterday morning and which
we’ll hear a little bit more about in John’s presentation later this afternoon. And all the coding instructions for all those
item sets that no longer exist were also removed from the manual. For item A0310E, there were a couple of small
clarifying edits made there. The first was to amend the coding tips to
accommodate the IPA. You’re going to code A0310E as 0 for an IPA. And that is because the 5-day would have to
have already been completed in order for an IPA to be completed. So if you remember from yesterday morning,
the ARD for an IPA can’t proceed that of a 5-day. And that makes sense, right. Because the 5-day has to be completed before
the IPA. The second clarification here is in the note. The acronym OBRA was added here to say that
the first submitted assessment may not be a OBRA Admission Assessment. And we had some folks ask why that is. Well, if you recall, if you have a newly certified
facility, if an Admission Assessment was already completed prior to the certification date,
the facility would just continue on with the OBRA schedule and the next expected assessment
using the actual admission date as day one. This is referring back to that policy. The next assessment wouldn’t be an entry in
OBRA. It could be a quarterly, it could be a discharge. So when the facility submits that next assessment,
all you get is that sequencing warning saying, you know, this seems like out of order to
us, but you still submit that assessment. That’s what this is referring to, it’s referring
back to that policy. Okay. A0310G type of discharge. The only change here really was that a coding
tip was added to enter the number of the type of discharge that you’re going to complete. So 1 for planned, 2 for unplanned. Again, something you already knew but it wasn’t
in the manual. So here is the new item for interrupted stay,
the item number is A0310G1. And this is associated with the PDPM. Here is a snapshot of that new item which,
as you can see, again, is a very simple item, a yes/no response. You’ll see this item on the comprehensive
for an entry, quarterly and PPS Assessments, nursing home and swing bed and the OBRA discharge. In this item you’ll indicate whether or not
an interrupted stay has occurred. You’re going to Code 0, no, if an interrupted
stay did not occur, and code 1, yes, if an interrupted stay did occur. So now we’re going to go a little bit more
into the interrupted stay policy. I gave you the definition yesterday. So an interrupted stay is a Medicare Part
A SNF stay in which a resident is discharged from SNF care, that is, the resident is discharged
from a Medicare Part A covered stay and subsequently resumes SNF care in the same SNF for a Medicare
Part A covered stay during the interruption window. The interruption window is the first non-covered
day following a Part A covered stay ending at 11:59 p.m. on the third consecutive non-covered
day following a Part A stay. And when we talk about resumption of care,
or the Part A covered stay, we mean that if a resident was in the Medicare Part A SNF
stay and they’re discharged from Part A, the resident must resume Part A services or return
to the same SNF to resume Part A services if they were physically discharged by 11:59
p.m. at the end of that third calendar day. In order to be considered an interrupted stay,
the conditions that I spoke about on the last slide and shown here a little bit more abbreviated
need to be met. The resident has to be discharged from a Part
A stay and they either return to the facility to resume Part A services in the same SNF
or resume care if they remained in the same facility by 11:59 p.m. at the end of that
third day. The subsequent stay following an interruption
is considered a continuation of the previous Part A stay for the purposes of the Variable
Per Diem schedule and for PPS Assessment completion. So what this means is the assessment schedule
and Variable Per Diem schedules do not reset after an interrupted stay. And that’s because the Part A stay doesn’t
end. So the Variable Per Diem and PPS Assessment
completion schedules just continue from the point prior to discharge and John will talk
a little bit more about that in his presentation. As I’ve stated, the interrupted stay policy
can apply to residents who are either physically discharged or those who remain in the facility. The information here on this slide shows some
of the reasons for which the discharge from Part A can occur. These can include the resident leaving against
medical advice or the resident could be transferred to acute care, a psychiatric hospital, out-patient
facility due to a change in condition or for an evaluation of treatment, or the resident
could go to another type of facility like a SNF, an assisted living, a private residence,
or home with home health services. Remember, if they do get discharged from Part
A and they leave the facility, it would only be considered an interrupted stay if the resident
returned to the same facility within that 3-day window. If they don’t return within that 3-day window,
it’s not an interrupted stay. On this slide, we see some examples of situations
where a resident remains in the facility but the Part A stays stops being covered under
the PPS benefit. These situations could include the election
and revocation of the hospice benefit, refusal to participate in rehabilitation, and there’s
no other daily skilled need, the resident’s payer source changes from Medicare Part A
to another payer source like Part C, or private pay, private insurance, hospice. So remember again here, if the resident does
get discharged from Part A, it would only be considered an interrupted stay if the resident
resumed Part A services within the 3-day window. If they did not, it’s not an interrupted stay. So let’s look at some examples of what would
