The Centers for Medicare & Medicaid Services (CMS) recently released a revised version of the MDS 3.0 Resident Assessment Instrument (RAI) User’s Manual.

The changes were mostly clarifications and include:

Chapter 2

  • ADDED: If a resident goes from Medicare Advantage to Medicare Part A, the Medicare PPS schedule must start over with a 5-day PPS assessment as the resident is now beginning a Medicare Part A stay.  The 1st day of Medicare A becomes day 1 for the SNF PPS assessment. (Pg. 2-45)

Chapter 3

  • Hyperlinks updated
  • Coding Conventions:

REVISED: There are four date items (A2400C, O0400A6, O0400B6, and O0400C6) that use a dash-filled value to indicate that the event has not yet occurred. For example, if there is an ongoing Medicare stay, then the end date for that Medicare stay (A2400C) has not occurred, therefore, this item would be dash-filled. (Pg. 3-4)

  • C0100 Should the BIMS be conducted? Coding Tips:

NEW: Includes residents who use American Sign Language (ASL).           (Pg. C-2)

  • M0210 Unhealed Pressure Ulcers, Planning for Care:

REVISED: Pressure ulcer staging is an assessment system that provides a description and classification based on of anatomic depth of soft the extent of visible tissue damage. This tissue damage can be visible or palpable in the ulcer bed. Pressure ulcer staging and also informs expectations for healing times. (Pg. M-4)

  • M0210 Unhealed Pressure Ulcers, Coding Tips:

NEW:  Oral Mucosal ulcers caused by pressure should not be coded in Section M.  These ulcers are captured in item L0200C, Abnormal mouth tissue. Mucosal ulcers are not staged using the skin pressure ulcer staging system because anatomical tissue comparisons cannot be made.           (Pg. M-5).

REVISED: If a pressure ulcer is surgically closed (replaces “repaired”)  (Pg. M-5).

  • M0300D Stage 4 Pressure Ulcers Coding Tips:

NEW: Cartilage serves the same anatomical function as bone.  Therefore, pressure ulcers that have exposed cartilage should be classified as a Stage 4. (Pg. M-15)

  • M0800 Worsening in Pressure Ulcer Status Since Prior Assessment Coding Tips:

NOTE: Term ‘numerical staging’ is substituted for worsened, current, and was, as appropriate. (Pg. M-26)

  • M1040HMoisture associated skin damage MASD:

REVISEDMoisture associated skin damage (MASD) is a result of skin damage caused by moisture rather than pressure. It is caused by sustained exposure to moisture which can be caused, for example, by incontinence, wound exudate and perspiration. It is characterized by inflammation of the skin, and occurs with or without skin erosion and/or infection. MASD is also referred to as incontinence-associated dermatitis and can cause other conditions such as intertriginous dermatitis, peri-wound moisture-associated dermatitis, and peri-stomal moisture-associated dermatitis. Provision of optimal skin care and early identification and treatment of minor cases of MASD can help avoid progression and skin breakdown. (pg. M-35)

  • O0100M

Hyperlinks updated (Pg. O-5)

Chapter 5

 5.7 Correcting Errors in MDS Records That Have Been Accepted Into the QIES ASAP System.

  • Modification Request

REVISED: Effective May 19, a modification may now be used for typographical errors in the following items:

      • A0310: Type of Assessment; where there is no Item Set Code (ISC) change.
      • A1600: Entry Date
      • A2000: Discharge Date
      • A2300: Assessment Reference Date (ARD)
      • Clinical Items (B0100–V0200C)

NOTE: The ARD (Item A2300) can be modified when the ARD on the assessment represents a data entry/typographical error. However, the ARD cannot be altered if it results in a change in the look back period and alters the actual assessment timeframe.

An inactivation request is still required for errors in the following items:

      • A0200: Type of Provider
      • A0310: Type of Assessment; where there is an ISC change.

(Pg.5-10 &5-11)

Click here to access the updated manual.



CMS issues more in-depth survey guidelines to reduce readmissions; invites comments on assistant reporting

CMS issues final rule on Medicaid payments for preventable injuries and illness

The Centers for Medicare & Medicaid Services has revised the provider certification manual for hospitals, giving more in-depth guidelines around discharge planning. The goal is for hospitals to reduce readmissions by partnering with post-acute providers.

The update was made to the State Operations Manual, Hospital Appendix A.

Discharge planning evaluations should assess whether a patient’s post-discharge needs can be met in his or her next environment, such as a skilled nursing facility, the revision states. The evaluation also should consider whether the patient’s insurance would cover needed services in the next care setting. A discharge plan based on the evaluation must be developed and placed in the patient’s medical record in a timely fashion, the guidelines say.

