Definition: Legal name in record.
Coding: Use printed letters. Enter in the following order:
a. First Name
b. Middle Initial; if the resident has no middle initial, leave Item b. blank.
c. Last Name
d. Jr./Sr.
A2. Room Number
Intent: Another identifying number for tracking purposes.
Definition: The number of resident’s room in the facility.
Coding: Start in the left most box; use as many boxes as needed.
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Example
Mr. F lives in Room N305 at your facility. The N stands for New Building in your two building complex. The three hundred series of rooms are on the third floor. |
Intent: To establish a common reference point for all staff participating in the resident’s assessment. As staff members may work on a resident’s MDS assessment on different days, establishing the Assessment Reference Date ensures a common assessment period. In other words, the ARD designates the end of the observation period so that all assessment items refer to the resident’s objective performance and health status during the same period of time. See Chapter 2 for completion timing requirements for each assessment type.
Definition: This date refers to a specific end-point for a common observation period in the MDS assessment process. Almost all MDS items refer to the resident’s status over a designated time period referring back in time from the Assessment Reference Date (ARD). Most frequently, the observation period is a 7-day period ending on this date. Some observation periods cover the 14 days ending on this date, and some cover 30 days ending on this date.
Clarifications: ¨ The ARD is the common date on which all MDS observation periods end. The observation period is also referred to as the look-back period. It is the time period during which data is captured for inclusion on the MDS assessment. The ARD is the last day of the observation period and controls what care and services are captured on the MDS assessment. Anything that happens after the ARD will not be captured on that MDS. For example, for a MDS item with a 7-day period of observation (look back period), assessment information is collected for a 7-day period ending on and including the Assessment Reference Date (ARD), which is the 7th day of this observation period. For an item with a 14-day observation period (look back period), the information is collected for a 14-day period ending on and including the ARD (Item A3a).
NOTE: Medicare Fiscal Intermediaries have often used the term “completion date” differently when applied to SNF payment. For Part A billing, the RUG-III payment rate may be adjusted on the ARD of a non-scheduled assessment; e.g., Significant Change in Status or OMRA. In these situations, the ARD of the non-scheduled assessment has sometimes been referred to as the completion date, and is used to indicate a change in the RUG-III group used for payment.
¨ When the resident dies or is discharged prior to the end of the observation period for a required assessment, the ARD must be adjusted to equal the discharge date. Generally, facilities are required to complete these assessments after the resident’s discharge in order to bill for Medicare or Medicaid payment. Facilities have 2 options to choose from when adjusting the ARD to the date of discharge. In the first situation, changing the ARD shortens the observation period. Since some facilities prefer to use data for a full observation period, even if it means collecting more information on the resident’s condition prior to admission to the nursing facility, CMS has established a second option that would allow the nursing facility to establish a full observation period.
Option 1 - Change the ARD to the date of discharge, but complete the MDS using less than a full observation period. In this case, the Assessment Reference Date had been set at Day 5, and the resident was discharged after 4 days of the observation period. For items with a 7-day observation period, the MDS would be completed using the data collected for the 4-day period in the nursing facility and the 2-day period prior to admission.
Option 2 - Change the ARD to the date of discharge, but extend the observation period prior to the date of admission, and collect additional data to complete the assessment. Generally, this expanded observation period would require additional data from the prior hospital stay. In this example, if the resident was discharged after 4 days, the MDS would be completed using the data collected for the 4-day period in the nursing facility. For a 7-day assessment item, hospital data could be used for the 3-day period prior to the nursing facility admission.
Nursing facility providers must select one of these options and apply it consistently in all cases where the resident is discharged prior to the end of the observation period. It is not appropriate to change options on a case-by-case basis in order to increase reimbursement.