be considered an interrupted stay and what assessments or records are required on discharge
and then resumption of Part A. One example of an interrupted stay would be if a resident
is discharged from SNF care, remains in the SNF, and resumes Part A covered stay in the
SNF within the interruption window. In this instance, no Discharge Assessment,
OBRA, or Part A PPS is required nor is an entry tracking record or 5-day required on
resumption. The subsequent stay is considered a continuation
of the previous Medicare Part A covered stay. This is considered an interrupted stay because
the criteria were met, there was a discharge from Part A, and the resumption of Part A
was within that 3-day interruption window. Makes sense so far? Another example of an interrupted stay would
be if a resident physically leaves the SNF and returns to resume Part A covered services
in the same SNF within the interruption window. On discharge, no Part A PPS discharge is required
because in this situation the Part A PPS stay doesn’t end, right? However, because the resident physically left
the facility, your OBRA rules take over here. So you have to complete an OBRA discharge
in this instance. Now of course you’re going to decide whether
its discharge return anticipated or not anticipated. Mostly you’re probably going to say return
anticipated, I would think. So on return to the same SNF, an Entry Tracking
Record would be required but no 5-day would be required. And that is, again, because the interrupted
stay doesn’t cause the Part A stay to end and the subsequent stay is still considered
that continuation of the Medicare Part A stay. One thing to remember is that when a person
physically leaves the facility, again, you have to follow those OBRA rules. So don’t get them confused with what’s required
for interrupted stay and not and what’s required for OBRA. Okay. Now, let’s look at another couple of examples
when there is no interrupted stay. If a resident is discharged from SNF care,
remains in the SNF and does not resume Part A within that interruption window, an interrupted
stay did not occur. In this situation, a Part A PPS discharge
is required and if the resident qualifies, a resumption of Part A occurs within the 30-day
window allowed by Medicare, a 5-day would be required. But no changes would be made to the OBRA schedule
at all. It would just continue from the resident’s
original date of admission which you would see in A1900. The subsequent stay would be considered a
new Part A stay. This is not considered an interrupted stay
because both of those criteria I mentioned weren’t met. Even though there was a discharge from Part
A, the resident did not resume Part A services within that 3-day interruption window. And finally, if a resident physically leaves
the SNF and does not return to resume Part A services within the same SNF, within the
interruption window, again, an interrupted stay did not occur. In this situation, both the OBRA Discharge
Assessment and the Part A PPS Discharge Assessment would be required and of course they can be
combined. If the resident did return to the same SNF,
that subsequent stay would be considered a new Part A stay and an Entry Tracking Record
and 5-day would be required. Now on the OBRA side of the equation, an OBRA
admission would be required if the discharge was completed return, not anticipated. If the discharge was return anticipated, no
OBRA assessment would be required. Does that make sense? Okay. This is not, again, considered an interrupted
stay because the criteria were not met for interrupted stay. Even though there was a discharge from Part
A, the resident did not return to the SNF to resume Part A services within that three-day
interruption window. Okay. We’re going to try some practice scenarios. So if you have your Slido ready, that would
be great. So Mr. J was receiving skilled services in
a SNF under Medicare Part A for rehabilitation. Mr. J fell and was sent to an acute care hospital
for an evaluation. Since staff expect Mr. J to return to the
facility, he was discharged return anticipated. Mr. J left the SNF on 4/23 at 4:00 p.m. and
returned to the same SNF to resume skilled services under Part A on 4/25 at 7:00 p.m. So the first question is, is this an interrupted
stay? Choose A for yes or B for no. Quite a few people coming in right away with
A. I’m going to wait a little bit longer here. Numbers continue to climb. So I’m going to wait just a couple more seconds. But it looks overwhelmingly like A might be
what folks think the answer is. Okay. So we’ll move on to the correct answer. And it’s A, yes, it is an interrupted stay. And of course the rationale here is that the
interrupted stay policy applies to residents who leave the facility and are discharged
from Part A and return to the same SNF resuming Part A services within a 3-day interruption
window. Transfer to an acute care hospital is part
of this policy. Additionally, the two criteria for interrupted
stay were met. It’s that Mr. was on skilled services under
Part A when he transferred to the acute care hospital and he returned to the same SNF before
the end of that third calendar day which is within that interruption window. Okay. Here’s another question associated with that
scenario. Which of the following assessments are required
when Mr. J leaves the facility? Is it A the OBRA discharge? B, Part A PPS discharge? C, combined Part A PPS discharge and OBRA
discharge? Or D, none of the above? Okay. We’ve got quite a few people choosing OBRA
discharge. We’ve got some numbers changing still. So I’m just going to wait a little bit longer
here. Okay. Let’s move on and see what the answer is. Correct answer is A, OBRA discharge, that’s
right. And the rationale here is that because Mr.
J had an interrupted stay, his Part A PPS stay did not end and therefore the Part A
PPS discharge was not required. However, because he physically left the facility,
the OBRA Discharge Assessment was required. Okay. You have one more question associated with
this. Which of the following assessments/records
are due when Mr. J returns to the facility to resume Part A services? Is it the 5-day assessment? The OBRA admission? An Entry Tracking Record? Or is it A and B which are 5-day and an OBRA
admission? We’ve got overwhelmingly folks looking at
the Entry Tracking Record. And it doesn’t look like the others are changing
much. So I think we can go on to the answer. And the answer is C, Entry Tracking Record. That’s correct. And the rationale here is that the Entry Tracking
Record is required anytime a resident leaves and returns to the
facility, he or she was discharged from and returns to the facility within 30 days. Right? That’s your typical Entry Tracking Record
requirements. So since Mr. J was discharged return anticipated,
an OBRA admission wasn’t required, right? Had he been discharged return not anticipated,
an OBRA admission would have been required in this situation. And then on return to the SNF, no 5-day was
required because Mr. J’s Part A PPS stay did not end because he was in an interrupted stay. As far as the payment, the resumption on the
Variable Per Diem schedule would come from the day of discharge again because the Part
A stay did not end. Okay. So let’s move on to A0410 which is the unit
certification or licensure designation item. The change in this item is under code 1, the
coding instructions were clarified to add “neither CMS nor the State has authority to
collect MDS information for residents on the unit.” This is pretty much what it always meant. So basically, again, the addition of CMS here
is just to clarify that neither CMS nor the State can receive that information. The item rationale for A0410 was updated basically
to state that nursing homes should only be submitting MDS for those residents who are
on a Medicare or Medicaid-certified unit and that swing bed facilities should only be submitting
MDS assessments for those whose stay is covered by Medicare Part A benefits. So that’s new. A0600, social security and Medicare numbers. There have been a couple of changes here. The update in A0600A is that a valid social security
number should be submitted in this item whenever it’s available. And that’s because they need this on the back
end for resident matching. So that needs to be as accurate as possible. The update made in A0600B was that the parenthetical
statement that was there which was “or comparable railroad insurance number” was removed and
the coding instructions were updated to add code 08 for the IPA and to say that A0600B
must be a Medicare number. The definition also changed to state that
the Medicare number is different, it used to say it may be different from the social
security number and may contain both of those both letters and numbers. So A0700, Medicaid number. A coding instruction was just added here to
include that a letter can also be part of that number. A0800, Gender. This just had one clarification and that was
that the coding instruction was updated to say that the resident gender has to match
what’s in the system on the social security side. A1500 and A1510, these are the PASRR items. So the parenthetical statement mental retardation
in federal regulation was removed from the item set in both A1500 and A1510. This language had already been removed from
the text of the manual and we are just making sure that the item set matches that now. The next item is A2400 which is the Medicare
stay. In this snapshot, what you’ll notice is up
at the top, right under where it says A2400 Medicare stay, there’s a new sub header, and
the sub header says complete only if A0310G1 equals 0. This corresponds to the first coding tip here
on this slide and relates to the interrupted stay policy. A2400 is only completed when there has not
been an interrupted stay. That’s because when there is an interrupted
stay, the subsequent stay is considered a continuation of the Medicare Part A stay,
so it’s not a new Part A stay. When the OBRA Discharge Assessment indicates
that an interrupted stay has occurred, that is if A0310G1 equals 1, items A2400A through A2400C
are inactive, you won’t see them active on your item set. Moving onto Section I, Active Diagnoses. The items in this section are intended to
code diseases that have a direct relationship to a resident’s current functional, cognitive,
mood or behavior status, medical treatments, nursing monitoring, and risk of death. And of course, the important functions of
the MDS are to generate an updated an accurate picture of a resident’s current health status. Starting with I0020. This item is used as a risk adjuster for the
new Skilled Nursing Facility Quality Reporting Program Functional Outcome Measures. And those, as you learned yesterday from Alice,
include quality measures that look at self care and mobility discharge scores and the
changes in those scores. I0020B is also used in PDPM to identify the
primary diagnosis clinical category. So the revisions to these items you can see
highlighted on this slide. The older version is in the upper left corner
and the new version is in the lower right. Since I0020 is associated with the Part A
stay, it’s completed only if A0310B equals 01 which is the 5-day. One of the revisions to this item is the sub
header and that is the item will also be completed on an IPA, you’ll see there A0310B equals
08. There have been three additional revisions
in this item as you can see in the snapshot to the lower right. The I0020 response code number 14, other medical
condition was removed as was I0020A. Now you just have there I0020B, which is now
where you’re going to enter your ICD code. So the item rationale here is that disease
processes can have significant adverse effects on a resident’s functional improvement and
therefore improve their quality of life. Under planning for care, this item is going
to identify the primary medical condition category that best describes the primary reason
for the admission to the SNF stay so that you can plan for the resident’s care. In order to complete this item you need to
identify the resident’s primary medical condition category that best describes that primary
reason for the Medicare Part A admission. The places that you’ll look for, this information
can vary, but generally, you’ll find resident diagnoses in any one or a combination of the
medical record sources listed on this slide. The most recent history or physical, a transfer
document from the prior acute stay, discharge summaries, progress notes and other resources
as you have them available to you. Most frequently, but not always, the diagnosis
you’ll get from the acute stay. Of course, although open communication regarding
all of this information is really important, it also needs to be documented. So make sure that you have your documentation
aligned with the resident information that’s coming in. In order to complete I0020, the first step
is to identify the diagnoses associated with the SNF admission and assign it to one of
13 primary medical condition categories that best describe the primary reason for that
admission to the SNF. It may be that the resident has some documented
diagnosis for which you believe more than one of these medical conditions could apply. What you’re going to do is choose the one
that has the most effect on the resident’s health and function the most. So the first seven categories here are stroke,
non-traumatic brain dysfunction, traumatic brain dysfunction, non-traumatic spinal cord
dysfunction, traumatic spinal cord dysfunction, progressive neurological conditions, and other
neurological conditions. This slide has the remaining six of those
categories, which are amputation, hip and knee replacement, fractures and other multiple
trauma, other orthopedic conditions, debility, cardiorespiratory conditions, and medically
complex conditions. So once you indicate the resident’s primary
medical condition category, you’re going to enter the ICD code for that condition in I0020B. Remember that the ICD code in the item is
used in the PDPM to identify the primary diagnosis clinical category. Again, this item is completed on the 5-day
or on the IPA. You will still include the primary medical
condition code in item I0020 in Section I0100 through I8000 which are the active diagnoses
in the last seven days. This slide and the following three show the
response codes for each of the 13 primary clinical categories with the examples included. I’m not going to go through all of the details
on each of these, but they’re here for your reference. They’re also obviously in the manual. These are the examples for codes 01 through 03, and
for codes 04 through 06, and for 07 through code 10. There is one thing that I do want to point
out about code 10 is, that if a hip replacement is secondary to a hip fracture, you’re going
to code it as code 10 fracture. You’re not going to code the hip replacement
code. You’re going to code under fractures under
10. Then code 11, through code 13. We did have a question come in about what
category you would choose for a circulatory surgery or a digestive surgery. And for circulatory, you would code 12. That would be under debility cardiorespiratory
conditions. And for digestive, you would code that under
13, medically complex. Let’s look at some practice coding scenarios
for I0020. In these practice scenarios, you’re going
to notice that there are some ICD codes provided there. And I just wanted to let you know that they’re
just examples, there could be other different ones, but these are the ones that were chosen
for these particular scenarios. So Mr. K is a 67-year-old male with a history
of Alzheimer’s dementia and diabetes who was admitted for Part A after a stroke. The diagnosis of stroke as well as the history
of Alzheimer’s dementia and diabetes is documented in Mr. K’s history and physical
by the admitting physician. So how would you code I0020? Would you code it under Code 01, which is
A? Code 06, B? Code 12, C? Or code 13, D? It looks like an overwhelming amount of people
are looking at stroke. Everybody good? We’re well over 335. I do encourage the people that are watching
online to also participate if you can. Okay. It looks like we can go on to the answer. And yes, the answer is code of 01 stroke. The rationale is that the physician’s history
and physical documents the diagnosis of stroke as the primary medical reason that resulted
in Mr. K’s admission to the SNF. Remember, item I0020 is not asking why the
resident is skilled in the SNF, it’s asking for the diagnosis that best represents the
primary medical condition category that resulted in the resident’s admission to the SNF. So keep that in mind. As noted here on the slide, they could have
used ICD Code I69.051 which is hemiplegia and hemiparesis following a non-traumatic
subarachnoid hemorrhage to code the ICD code. Here’s the second practice coding scenario. Mrs. H is a 78 year-old female with a history
of hypertension and a hip replacement two years ago. She had an extended hospitalization for idiopathic
pancreatitis. She had a central line placed during the acute
care stay to receive total parenteral nutrition or TPN. During her stay, Mrs. H is being transitioned
from taking nothing by mouth and receiving TPN with the goal of being able to tolerate
oral nutrition. The hospital discharge diagnosis of pancreatitis,
hypertension, and malnutrition was incorporated into Mrs. H’s medical record. So how would you code I0020? Would you choose A, Code 09? B, Code 10? C, Code 11? Or D, Code 13? Wow. Quite a few right out of the gate with D.
I’m just going to wait a couple more minutes here. It looks like people are still responding. Okay. Let’s move on to the answer. And yes, the answer is Code 13, medically
complex conditions which was D. So I0020 would be coded as, 13, medically
complex conditions because Mrs. H had hospital care for pancreatitis immediately prior to
her SNF stay. Her principle diagnosis of pancreatitis was
included in the summary from the hospital. The surgical placement of a central line doesn’t
change her care to surgical care because it’s not considered major surgery. Again, the ICD code here that was provided
for this example was K85.00 which is idiopathic acute pancreatitis without necrosis or infection. Okay. Let’s move on to I5900 which is bipolar disorder. As you can see in the snapshot in the upper
left corner of the slide, the label of I5900 says “manic-depression bipolar disease.” This has just been simply revised to say “bipolar
disorder” which is more appropriate. And that’s seen on the snapshot in the lower
right hand corner of the slide. We’re on to Section J. There were a couple
of small changes in items J1800 and J1900. We have two new items in this section to look
at as well. So under the intent statement, Section J was
updated to reflect those new items in this section. So the intent statement now reads that the
items in this section assess dyspnea, tobacco use, prognosis, problem conditions, falls,
prior surgery, and surgery requiring active SNF care and surgical procedures. So there are a couple of changes in J1800. And they relate to falls. The coding instruction for Code 0, no, in
J1800 was updated to allow for a new skip pattern. So you see that new skip pattern highlighted
on the screen there. You notice now if you Code 0, no, you’re going
to skip to the swallowing disorder item which is K0100. If you’re completing a 5-day and code 0, no,
you’re going to skip to J2000, which is the prior surgery item. So obviously, what you’re seeing there is
for the 5-day. So J1900, a couple more changes here in this
section. And they’re in the examples. This is just a reminder for you of what J1900
looks like. This item captures the number of falls since
admission, entry or reentry or prior assessment, whichever is more recent. So in the Example 1, there was language added
to clarify that Mrs. K slipped out of her wheelchair onto a dining room floor. She did have an assessment to make sure she
was okay. So there wasn’t any language in there that
talked about an assessment being completed. So it was added that a range of motion assessment
was completed prior to her being assisted back into the wheelchair which indicated no
injury. And that shortly after the fall the staff
completed a skin assessment to ensure there were no injuries to her skin. The coding and the rationale for that example
did not change. And then for Example 5, this example supports
the idea that when a resident falls, an injury may not necessarily show up immediately after. And sometimes you may need to go back and
correct an assessment that’s been submitted to acknowledge that an injury did occur during
that time frame. So in the example that’s in the manual, the
resident fell on his right hip and the quarterly assessment was completed and submitted showing
that the resident had no injury because the assessment of the resident and the initial
x-ray didn’t show any injury. But a few days later the resident complained
of increasing pain in the right hip and had difficulty ambulating so a follow up x-ray
was completed and that showed a hairline fracture of the hip. The physician noted that that fracture was
indeed attributable to the fall that occurred during the look-back period of that recently
submitted quarterly assessment. So when we look now at the coding for the
example, the rationale in the coding for the modification of the quarterly assessment did
not change. What did change was the addition made in the
original coding to clarify that J1900C, Major Injury was originally coded as 0, none on
the quarterly that was originally submitted. So the overall rationale for coding did not
change. But it’s provided here for context, so I’m
going to summarize it. So even though the extent of the injury didn’t
present right after the fall, it was directly related to the fall. And since the assessment was already submitted
to QIES ASAP with an inaccurate code of no injury, the SNF had to go back and modify
that quarterly assessment to reflect that there was an injury sustained during the fall
that occurred during the look-back of that quarterly assessment. So let’s move on to the new item, J2100, Recent
Surgery requiring active SNF care. J2100 would only be completed if the assessment
is a 5-day which is A0310B is 01, or an IPA which is A0310B equals 08. If you answer J2100 as 1, yes, then you’ll
complete the other new item in this section which is surgical procedures and those are
items J2300 through J5000. Looking at the item rationale for J2100, a
recent history of major surgery during the inpatient stay that’s directly prior to the
resident’s Part A admission can affect a resident’s recovery. So it’s important information for you to know. This item identifies whether the resident
had a major surgery during that inpatient stay that preceded the resident’s Part A admission
which will require active care while that person is in the SNF. In order to complete the assessment, you will,
as always, talk to the resident and family, or significant other about surgical procedures
that occurred during the inpatient hospital stay that immediately preceded the Part A
admission. You’re also obviously going to review the
medical record and information that comes to you from the inpatient hospital stay and
similar to I0020, you’re going to look at all those same medical
record resources to get that information. Coding of J2100 also should be supplemented
and supported by the documentation that you have in the medical record. So to code J2100, you are going to enter no,
0 if the resident did not have major surgery during that inpatient stay that preceded the
Part A admission. And you’re going to code 1, yes if major surgery
did occur. You’re going to code 8, unknown if you don’t
know or can’t determine if there was a major surgery in that prior inpatient stay. So the coding tips here in J2100 refer to
the criteria that constitute major surgery. In J2100, they’re similar to what we have
in J2000, Prior Surgery but the difference there is the time span. So in J2000, we look at 100 days prior to
admission to the SNF for surgery. But for J2100, major surgery refers to a procedure
that occurred during an acute care hospital inpatient stay of at least 1 day and 30 days
prior to the admission to the SNF. The surgery did have to carry some degree
of risk to the resident’s life, or potential for severe disability. So now let’s look at the surgical procedures
which are J2300 through J5000 and how this interacts with J2100. So this is just a partial snapshot of what
the item looks like. As you can see from this snapshot, there are
surgical procedures listed that are grouped under major headings such as major joint replacement,
spinal surgery, other orthopedic surgery, and so on. There are other headings not shown here that
include cardiopulmonary surgery, Genitourinary surgery, and other major surgery. This is a check-all-that-apply item so you
are going to check all that apply for the resident. As you can see here for each of the procedures,
there are examples provided. As we said previously, this item is only completed
if J2100 is coded 1, yes, which means that the resident did have a major surgery requiring
SNF care. The item rationale for J2300 through J5000
is essentially the same as in J2100 and that is that a recent major surgery can affect
the resident’s recovery, that this item identifies whether the resident did have a major surgery
during the inpatient stay immediately prior to the admission to the SNF. So there’s a two-step process to determine
whether or not the surgery identified requires active care in a SNF. The first is to identify recent surgeries
