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ADL Coding and Scoring for MDS 3.0
http://ping.fm/1Dg5U

Wednesday, November 7, 2007

ADL Documentation Part 2 of 2

Harmony Healthcare International provides the long term care industry the tools to obtain accurate reimbursement and ultimately provide better care to its residents. Through seminars and consulting services, Harmony educates, trains and advises with a client centered approach. We also provide monthly onsite audits to ensure MDS accuracy, Medicare compliance and Case Management review.

ADL CODING Part 2

Accuracy in ADL documentation is critical for both care planning and reimbursement.
Harmony clarifies the difference between the extensive and limited assist levels. Common misconception includes coding based upon who is doing more of the activity which is incorrect.
The key determination in the extensive and limited assist levels is weight-bearing support or total dependence in a portion of a sub-task.

· Independent: No staff intervention

· Supervised: Verbal cues or visual oversight.

· Limited Assist: Hands on assist that includes contact guard, guided maneuvering or non-weight bearing support (3 episodes in the past 7 days).

· Extensive Assist: Hands on assist (3 episodes in the past 7 days), that includes any weight bearing support or dependence in a portion of the sub-task during some but not all of the observation period.

· Total Dependence: Full staff performance or in other words, the patient did not participate in performing the task whatsoever.

Note that weight-bearing support does not indicate that the patient has a weight-bearing restriction. Weight-bearing support reflects that staff bore the weight of the patient and is the difference between lifting an extremity during the task of dressing versus guiding the limb into the sleeve of a shirt. There is not a percentage of weight supported factored into this coding. Also note that the 3 episodes or occurrences may occur during one shift alone.

An increased focus upon the levels of assistance provided with fluid and nutritional intake may also yield a more accurate RUG score and rate of reimbursement. Consider all episodes of intake with snacks, meals, supplements, fluids given throughout the nighttime. Note that the patient that is assisted with fluid intake during the night shift is to be considered when coding eating in Section G of the MDS. Harmony notes that entries on nights that reflect an increase in assistance was provided by coding a 2,2 in eating require clarification of the limited versus extensive assist with night shift for the additional ADL point.

The resident's performance may vary from day to day, shift to shift, or within shifts. ADL coding is also intended to be an interdisciplinary team process. The physical assistance provided to the patient while in therapy is to be reflected in the ADL coding in Section G of the MDS. An individualized plan of care can be successfully developed only when the resident's self-performance is accurately assessed and the amount and type of support provided to the resident by others is properly evaluated.

The RAI Manual further encourages that the assessor to "engage direct care staff, from all shifts, which have cared for the resident over the past 7 days in discussions regarding the resident's ADL functional performance. Remind the staff that the focus is on the last seven days only. Ask probing questions, beginning with the general and proceeding to the more specific." It is with these discussions that inconsistencies can be identified and corrected. Harmony recommends that the assessor schedules time to sit with the CNA's while they are documenting. This will allow for review and discussion of the coding increasing the understanding of its value from a clinical as well as financial standpoint.
There will be patients that are very high functioning during the day and evening shifts. The night shift documentation is extremely valuable as quite often the patient may be exhausted or with discomfort from strenuous rehabilitation programs and require a degree of assistance during this time only. Capture all resources that are utilized to care for each patient.

As support is required for ADL coding on the MDS; Harmony discusses the opportunity to write a brief narrative note in the event that CNA documentation does not represent an accurate ADL status. Nursing notes are also valuable in further describing ADL status, such entries may include:

Ø "Patient was admitted via stretcher and received extensive assist of three to move from the stretcher to the bed. Patient received extensive assist of two to position in the bed."

Ø "Patient received extensive assist of two q 2 hours for bed mobility. Received extensive assist of two to transfer bed to chair and with toilet transfers x2."

Ø "Patient received limited assist with dressing, extensive assist of one for transfers, toileting and transfers."

Ø "Patient is experiencing back and hip pain. Patient received extensive assist of two assist for positioning due to pain and was transferred to bedside commode x3 with extensive assist of two."

Ø "Patient received limited assist (contact guard) with transfers due to high risk for loss of balance and falls."

Ø "Patient can toilet independently however is incontinent and received extensive assist of one x3 with incontinence care."

Ø "Patient received extensive assist with feeding for breakfast and lunch to complete the meal due to fatigue and highly distracted. Extensive assist with fluids provided throughout the day to meet fluid requirements."


For more information on ADL Coding, Skilled Nursing, Part A and Case Mix revenue enhancement and training go to: http://www.harmony-healthcare.com/ or email jrouthier@harmony-healthcare.com

ADL Documentation Part 1 of 2

Harmony Healthcare International provides the long term care industry the tools to obtain accurate reimbursement and ultimately provide better care to its residents. Through seminars and consulting services, Harmony educates, trains and advises with a client centered approach. We also provide monthly onsite audits to ensure MDS accuracy, Medicare compliance and Case Management review.


ADL DOCUMENTATION Part 1

ADL Documentation and Coding: Harmony clarifies that CNA documentation is but one of many areas to support ADL coding of the MDS. The entire medical record may be used in identifying a true ADL status. Harmony recommends review of the therapy documentation to investigate support for higher ADL coding. The translation from therapy terminology to MDS coding is as follows:

MDS Score
MDS Terminology
Therapy Terminology
Therapy Definition
0
Independent
Independent
No physical or cognitive assistance required.
1
Supervision
Supervision/
Stand By Assistance
Therapist is needed for supervision for safety and performance specifics.
2
Limited Assistance
Contact Guard
Therapist is in contact with patient via gait belt, just in case physical assistance is needed.
3
Extensive Assistance
Minimal Assistance
Therapist provides 25% of physical output needed for task; patient does 75% of work.
3
Extensive Assistance
Moderate Assistance
Therapist provides 50% of physical output needed for task, patient does 50% of work.
3
Extensive Assistance
Maximum Assistance
Therapist provides 75% of physical output needed for task, patient does 25% of work.
4
Total Dependence
Dependent / Total Assistance
Therapist provides 100% of physical output needed for task, patient does 0%.

ADL's comprise approximately 30% of the rate of reimbursement associated with the RUG score/rate. On admission or return from outside appointments it is important to ask nursing to detail the mode of transfer from stretcher to bed and positioning. Often, the patient may receive more assist on return which may be included on the admission or return re-admission nursing assessment form.
Example:
Ø "This 78 year old male is admitted from MCH via ambulance stretcher. Patient transferred from stretcher to bed and positioned in bed with assist of (3)."

This documentation may be the difference between two RUGS levels.

ADL Coding $ Impact: (Essex County, MA RUG Rate) RUX ($626.00) vs RUL ($549.75)=$76.25/day x 14 days =$1,067.50

This example is for one assessment.

Part 1 of 2. To be Continued


For more information on ADL Documentation, Skilled Nursing, Part A and Case Mix revenue enhancement go to: http://www.harmony-healthcare.com or email jrouthier@harmony-healthcare.com