¨ The observation period may not be extended simply because a resident was out of the facility during a portion of the observation period; e.g., a home visit or therapeutic leave. For example, if the ARD is set at Day 14, and there is a 2-day temporary leave during the observation period, the two leave days are still considered part of the observation period. When collecting assessment information, you may use data from the time period of the LOA as long as the particular MDS item allows you. For example, section P7, if the family takes the resident to the physician, the visit may be counted. For information on coding minutes of therapy while the resident is out of the SNF, see pages 3-185 and 3-186. This procedure applies to all assessments, regardless of whether or not they are being completed for clinical or payment purposes.
¨ If the resident is admitted to the hospital prior to completing the Admission assessment, and returns to the facility, the facility staff may choose to complete the original Admission assessment or start a new assessment. If the staff chooses to complete the original assessment, then the original Assessment Reference Date must be retained and staff must properly identify those MDS items that can be coded only when furnished during the nursing facility stay. For example, services such as therapy or doctor visits occurring during the resident’s hospital stay would not be coded on the MDS. The facility can also choose to start a new assessment upon the resident’s return. The facility would then have 14 days from the return date (A4a) to perform the Admission assessment.
If the resident was in a Medicare Part A stay prior to the hospitalization, the facility will generally complete all or part of a 5-Day Medicare assessment in order to establish a RUG-III group for payment purposes. Then, when the beneficiary returns, the facility will complete a Medicare 5-Day Readmission/Return assessment (Item A8b=5). The Medicare Readmission/ Return assessment may be combined with the Admission assessment.
Coding: Complete the boxes with the appropriate date. Do not leave any boxes blank. If the month or day contains only a single digit, fill the first box with a “0”. Use four digits for the year. For example, August 2, 2002 should be entered as:
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0 |
8 |
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0 |
2 |
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2 |
0 |
0 |
2 |
This item appears on the MDS Reentry Tracking form-see forms in Chapter 1.
Definition: 1. Private Home or Apartment - Any house, condominium, or apartment in the community whether owned by the resident or another person. Also included in this category are retirement communities, and independent housing for the elderly.
2. Private Home/Apt. with Home Health Services - Includes skilled nursing, therapy (e.g., physical, occupational, speech), nutritional, medical, psychiatric and home health aide services delivered in the home. Does not include the following services unless provided in conjunction with the services previously named: homemaker/personal care services, home delivered meals, telephone reassurance, transportation, respite services or adult day care.
3. Board and Care/Assisted Living/Group Home - A non-institutional community residential setting that includes services of the following types: home health services, homemaker/personal care services, or meal services.
4. Nursing Home - An institution (or a distinct part of an institution) that is primarily engaged in providing skilled nursing care and related services for residents who require medical or nursing care, or rehabilitation services for injured, disabled or sick persons.
5. Acute Care Hospital - An institution that is engaged in providing, by or under the supervision of physicians for inpatients, diagnostic services, therapeutic services for medical diagnosis, and the treatment and care of injured, disabled or sick persons.
6. Psychiatric Hospital, MR/DD Facility – A psychiatric hospital is an institution that is engaged in providing, by or under the supervision of a physician, psychiatric services for the diagnosis and treatment of mentally ill patients. An MR/DD facility is an institution that is engaged in providing, under the supervision of a physician, any health and rehabilitative services for individuals who are mentally retarded or who have developmental disabilities.
7. Rehabilitation Hospital - An Inpatient Rehabilitations Hospital (IRF) that is engaged in providing, under the supervision of physicians, rehabilitation services for the rehabilitation of injured, disabled or sick persons.
8. Other - Includes hospices and chronic disease hospitals.
Process: Review admission records. Consult the resident and the resident’s family.
Coding: Choose only one answer.
A5. Marital Status
Coding: Choose the answer that best describes the current marital status of the resident: 1. Never Married, 2. Married, 3. Widowed, 4. Separated, or 5. Divorced.
A6. Medical Record Number
Definition: This number is the unique identifier assigned by the facility for the resident. If not on the medical record, it is available from the facility’s admissions office, business office, or Health Information Management Department.
A7. Current Payment Source(s) for Nursing Home Stay
Intent: To determine payment source(s) that covers the daily per diem or ancillary services for the resident’s stay in the nursing facility over the last 30 days.
Definition: a. Medicaid Per Diem - Room, board, nursing care, activities, and services included in the routine daily charge. Check this item if Medicaid is pending.
b. Medicare Per Diem – Room, board, nursing care, activities, and services included in the routine daily charge.
c. Medicare Ancillary Part A - Services such as medications, equipment for treatments, or supplies billed outside of the daily routine per diem charge.
d. Medicare Ancillary Part B
e. CHAMPUS Per Diem – The resident’s military insurance is covering daily charges.
f. VA Per Diem – The Veterans Administration has contracted with the facility to pay for the resident’s daily charges.
g. Self or Family Pays for Full Per Diem - Includes full private pay by resident or family.
h. Medicaid Resident Liability or Medicare Co-Payment - The resident is responsible for a co-payment.
i. Private Insurance Per Diem (Including Co-Payment) - The resident’s private insurance company is covering daily charges.
j. Other - Examples include Commission for the Blind, Alzheimer’s Association.
Process: Check with the billing office to review current payment sources. Do not rely exclusively on information recorded in the resident’s clinical record, as the resident’s clinical condition may trigger different sources of payment over time. Usually business offices track such information.
Coding: Check all that apply. We recognize that many facility staff have had a lot of difficulty in reporting payment source. To a great extent, the problems are the result of lack of information; business office staff is more aware of secondary insurance coverage than clinical staff. For this reason, we are evaluating the usefulness of this item in our MDS 3.0 development. For now, please continue to use the definitions provided. When evaluating the accuracy of MDS coding at a facility, errors in just the Payment Source item should not be heavily weighted. If the clinical coding and key identifiers are coded accurately, Payment Source errors should not be cited as evidence of inaccurate MDS processing.
A8. Reasons for Assessment
Intent: To document the key reason for completing the assessment, using the various categories of assessment types mandated by Federal regulation. For detailed information on the scheduling and timing of the assessments, see Chapter 2, Section 2.2.
a. Primary Reason for Assessment
Definition: 1. Admission Assessment (required by day 14)
2. Annual Assessment
3. Significant Change in Status Assessment
4. Significant Correction of Prior Full (Comprehensive) Assessment
5. Quarterly Review Assessment
6. Discharged-Return Not Anticipated
7. Discharged-Return Anticipated
8. Discharged Prior to Completing Initial Assessment
9. Reentry
10. Significant Correction of Prior Quarterly Assessment
0. NONE OF ABOVE - Use this code when preparing Medicare assessments or when your State requires you to complete one of the additional assessment types referenced in Item AA8b (below). It indicates that the assessment has been completed to comply with State-specific requirements (e.g., case mix payment). Select the code under Item AA8b (below) that indicates the Medicare or State Reason for Assessment. Also, use this code when completing a PPS-only assessment or an assessment for another payer, such as an HMO.
Coding: Enter the number corresponding to the primary reason for assessment. This item contains 2 digits. For codes 1-9, leave the first box blank, and place the correct response in the second box. If you were coding this item for an OBRA-only assessment, you would not complete the Medicare Reasons for Assessment (AA8b). However, if you were combining an OBRA assessment with a Medicare assessment, you would have a code in both Items AA8a and AA8b.
b. Assessment Codes Used for the Medicare Prospective Payment System
Definition: 1. Medicare 5-Day Assessment
2. Medicare 30-Day Assessment
3. Medicare 60-Day Assessment
4. Medicare 90-Day Assessment
5. Medicare Readmission/Return Assessment
6. Other State-Required Assessment
7. Medicare 14-Day Assessment
8. Other Medicare Required Assessment
Coding: Enter the number corresponding to the assessment code used for the Medicare Prospective Payment System. It is possible to select a code from both AA8a and AA8b (e.g., Item AA8a = coded “3” [Significant Change in Status assessment], and Item AA8b = coded “3” [60-Day assessment]). See Chapter 2, Section 2.6 for details on combining assessments.
If there are two Medicare Reasons for Assessment, i.e., an OMRA combined with a regularly scheduled Medicare assessment, code Item AA8b = 8.
When the Primary Reason for Assessment is “00”, and the Medicare Reason for Assessment is “6” or blank, the record is not edited or stored in the State MDS database. Facilities completing Medicare assessments on a standby basis should code AA8b as 1, 2, 3, 4, 5, or 7 to make sure that the assessments are properly edited and retained in the database.
A9. Responsibility/Legal Guardian
Intent: To record who has responsibility for participating in decisions about the resident’s health care, treatment, financial affairs, and legal affairs. Depending on the resident’s condition, multiple options may apply. For example, a resident with moderate dementia may be competent to make decisions in certain areas, although in other areas a family member will assume decision-making responsibility. Or a resident may have executed a limited power of attorney to someone responsible only for legal affairs. Legal oversight such as guardianship, durable power of attorney, and living wills are generally governed by State law. The descriptions provided here are for general information only. Refer to the law in your state and to the facility’s legal counsel, as appropriate, for additional clarification.
Definition: a. Legal Guardian - Someone who has been appointed after a court hearing and is authorized to make decisions for the resident, including giving and withholding consent for medical treatment. Once appointed, only another court hearing may revoke the decision-making authority of the guardian.
b. Other Legal Oversight - Use this category for any other program in your state whereby someone other than the resident participates in or makes decisions about the resident’s health care and treatment.
c. Durable Power of Attorney/Health Care - Documentation that someone other than the resident is legally responsible for health care decisions if the resident becomes unable to make decisions. This document may also provide guidelines for the agent or proxy decision-maker, and may include instructions concerning the resident’s wishes for care. Unlike a guardianship, durable power of attorney/health care proxy terms can be revoked by the resident at any time.
d. Durable Power of Attorney/Financial - Documentation that someone other than the resident is legally responsible for financial decisions if the resident becomes unable to make decisions.
e. Family Member Responsible - Includes immediate family or significant other(s) as designated by the resident. Responsibility for decision-making may be shared by both resident and family.
f. Resident Responsible for Self - Resident retains responsibility for decisions. In the absence of guardianship or legal documents indicating that decision-making has been delegated to others, always assume that the resident is the responsible party.
g. NONE OF ABOVE
Process: Legal oversight such as guardianship, durable power of attorney, and living wills are generally governed by State law. The descriptions provided here are for general information only. Refer to the law in your state and to the facility’s legal counsel, as appropriate, for additional clarification.
Consult the resident and the resident’s family. Review records. Where the legal oversight or guardianship is court ordered, a copy of the legal document must be included in the resident’s record in order for the item to be checked on the MDS form.
Coding: Check all that apply.
A10. Advanced Directives
Intent: To record the legal existence of directives regarding treatment options for the resident, whether made by the resident or a legal proxy. Documentation must be available in the record for a directive to be considered current and binding. The absence of pre-existing directives for the resident should prompt discussion by clinical staff with the resident and family regarding the resident’s wishes. Any discrepancies between the resident’s current stated wishes and what is said in legal documents in the resident’s file should be resolved immediately.
Definition: a. Living Will - A document specifying the resident’s preferences regarding measures used to prolong life when there is a terminal prognosis.
b. Do Not Resuscitate - In the event of respiratory or cardiac failure, the resident, family or legal guardian has directed that no cardiopulmonary resuscitation (CPR) or other life-saving methods will be used to attempt to restore the resident’s respiratory or circulatory function.
c. Do Not Hospitalize - A document specifying that the resident is not to be hospitalized even after developing a medical condition that usually requires hospitalization.
d. Organ Donation - Instructions indicating that the resident wishes to make organs available for transplantation, research, or medical education upon death.
e. Autopsy Request - Document indicating that the resident, family or legal guardian has requested that an autopsy be performed upon death. The family or responsible party must still be contacted upon the resident’s death and re-asked if they want an autopsy to be performed.
f. Feeding Restrictions - The resident or responsible party (family or legal guardian) does not wish the resident to be fed by artificial means (e.g., tube, intravenous nutrition) if unable to be nourished by oral means.
g. Medication Restrictions - The resident or responsible party (family or legal guardian) does not wish the resident to receive life-sustaining medications (e.g., antibiotics, chemotherapy). These restrictions may not be appropriate, however, when such medications could be used to ensure the resident’s comfort. In these cases, the directive should be reviewed with the responsible party.
h. Other Treatment Restrictions - The resident or responsible party (family or legal guardian) does not wish the resident to receive certain medical treatments. Examples include, but are not limited to, blood transfusion, tracheotomy, respiratory intubation, and restraints. Such restrictions may not be appropriate to treatments given for palliative reasons (e.g., reducing pain or distressing physical symptoms such as nausea or vomiting). In these cases, the directive should be reviewed with the responsible party.
i. NONE OF ABOVE
Process: You will need to familiarize yourself with the legal status of each type of directive in your state. In some states only a health care proxy is formally recognized; other jurisdictions allow for the formulation of living wills and the appointment of individuals with durable power of attorney for health care decisions. Facilities should develop a policy regarding documents drawn in other states, respecting them as important expressions of the resident’s wishes until their legal status is determined.
Review the resident’s record for documentation of the resident’s advance directives. Documentation must be available in the record for a directive to be considered current and binding.
Some residents at the time of admission may be unable to participate in decision-making. Staff should make a reasonable attempt to determine whether or not the new resident has ever created an advance directive (e.g., ask family members, check with the primary physician). Lacking any directive, treatment decisions will likely be made in concert with the resident’s closest family members or, in their absence or in case of conflict, through legal guardianship proceedings.
Coding: The following comments provide further guidance on how to code these directives. You will also need to consider State law, legal interpretations, and facility policy.
The resident (or proxy) should always be involved in the discussion to ensure informed decision-making. If the resident’s preference is known and the attending physician is aware of the preference, but the preference is not recorded in the record, check the MDS item only after the preference has been documented.
If the resident’s preference is in areas that require supporting orders by the attending physician (e.g., do not resuscitate, do not hospitalize, feeding restrictions, other treatment restrictions), check the MDS item only if the document has been recorded or after the physician provides the necessary order. Where a physician’s current order is recorded, but resident’s or proxy’s preference is not indicated, discuss with the resident’s physician and check the MDS item only after documentation confirming that the resident’s or proxy’s wishes have been entered into the record.
If your facility has a standard protocol for withholding particular treatments from all residents (e.g., no facility staff member may resuscitate or perform CPR on any resident; facility does not use feeding tubes), check the MDS item only if the advanced directive is the individual preference of the resident (or legal proxy), regardless of the facility’s policy or protocol.
Check all that apply. If none of the directives are verified by documentation in the medical records, check NONE OF ABOVE.
42 CFR 483.10 requires facilities to protect and promote the rights of each resident, including the right to “formulate an advanced directive.” There is no regulatory text specifying a location for advanced directive information. Unless there are State codes or regulations regarding this matter, the method of communicating the information is up to the facility. If documentation is not available in the resident’s clinical record, facility staff should be the source of this information, and surveyors will assess whether or not the staff knowledge and actions are in agreement with resident/family wishes. Some facilities elect to maintain the information in the resident’s clinical record and may even verify the advanced directive was properly prepared, i.e., not witnessed by someone who will benefit from the resident’s death. Make sure you are well aware of your facility’s policies.