that have been documented by a physician and all of those non-physician practitioners,
right. So anytime I say physician, think nurse practitioner,
physician assistant, any of those folks that are allowed under state licensure law to diagnose. And that would have to have occurred within
the last 30 days and during the inpatient stay that preceded the Part A admission. The second step is to determine whether the
surgery identified requires active care during the SNF. Surgeries that require active care during
the SNF stay are surgeries that have a direct relationship to the resident’s primary SNF
diagnosis. So you’re looking back at I0020B. You’re not going to include conditions that
have been resolved or don’t affect the resident’s current status and don’t drive the patients
or the resident’s plan of care. So you’re going to check information sources
in the medical record for the last 30 days to identify active surgeries. And you’re going to find that information
in the same areas that we talked about already. So transfer documents, discharge summaries,
progress notes, other resources that you have available to you. And again, remember whatever’s communicated
verbally should be documented in your medical record and aligned with the care that the
resident’s going to receive. How do you determine whether a surgery should
be coded as requiring active care during the SNF stay? Well, there may be specific documentation
in the medical record that indicates the SNF stay is for treatment related to the surgical
procedure. This may be documented again by a physician
or those non-physician practitioners. A determination of whether a surgery should
be coded as requiring active care during the SNF stay can also be made even if there is
no specific documentation but the complexity of the services prescribed for the resident
can only be performed safely and effectively by or under the general supervision of skilled
nursing and/or rehabilitation staff such as surgical wound care, for example, to monitor
infection or drainage, daily skilled therapy to restore functional loss after a surgical
procedure, and administration of medication and monitoring that requires skilled nursing. The reasoning here is not so much different
than what it is mentioned in Section I regarding active diagnoses when there’s no specific
documentation. So there, for example, the manual says to
look at signs and symptoms that would relate back to a specific diagnosis like intermittent
claudication for peripheral vascular disease or medication that was prescribed for ongoing
condition that requires nursing monitoring. Okay. So let’s just go over some of the key points
here. Once you’ve determined if the surgical procedure
requires active care during the SNF stay, you’re going to complete items J2300 through
J5000 by checking all of the surgical procedures that apply and are documented to have occurred
during the last 30 days and during that inpatient stay that preceded the resident’s Part A admission
and that also have a direct relationship, again, to the ICD code in I0020B. All of this has to also drive the resident’s
plan of care. In reference to inpatient stays at the May
training, somebody asked if admission to observation stay was included in coding these items, and
no. Admission to observation stay is not considered
inpatient. Right, a person is only considered an inpatient
when they’re formally admitted to the hospital by a physician. So let’s look at some practice coding scenarios
for J2100. So in this first scenario, Mrs. V was hospitalized
for gram-negative pneumonia. Since this was her second episode of pneumonia
in the past six months, a diagnostic bronchoscopy was performed while she was in the hospital. She also has Parkinson’s disease and rheumatoid
arthritis. Mrs. V was discharged from the acute care
hospital to a SNF for continued antibiotic treatment for her pneumonia and she requires
daily skilled care. How would you code J2100? Would you Code 0, no? 1, yes? Or 8, unknown? Okay. Quite a few people are already starting out
with Code 0, no which is choice A. A little bit of vacillation between B and C. But it
looks like the majority are going for A. Okay. It looks like the changes are only adding
to A, so let’s go on to the answer. And the answer is, yes, A, Code 0, no. J2100 is coded, 0, no, because there is no
documentation that indicates that the resident had major surgery during the prior inpatient
stay before she was admitted to the SNF for continued care due to needing antibiotic treatment
for her pneumonia and the requirement for daily skilled care. If we were coding I0020, it would be coded
as 13, Medically Complex Conditions. And for I0020B, the SNF ICD-10 code that the
SNF could have used there is J15.6 which is pneumonia due to other aerobic gram negative
bacteria. Okay, let’s try another scenario. Mr. O is a diabetic who was hospitalized for
sepsis from a methicillin-susceptible staphylococcus aureus infection that developed after out-patient
bunion surgery. A central line was placed to administer antibiotics
and he was discharged to a SNF for continued antibiotic treatment and monitoring. How would you code J2100 for this resident? Would it be A, Code 0? No, b, code 1, yes. And C code 8, unknown? And again, quite a few people starting off
with Code A, some working on code B. Okay. And it looks like most of the changes are
happening in code A. Let’s move on to the next slide. And yes, the answer is Code 0, no which was
choice A. So this was coded no because there was no documentation that indicated that the
resident had major surgery. Neither the placement of a central line nor
the out-patient bunion surgery would be considered major surgery, but the resident was admitted
to the SNF for continued antibiotic treatment and monitoring. If we were also coding I0020, this would
be coded as 13, Medically Complex Conditions. And for example, since the infection was staphylococcus
aureus, the SNF would choose in this instance, A41.01, which is sepsis due to methicillin
susceptible staphylococcus aureus. We have one more practice coding scenario. Mrs. J had a craniotomy to drain a subdural
hematoma after falling at home where according to the hospital discharge summary, she had
a loss of consciousness of about 45 minutes. She has COPD and she uses oxygen at night. In addition, she has moderate congestive heart
failure. She’s moderately overweight and has hypothyroidism. After a 6-day hospital stay, she was discharged
to a SNF for continuing care. How would you code J2100 in this instance? Would you choose O, no? 1, yes? Or 8, unknown? We have quite a few people looking at code
B. And it looks like it’s mostly the majority. Okay. I think it’s safe to say that we can go on
to the answer slide for this one. And that’s correct. Code 1, yes is the correct response. And this would be coded, 1, yes, because there
is documentation that indicates the resident had major surgery which was a craniotomy. She was inpatient in an acute care hospital
for at least 1 day in the 30 days prior to her admission to the SNF. The surgery did carry some degree of risk
to the resident’s life or potential for severe disability. If we were coding I0020 it would be coded
here as 07 which is other neurological conditions. And the ICD code in I0020B might have been
S06.5X2D which is a traumatic subdural hemorrhage with loss of consciousness of 31 to 59 minutes
subsequent encounter. In this instance, you would also check J2600
which is neurosurgery of the brain surrounding tissue or blood vessels. Okay. Now we’re onto Section O, how is everybody
holding up? Coffee kicking in? (Laughter)
Okay. Remember that the intent of Section O is to
identify any special treatments, programs, or procedures that the resident received during
the specified times that are within these items in Section O. So the first change that you’re going to see
is in O0400 which is therapies. Group therapy was updated as you well know
now from 4 to 2-6 as of the publishing of the SNF PPS Final Rule. This information was also updated in the group
minutes steps for assessment, co-treatment for Part A and modes of therapy in the group
therapy Medicare Part A section of the manual. The examples in this section were also revised
with using more updated years. I think a lot of them had 2010 so they updated
them all to more current years. The next item that we’re going to focus on
is a new item, O0425, Part A Therapies. This item was added due to the new PDPM payment
system. This slide and the two following are snapshots
of O0425 which captures for each type of therapy the number of minutes the different modes
of therapy were received by the resident since the start date of the resident’s most recent
Medicare Part A stay as documented in A2400B. The modes of therapy include individual, concurrent,
and group therapy. Co-treatment minutes and therapy days are
also included in this item. These items are only captured at the end of
a resident’s Part A stay on the Part A PPS discharge indicated by A0310H equals 1. So you have a section here for speech-language
pathology and audiology services. The same section for occupational therapy,
and another one for physical therapy. The item rationale for O0425 speaks to how
critically important it is for the maintenance of as much independence as possible in activities
of daily living, and mobility and communication is to most people. I’m thinking all of us. Functional decline of course can lead to things
like depression, withdrawal, social isolation, breathing problems, complications of immobility
such as pressure ulcer/injuries and incontinence and these, of course, all do contribute to
a diminished quality of life. The qualified therapist along with a physician
and nursing is responsible to determine the necessity for and the frequency and duration
of therapy services provided to residents. Rehabilitation, whether it’s speech-language
pathology, OT, PT, respiratory, psychological, recreational therapy, all of this can help
residents attain and/or maintain their highest level of well being and improve their quality
of life. And as part of planning for care, what we’re
looking at in this section are only those medically necessary therapies that occurred
after admission or readmission to the nursing home that were ordered by a physician or those
non-physician practitioners and based on the qualified therapist assessment and treatment
plan. Those that were documented in the resident’s
medical record and care planned and periodically evaluated to ensure that the resident receives
needed therapies and current treatment plans are effective, or those that occurred either
inside or outside the facility. You can find definitions of the types of therapies
listed in this section in the glossary in Appendix A of the RAI Manual. Regarding the steps for assessment in this
item, as I stated previously, you’re going to complete this item at the end of a Part
A stay on the Part A PPS Discharge Assessment. In order to collect the information required
to complete this item, providers should review the resident’s medical record such as the
rehab therapy evaluation and treatment records, recreational therapy notes, mental health
professional, progress notes and you should be consulting with each of these qualified
care providers. Since this item captures the entire stay,
we would be looking to obtain this information starting with day 1 all the way through to
the last day of the Part A stay. So all of your calculations will be completed
on the backend of your software, generally with the result being percentage of all therapies
provided to the resident. If the combined amount of group and concurrent
by discipline is over 25%, it would be deemed as noncompliant. And you would receive a warning message on
your Validation Report about that. So this slide was provided to show you how
these items would be calculated manually. So if you want to perform this exercise for
yourself you can do that following the steps on this slide or you can let your software
do it for you. I mentioned these earlier but the modes of
therapy included that a resident may receive are individual, concurrent and group. These may be provided during the same day
or even during the same treatment session. When developing your plan of care, the therapist
and assistant must determine the modes of therapy and the amount of time the resident
receives for each mode of therapy and code it on the MDS as appropriate. The therapist and assistant should be documenting
the reason for choosing a specific mode of therapy as well as anticipated goals for that
mode of therapy. For any therapy that does not meet one the
therapy mode definitions, those minutes may not be counted on the MDS. For detailed descriptions of how to code minutes
of therapy and an explanation of skilled versus non-skilled therapy services, co-treatment,
therapy aids and students, please refer to these topic headings under item O0400 in Section
O of the RAI Manual because those would apply here as well. So I’m going to briefly go over the coding
instructions for each mode of therapy for speech, occupational, and physical therapies. This information is for Part A only as I’m
sure you know there are different rules for Part B. So this is just for Part A.
So for individual therapy, that is treatment that is provided by one therapist or assistant
to one resident at a time. To enter individual minutes, you’re going
to enter the total number of minutes of therapy that were provided on an individual basis
during the entire Part A stay. So remember from Day 1 to the last day. And you’re going to enter 0 if none were provided. Concurrent therapy, that is treatment of two
residents at the same time when the residents are not performing the same or similar activities,
regardless of payer source, both of whom must be in the line-of-sight of the treating therapist
or assistant. To enter minutes for concurrent therapy, you’re,
again, going to look over the total minutes for the entire Part A stay. And if none were provided in concurrent therapy,
you’re going to enter 0. Group therapy is the treatment of two to six
residents, regardless of payer source, who are performing the same or similar activities
and are supervised by a therapist or an assistant who is not supervising other individuals. So for group minutes again, you’re going to
enter all of those minutes that occurred during that Part A stay and you’ll enter 0 if none
were provided. So finally, we’re going to look at co-treatment
which is when two clinicians, therapists or therapy assistants, each from a different
discipline, treat one resident at a time with different treatments. To enter co-treatment minutes, you’ll enter
the total number of minutes each discipline of therapy was administered to the resident
in co-treatment sessions during that entire Part A stay. If no co-treatment minutes were administered,
you’re going to skip to item O0430 which is distinct calendar days. Again, for all of these modes of therapy,
you’re going to refer to O0400 in Section O for detailed definitions and examples. Okay. So now we’re going to look at therapy days. Remember that a day of therapy is defined
as skilled treatment for 15 minutes or more provided during the day. You are going to use total minutes of therapy. So that’s individual, plus concurrent, plus
group without any adjustment to determine if a day is counted. So if a resident receives more than one therapy
discipline on a given calendar day, this may only count for one calendar day for coding
this item. For example, if a resident received 20 minutes
of concurrent therapy, that day requirement would be considered met. That’s nothing new. Okay. So coding therapy days is the same for all
three types of therapy. For speech-language pathology, you’re going
to enter the number of days that speech-language pathology therapy services were provided over
the entire Part A stay. You’ll enter 0 if therapy was provided but
for less than 15 minutes every day during the stay. And if the total minutes, individual plus
concurrent, plus group, during the stay is 0, you’re going to skip this item and leave
it blank. So that same pattern holds true for occupational
therapy. You’re going to enter the number of days of
OT services that were provided over the entire Part A stay. You’ll enter 0 if therapy was provided for
less than 15 minutes every day during the stay. And if the total number of minutes, individual,
plus concurrent, plus group during the stay was 0, you’ll just skip this item and you’ll
leave it blank. And again for physical therapy, the instructions
to complete are the same SLP and OT but for PT services. The next item we’re going to look at is O0430,
distinct calendar days of Part A therapy. This item is only completed on a Part A PPS
Discharge Assessment. And that’s indicated by coding A0310H as 1. This item records the number of calendar days
that the resident received speech, OT or PT for at least 15 minutes during the Part A
stay. For this item you’re going to enter the number
of calendar days that the resident received speech, OT, or PT for at least 15 minutes
a day during the entire SNF stay. If a resident receives more than one therapy
discipline on a given calendar day, this may only count again for 1 calendar day for the
purposes of coding this item. So we’re going to look at this example together. Mrs. T was admitted to the SNF on Sunday 10/6/18
and discharged on Saturday, 10/26/18. She received a total of 60 minutes of physical
therapy every Monday, Wednesday and Friday during the SNF stay. Mrs. T also received a total of 45 minutes
of occupational therapy every Monday, Tuesday, and Friday during the stay. So if we were to plot this out on a calendar,
it might look something like this. Given that the therapy services received by
Mrs. T during the stay, it would be 12 distinct calendar days in which Mrs. T received therapy
services. And that’s what would be coded in O0430. Because therapy services were provided for
at least 15 minutes on 12 distinct calendar days during the stay. Every Monday, Tuesday, Wednesday and Friday. Now some people were a little bit confused
about this example at the training in May saying that Mrs. T would not have been considered
skilled because she didn’t receive rehabilitation skilled services for at least five days. That would be correct if that was the only
skilled service she was receiving. But if she was receiving nursing skilled services,
she would be skilled. Does that make sense? So it’s important to remember that this item
really is only capturing skilled therapy services. Item O0450, Resumption Of Therapy. Good news here, this item is no longer required
by CMS. (Laughter) However, some States may continue
to require completion of this item. It’s important again to know, again, your
state’s requirements for completing this item. This will only be seen on the OSA. In O0500, restorative nursing. In the steps for assessment under restorative
nursing, in the third step bullets four and five have a statement included relating to
not coding services that actually require the involvement of a qualified therapist. So this step for assessment directs providers
to ensure that those services are coded in O0400 and O0425, not here in restorative nursing. Okay. It looks like I’m finishing a little early. In this lesson you learned about the updates
in Sections A, I, J and O and how to apply the coding instructions to accurately code
those practice coding scenarios, which you guys did a great job on. Hopefully it’s prepared you to be able to
integrate this knowledge into what you’re doing at your facilities. And hopefully it will help you later on in
the day when you’re completing the Integrated Coding and PDPM Case Study which we’ll be
doing this afternoon after John’s presentation. And again, just a reminder to complete your
Action Plan. If there’s anything that you learned in this
presentation that you will need to address when you turn back to your facilities, be
sure to notate it in the Action Plan page for this particular session. And if you have any questions, please enter
them into Slido. If you do, again, see any questions that are
similar to your own, just up-vote that question. Sometimes it may not be worded exactly as
the question you want to ask, but if you think the answer might be similar, I would suggest
that you up-vote that question instead of entering another one. So thank you so much for your time and attention
this morning. I’m going to turn it back over to Brigitte. (Applause).