The hospital is responsible for initial implementation of this discharge plan, including arranging the transfer, and providing information to the patient about the goal of treatment in the next setting. The revised guidelines also include new information about the requirement to give patients with skilled nursing needs a list of potential SNFs. Hospitals must disclose certain financial interests in these nursing homes.

The guidelines include a bulleted list of medical information that the hospital must give to the next care provider, such as a copy of the patient’s advanced directive, if there is one.

Blue boxes in the revised manual contain suggested best practices for discharge planning. Surveyors are not to cite hospitals for failing to adopt these practices. One suggestion is for hospitals to obtain input from SNFs and other post-acute providers when developing discharge planning policies and procedures. Click here to see the revisions to the manual and a related CMS memorandum.

In a separate action, CMS invited comments from nursing homes about feeding assistant reporting requirements. Providers have until June 17 to submit feedback about the requirement to keep a record of all paid feeding assistants. Click here for further information.

Updates on the Therapy Limitation and Manual Medical Review Process for Therapy Threshold

Posted 05/16/2013

This article will serve to notify providers of an update to the Manual Medical Review Process for claims impacted by the 2013 Therapy Threshold.

Effective with claims submitted on 4/1/13 and later are subject to subject to the Manual Medical Review Process will be reviewed by the Recovery Auditor (RA) Contractor. Supporting medical documentation must be submitted to the RA at the address indicated on the request. RAs will complete two types of review:

  • Prepayment Review – Claims submitted in the RA Prepayment Review Demonstration states will be reviewed on a prepayment basis (National Government Services states of Illinois and New York). A request will be generated from National Government Services for the supporting documentation once a claim for payment is submitted. Instructions regarding submission of that documentation will be included on the request indicating submission should be to the appropriate RA.
  • Post payment Review – In the remaining states National Government Services will issue payment on impacted claims. The appropriate RA will then issue a request for the supporting documentation on paid claims to complete the review post payment. Documents should be submitted to the RA.

As a reminder, medical documentation must be forwarded to the appropriate RA and not to National Government Services. Supplying documentation to National Government Services may result in a delay of a determination on your claim.

Please visit our Web site under Review Process > Medical Review to review the complete information related to the Manual Medical Review Process for Therapy Threshold for 2013.


FY2014 SNF PPS Proposed Rule: Draft Posted for Public Comment (5/13) CMS

SUMMARY: This proposed rule would update the payment rates used under the prospective payment system (PPS) for skilled nursing facilities (SNFs) for fiscal year (FY) 2014, would revise and rebase the SNF market basket, and would make certain technical and conforming revisions in the regulations text. This proposed rule also includes a proposed policy for reporting the SNF market basket forecast error correction in certain limited circumstances and a proposed new item for the Minimum Data Set (MDS), Version 3.0.

DATES: To be assured consideration, comments must be received no later than 5 p.m. on July 1, 2013.

SNF PPS 2014 Draft Rule Proposes to:

  1. Add item O0420 to the MDS Item Set, “Distinct Calendar Days of Therapy”. Effective October 1, 2013, facilities would be required to record under this item the number of distinct calendar days of therapy provided by all the rehabilitation disciplines over the 7- day look-back period for the current assessment, which would be used to classify the resident into the correct Rehabilitation RUG category based on the requirements for number of days of therapy.
  2. Revise and rebase the market basket total cost data from 2004 to data reflective of FY 2010 based SNF market basket index for routine, ancillary, and capital-related expenses.
  3. Increase rates by 1.4 % including the multifactor productivity and the SNF market basket update.
  4. Discusses presumption of coverage for residents admitted directly from the hospital and who qualify for one of the upper 52 RUG levels provided that the services are also reasonable and necessary.
  5. Specifically invites public comments identifying HCPCS codes in any of these four service categories (chemotherapy items, chemotherapy administration services, radioisotope services, and customized prosthetic devices) representing recent medical advances that might meet the criteria for exclusion from SNF consolidated billing.
  6. Currently, the therapy payment rate component of the SNF PPS is based solely on the amount of therapy provided to a patient during the 7-day look-back period, regardless of the specific patient characteristics. The amount of therapy a patient receives is used to classify the resident into a RUG category, which then determines the per diem payment for that resident. CMS has contracted with Acumen, LLC and the Brookings Institution to identify potential alternatives to the existing methodology used to pay for therapy services received under the SNF PPS.

Here is the link for the full text of the proposed rule and instructions on where to submit comments: