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Revised
Swing Bed
Minimum Data Set
Assessment
Training Manual
Version 1.0
October 2003
Revised April 2004
Revised June 2005
Revised November 2005
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CMS’s SB Version 1.0 Manual
REVISED SWING BED MINIMUM DATA SET
ASSESSMENT TRAINING MANUAL
For Use With The
Swing Bed Minimum Data Set Assessment
Centers for Medicare and Medicaid Services
The Revised Swing Bed Minimum Data Set Assessment
Training Manual is published by the Centers for
Medicare and Medicaid Services (CMS) and is a public
document. It may be copied freely, as our goal is to
disseminate information broadly to facilitate accurate
and effective use of the MDS for swing bed hospitals.
This revised manual replaces the original May 2002
manual.
Swing Bed Minimum Data Set Training Manual
Authors:
Carol Job, Kathy Wade, Cathy Petko
Jan Courtney, and Sheila Lambowitz
October 2003
CMS’s SB Version 1.0 Manual
We also want to acknowledge the contributions of our MDS Work
Group who have given freely of their time, intelligence and energy
to develop the MDS coding clarifications included in this manual:
Dana Burley, Rosemary Dunn, Cindy Hake, Lisa Hines, Susan
Joslin, Tina Miller, Mary Pratt, and Yael Harris.
Thanks are also due to Donna Coszalter, Myers and Stauffer, for her
long, hard work in creating, formatting, and editing this manual
under very tight time frames.
CMS’s SB Version 1.0 Manual
CENTERS FOR MEDICARE AND MEDICAID SERVICES
ACKNOWLEDGEMENT
The original SB-MDS Training Manual was developed from a subset of the Long Term Care
Resident Assessment Instrument (RAI) User's Manual, Version 2.0 published in October 1995.
The RAI manual was developed under a contract with the Hebrew Rehabilitation Center for
the Aged (HRCA). We want to acknowledge John Morris, Katherine Murphy, and the entire
team of experts who contributed to the development of the original manual. Particular thanks
are due to Sue Nonemaker, the Project Officer responsible for the original RAI development
effort, including the design of the MDS 2.0.
We also want to express our appreciation to the many professional associations, clinical
experts, and State and Regional Office personnel for their continued involvement and support.
Our RAI Coordinators have worked long and hard to train providers how to accurately assess
and code MDS items, and have alerted us to issues needing clarification or reevaluation. They
have served as our “eyes and ears” and played key roles in establishing and standardizing
MDS coding policies.
In addition, we want to thank our technical experts for transforming the RAI process from a
manual paper-driven process to an automated data collection and transmission system. We
particularly appreciate the efforts of Jack Williams and his staff in customizing the MDS data
collection, transmission and data base capabilities for swing bed hospitals. Many thanks to the
staff at the Iowa Foundation For Medical Care, to Bob Godbout and to John Jackson for their
dedication and enthusiasm in supporting the expansion of the SNF PPS to swing bed hospitals.
Lastly, this work would not have been possible without the support of management within the
Center for Medicare Management (CMM) and the Center for Medicaid and State Operations
(CMSO) particularly Laurence Wilson, CMM, and Helene Fredeking and Fred Gladden,
CMSO.
For questions related to the SB-MDS assessment, please refer to the list of contacts included in
the appendix.
For information, please check our CMS web site:
www.cms.hhs.gov/providers/snfpps/snfpps_swingbed.asp.
CMS’s SB Version 1.0 Manual
TABLE OF CONTENTS
Chapter 1: Overview of the Swing Bed Minimum Data Set Assessment
1.1
1.2
1.3
1.4
1.5
1.6
1.7
Background .........................................................................................................................1-1
Regulatory Authority ..........................................................................................................1-1
Protecting the Privacy of SB-MDS.....................................................................................1-2
Privacy Act Statement...................................................................................................1-4
Participants in the Assessment Process...............................................................................1-5
Sources of Information for Completion of the SB-MDS Assessments...............................1-5
Review of the Patient’s Record.....................................................................................1-6
Communication With and Observation Of the Patient .................................................1-7
Communication With Direct Care Staff........................................................................1-8
Communication With Licensed Professionals, Patient’s, Physician and Family..........1-8
CMS Clarification Regarding Documentation Requirements ............................................1-9
Reproduction of the SB-MDS in the Patient’s Record and Maintenance of Assessments.............1-10
Swing Bed Minimum Data Set Assessment Form (SB-MDS) .....................................1-11
Chapter 2: Assessment Schedule for the Swing Bed Minimum Data Set
2.1
2.2
2.3
2.4
Minimum Data Set Requirements for Swing Bed Hospitals ..............................................2-1
Types of SB-MDS Assessments and Timing of Assessments.............................................2-2
Guidelines for Determining a Clinical Change in Patient Status..................................2-4
Swing Bed Minimum Data Set (SB-MDS) Assessment Schedule ...............................2-5
Factors Impacting the Assessment Schedule ......................................................................2-6
Discharge and Reentry Tracking Information.....................................................................2-8
SB-MDS Discharge and Reentry Flowchart.................................................................2-12
Chapter 3: Item-by-Item Guide to the Swing Bed Minimum Data Set Assessment
3.1
3.2
3.3
Overview and Standard Format of the Item-by-Item Guide ...............................................3-1
How to Use This Chapter....................................................................................................3-3
SB-MDS Coding Conventions......................................................................................3-5
Item-by-Item Instructions for the SB-MDS Assessment ....................................................3-6
Resident Name ..............................................................................................................3-6
Gender...........................................................................................................................3-6
Birth Date......................................................................................................................3-6
Marital Status ................................................................................................................3-6
Race/Ethnicity...............................................................................................................3-7
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Zip Code........................................................................................................................3-7
Social Security Number and Medicare Numbers .........................................................3-8
Medicaid Number .........................................................................................................3-9
Facility Provider Numbers............................................................................................3-9
Assessment Reference Date..........................................................................................3-10
Reasons for Assessment................................................................................................3-12
Prior Acute Care Stay....................................................................................................3-16
Admission Date.............................................................................................................3-16
Admission/Discharge Status Code................................................................................3-17
Discharge Date..............................................................................................................3-19
Reentry Date .................................................................................................................3-20
CLINICAL DATA:
Comatose.......................................................................................................................3-20
Short-Term Memory .....................................................................................................3-21
Cognitive Skills.............................................................................................................3-22
Making Self Understood ...............................................................................................3-24
Indicators of Depression ...............................................................................................3-24
Behavioral Symptoms...................................................................................................3-28
Activities of Daily Living (ADLs)................................................................................3-30
ADL Self-Performance ...........................................................................................3-31
Scoring ADL Self-Performance - Flowchart ..........................................................3-43
ADL Support Provided ...........................................................................................3-44
Toileting Programs........................................................................................................3-49
Diseases ........................................................................................................................3-50
Infections ......................................................................................................................3-52
Problem Conditions ......................................................................................................3-53
Weight Loss...................................................................................................................3-54
Nutritional Approaches .................................................................................................3-55
Parenteral or Enteral Intake ..........................................................................................3-56
Ulcers ............................................................................................................................3-59
Pressure Ulcers .............................................................................................................3-61
Other Skin Problems or Lesions ...................................................................................3-64
Skin Treatments ............................................................................................................3-65
Foot Care Problems.......................................................................................................3-66
Time Awake ..................................................................................................................3-67
Injections.......................................................................................................................3-68
Special Treatments and Procedures ..............................................................................3-69
Special Care ............................................................................................................3-69
Therapies.................................................................................................................2-71
Nursing Rehabilitation/Restorative Care ......................................................................3-76
Physician Visits.............................................................................................................3-82
Physician Orders ...........................................................................................................3-82
Ordered Therapies.........................................................................................................3-84
Case Mix Group............................................................................................................3-87
HIPPS Code ..................................................................................................................3-87
Signature .......................................................................................................................3-88
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Chapter 4: Submission and Correction of the Swing Bed Minimum Data Set
Assessment
4.1
4.2
4.3
4.4
4.5
4.6
4.7
Legal and Submission Authority.........................................................................................4-1
Computer Requirements .....................................................................................................4-1
Submission Rules................................................................................................................4-2
Submission File Structure ...................................................................................................4-3
Prospective Payment System (PPS) Requirements.............................................................4-3
Definitions for Correction Procedures................................................................................4-4
Timing and Types of Corrections........................................................................................4-6
SB-MDS Correction Policy Flowchart .........................................................................4-11
Chapter 5: Medicare Skilled Nursing Facility Prospective Payment System
(SNF PPS)
5.1
5.2
5.3
5.4
5.5
SNF PPS Coverage Guidelines...........................................................................................5-1
Payment Provisions Under SNF PPS..................................................................................5-2
Resource Utilization Groups Version III ............................................................................5-3
Relationship Between the SB-MDS and the Claim ............................................................5-5
RUG-III 53 Group Model Calculation Worksheet for Swing Beds....................................5-7
Appendices:
Appendix A
Glossary and Common Acronyms .......................................................................A-1
Glossary ...............................................................................................................A-2
Common Acronyms .............................................................................................A-11
Appendix B
Contact Information .............................................................................................B-2
State RAI Coordinators........................................................................................B-3
Appendix C
CPS Scoring Rules...............................................................................................C-1
Index
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Chapter 1: Overview of the Swing Bed Minimum
Data Set Assessment
1.1
Background
The 1986 Institute of Medicine (IOM) report recommended nursing facilities complete
comprehensive assessments, utilizing a minimum data set, to identify potential care problems to be
addressed in the resident’s individualized care plan. The Omnibus Budget Reconciliation Act of
1987 (OBRA ’87) mandated the development of a resident assessment instrument (RAI) for
individual’s residing in nursing facilities. The tool was required by law to produce a
“comprehensive, accurate, standardized, reproducible assessment of each resident’s functional
capacity.” This minimum data set became the federally mandated Minimum Data Set (MDS) used
in all Medicaid and Medicare certified nursing facilities. The MDS contains items that reflect the
acuity level of the resident, including diagnoses, treatments and an evaluation of the resident’s
functional status. Nursing facilities have been completing the MDS since October 1990 and
submitting their electronic MDS data to state repositories since June 22, 1998. The MDS is also
used as a data collection tool for Medicare and Medicaid payment systems, as well as for publicly
reported Quality Measures.
1.2
Regulatory Authority
Section 4432(a) of the Balanced Budget Act (BBA) of 1997 specifies that swing bed hospitals
providing Part A skilled nursing facility-level services must be incorporated into the Skilled Nursing
Facility Prospective Payment System (SNF PPS) by the end of the statutory transition period. For
the purposes of this manual, “swing bed” will be used to describe the facility that provides the Part A
SNF-level services reimbursable under the SNF PPS. Effective with cost reporting periods
beginning on or after July 1, 2002, swing bed payment is based on SNF PPS instead of the costrelated method. These payment rates cover all costs of furnishing covered swing bed services
(routine, ancillary, and capital-related costs) other than costs associated with operating approved
educational activities as defined in 42 CFR 413.85. The SNF PPS applies to Short-Term Hospitals,
Long-Term Hospitals, and Rehabilitation Hospitals certified as swing bed hospitals. Critical Access
Hospitals (CAHs) with swing beds are exempt from the SNF PPS.
Beginning on the first day of each hospital’s next cost reporting year, on and after July 1, 2002,
swing bed hospitals are required to complete a unique two-page MDS assessment form that will be
used to determine payment levels for Medicare beneficiaries. The Swing Bed MDS (SB-MDS)
assessment data is submitted electronically to a National Assessment Collection Database (national
database). The new SB-MDS uses a subset of the MDS information and includes only those items
required for payment and the ongoing analysis of swing bed utilization under the SNF PPS. A
registered nurse following the Medicare PPS assessment schedule will complete or coordinate the
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SB-MDS data set. A copy of the SB-MDS is included in this chapter, Pages 1-11 and 1-12. The
SB-MDS form can be downloaded at the following web site:
www.cms.hhs.gov/providers/snfpps/snfpps_swmds.asp.
It is the intent of this manual to offer clear guidance, through instruction and example, for the
effective completion of the SB-MDS assessment instrument. Basically, when everyone is speaking
the same language, the opportunity for misunderstanding or error is diminished considerably.
1.3
Protecting the Privacy of SB-MDS
SB-MDS assessment data is personal information about swing bed patients that facilities are
required to collect and keep confidential in accordance with federal law. The CFR Part 483.20
requires Medicare and Medicaid certified swing bed providers to collect patient assessment data that
comprises the SB-MDS. This data is considered part of the patient’s medical record and is protected
from improper disclosure by Medicare and Medicaid certified facilities under the Conditions of
Participation (CoP). By regulation at CFR 483.75(L)(2)(3) and 483.75(L)(2)(4)(i)(ii)(iii), release of
information from the patient’s clinical record is permissible only when required by:
1.
2.
3.
transfer to another health care institution,
law (both State and Federal), and/or
the patient.
Otherwise, providers cannot release SB-MDS data in individual level format or in the aggregate.
Swing bed providers are also required under CFR 483.20 to transmit SB-MDS data to a Federal data
repository. Any personal data maintained and retrieved by the Federal government is subject to the
requirements of the Privacy Act of 1974. The Privacy Act specifically protects the confidentiality of
personal identifiable information and safeguards against its misuse. The Privacy Act can be found at
www.usbr.justice.gov/04foia/privstat.htm.
The Privacy Act requires by regulation that all individuals whose data are collected and maintained
in a federal database must receive notice. Therefore, patients in swing bed facilities must be
informed that the SB-MDS data is being collected and submitted to the national database. The
notice shown on Page 1-4 of this section meets the requirements of the Privacy Act of 1974 for
swing beds. The form is a notice and not a consent to release or use SB-MDS data for health care
information. Each patient or family member must be given the notice containing submission
information at the time of admission. It is important to remember that patient consent is not required
to complete and submit SB-MDS assessments that are required for Medicare payment purposes.
Contractual Agreements
In the case where a swing bed submits SB-MDS data to CMS through a contractor or through its
corporate office, the contractor or corporate office has the same rights and restrictions as the swing
bed does under the Federal and State regulations with respect to maintaining patient data, keeping
such data confidential, and making disclosures of such data. This means that a contractor may
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maintain a database, but must abide by the same rules and regulations as the swing bed. Moreover,
the fact that there may have been a change of ownership of a swing bed that has been transferring
data through a contractor should not alter the contractor's rights and responsibilities; presumably, the
new owner has assumed existing contractual rights and obligations, including those under the
contract for submitting SB-MDS information. All contractual agreements, regardless of their type,
involving the SB-MDS data should not violate the requirements of participation in the Medicare
and/or Medicaid program, the Privacy Act of 1974 or any applicable State laws.
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SWING BED HOSPITALS
PRIVACY ACT STATEMENT – HEALTH CARE RECORDS
THIS FORM PROVIDES YOU THE ADVICE REQUIRED BY THE PRIVACY ACT OF 1974. THIS FORM IS
NOT A CONSENT FORM TO RELEASE OR USE HEALTH CARE INFORMATION PERTAINING TO YOU.
1.
AUTHORITY FOR COLLECTION OF INFORMATION, INCLUDING SOCIAL SECURITY NUMBER AND
WHETHER OR NOT DISCLOSURE IS MANDATORY OR VOLUNTARY.
Sections 1819(f), 1919(f), 1819(b)(3)(A), 1919(b)(3)(A), and 1864 of the Social Security Act.
Medicare and Medicaid participating swing bed hospitals are required to establish a database of patient
assessment information (SB-MDS), and to electronically transmit this information to the Centers for Medicare &
Medicaid Services (CMS).
Because the law requires disclosure of this information to Federal sources as discussed above, a patient does
not have the right to refuse consent to these disclosures.
These data are protected under the requirements of the Federal Privacy Act of 1974 and the MDS Long-Term
Care System of Records.
2.
PRINCIPAL PURPOSES FOR WHICH INFORMATION IS INTENDED TO BE USED
This form provides you the advice required by The Privacy Act of 1974. The personal information will facilitate
tracking of changes in your health and functional status over time for purposes of determining payment and
evaluating the quality of care provided by swing bed hospitals that participate in Medicare or Medicaid.
3.
ROUTINE USES
The primary use of this information is to study the effectiveness and quality of care given in swing bed hospitals
and to aid in the administration of the Skilled Nursing Facility Prospective Payment System (SNF PPS). This
system will also support regulatory, reimbursement analysis, policy, and research functions. This system will
collect the minimum amount of personal data needed to accomplish its stated purpose.
The information collected will be entered into the Swing Bed Minimum Data Set (SB-MDS) system of records,
System No. 09-70-1517. Information from this system may be disclosed, under specific circumstances, to the
Census Bureau and to: (1) Agency contractors, or consultants who have been engaged by the Agency to assist
in accomplishment of a CMS function, (2) another Federal or State agency, agency of a State government, an
agency established by State law, or its fiscal agent to administer a Federal health program or a Federal/State
Medicaid program and to contribute to the accuracy of reimbursement made for such programs, (3) to Quality
Improvement Organizations (QIOs) to perform Title XI or Title XVIII functions, (4) to insurance companies,
underwriters, third party administrators (TPA), employers, self-insurers, group health plans, health maintenance
organizations (HMO) and other groups providing protection against medical expenses to verify eligibility for
coverage or to coordinate benefits with the Medicare program, (5) an individual or organization for a research,
evaluation, or epidemiological project related to the prevention of disease or disability, or the restoration of
health, or payment related projects, (6) to a member of Congress or congressional staff member in response to
an inquiry from a constituent, (7) to the Department of Justice, (8) to a CMS contractor that assists in the
administration of a CMS-administered health benefits program or to a grantee of a CMS-administered grant
program, (9) to another Federal agency or to an instrumentality of any governmental jurisdiction that administers,
or that has the authority to investigate potential fraud or abuse in a health benefits program funded in whole or in
part by Federal funds to prevent, deter, and detect fraud and abuse in those programs, (10) to national
accrediting organizations, but only for those facilities that these accredit and that participate in the Medicare
program.
4.
EFFECT ON INDIVIDUAL OF NOT PROVIDING INFORMATION
The information contained in the Swing Bed Minimum Data Set (SB-MDS) is generally necessary for the facility
to provide appropriate and effective care to each patient. If a patient fails to provide such information, for
example on medical history, inappropriate and potentially harmful care may result. Moreover, payment for such
services by third parties, including Medicare and Medicaid, may not be available unless the facility has sufficient
information to identify the individual and support a claim for payment.
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1.4
Participants in the Assessment Process
Facilities have flexibility in determining who should participate in the assessment process, as long as
it is accurately conducted. A facility may assign responsibility for completing the SB-MDS to a
number of qualified staff members. In most cases, participants in the assessment process are
licensed health professionals. It is the facility’s responsibility to ensure that all participants in the
assessment process have the requisite knowledge to complete an accurate assessment. The SB-MDS
must be conducted or coordinated by an RN who signs and certifies the completion of the
assessment.
The attending physician is also an important participant in the SB-MDS process. The facility needs
the physician’s evaluation and orders for the patient’s immediate care, as well as for a variety of
treatments and laboratory tests. Furthermore, the attending physician may provide valuable input on
items in the SB-MDS.
1.5
Sources of Information
Assessments
for
Completion
of
the
SB-MDS
The process for performing an accurate assessment requires that information about patients be
gathered from multiple sources. It is the role of the individual completing the assessment to validate
the information obtained from the patient, patient’s family, or other health care team members
through observation, interviewing, reviewing lab results, and so forth to ensure accuracy. Similarly,
information in the patient’s record is verified by interacting with the patient and direct care staff.
The following sources of information must be used in completing the SB-MDS. Although not
required, the review sequence for the assessment process generally follows the order below:
•
Review of the patient’s record. Depending on whether the assessment is a 5-Day or
another scheduled assessment, the review could include: preadmission, admission or transfer
notes, current plan of care, recent physician notes and/or orders, documentation of services
currently provided, results of recent diagnostic and/or other test procedures, monthly nursing
summary notes, medical consultations, and a record of medications since admission.
•
Communication with and observation of the patient.
•
Communication with direct-care staff (e.g., nursing assistants) from all shifts.
•
Communication with licensed professionals (from all disciplines) who have recently
observed, evaluated, or treated the patient. Communication can be based on discussion or
licensed staff can be asked to document their impressions of the patient.
•
Communication with the patient’s physician.
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•
Communication with the patient’s family. For some patients, family members may be
unavailable or the patient may request that you not contact them. Where the family is not
involved, someone else may be very close to the patient, and the patient may wish that this
person be contacted. Even when family is involved, the patient may still wish for you to
contact another non-family member.
Review of the Patient’s Record
The patient’s record provides a starting point in the assessment process for reviewing information
about the patient in written staff notes across all shifts over multiple days. Starting with the patient
record, however, does not indicate that it is the most critical source of information, but only a
convenient source.
At admission, record review includes an examination of notes written since admission to the swing
bed for Part A SNF-level services, documentation that accompanied the patient at admission, facility
intake forms, acute care hospital information, or acute care hospital discharge information if
admitted from another hospital, and any preadmission test results.
Subsequent reassessments should focus on recorded information from earlier SB-MDS assessments
and written information from the previous assessment time frames that remains applicable to the
patient’s current status.
The following are important considerations when reviewing the patient’s record:
•
Review the information documented in the record, keeping in mind the required
SB-MDS definitions.
•
Ensure that the information taken from the record covers the same observation period
as that specified by the SB-MDS items. The SB-MDS refers to specific time frames for
each item; for example, ADL status is based on patient performance over a 7-day period. To
ensure uniformity, the SB-MDS has an Assessment Reference Date (Item 10a) that
establishes a common reference end-point for all items. Consequently, it is necessary to pay
careful attention to the notes regarding time frames for each section of the SB-MDS, and
also to the Item-by-Item instructions in Chapter 3.
•
Be aware of discrepancies and view the record information as preliminary only. Clarify
and verify all information during the assessment process. Be alert to information in the
record that is not consistent with verbal information or physical assessment findings.
Discuss discrepancies with other interdisciplinary team members (e.g., nurses, social
workers, therapists). The extent to which the record can be relied upon for information will
depend on the comprehensiveness of the record system. Note what information the record
usually contains (e.g., current service notes, care plans, flow sheets, medication sheets),
where different types of information are maintained in the clinical record, and more
importantly, what information is missing.
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•
Where information in the record is sufficiently detailed and conforms to SB-MDS
descriptions and time periods, complete the SB-MDS items. A few SB-MDS items can
be completed in full from information found in the record. Accurate assessment of most
items, however, requires information from other sources (e.g., the patient, the patient’s
family, and facility staff). Where information is incomplete or contradictory, make a note of
the issues in question. This note can help plan contacts with the patient, facility staff and the
patient’s family. There is no requirement that such a note be maintained as part of the
patient’s permanent record; it is a work tool only.
•
As you observe, talk with, and discuss the patient with other staff members, verify the
accuracy of what you learned from reviewing the record.
Communication With and Observation Of the Patient
The patient is a primary source of information and may be the only source of information for many
items. Become familiar with the SB-MDS items to make communication and observation of the
patient an ongoing everyday activity in the facility. For example, an RN can observe and interact
with a patient when medications are given, during meals, or when the patient comes to ask a
question. Interaction with the patient may be a crucial factor in confirming staff judgments of
patient problems. Weigh what the patient says and what is observed about the patient against other
information obtained from the patient record and facility staff.
To be most efficient, organize a framework for interviewing and observing the patient. Allow
flexibility to accommodate the patient. Carefully listen to and observe the patient for guidance as to
how to pursue the necessary information gathering. Try to interact with the patient, even if the
patient may have difficulty responding. The degree and character of the difficulty in responding, as
well as nonverbal responses (e.g., fearfulness) provide important information. Sensitive staff
judgment is necessary in gathering information.
It is important to observe, interview and physically assess the patient, and to interview staff. In
addition, the SB-MDS was designed to consider information obtained from family members,
although it is not necessary that every discussion with them be face-to-face. Assessors should
capture information that is based on what actually happened during the observation period, not what
usually happens. Problems may be missed when the patient’s actual status over the entire
observation period is not considered.
Any person completing any SB-MDS section is required to follow the Item-by-Item guidelines in
Chapter 3 of this manual that specify sources of information necessary for accurate coding. The
process of information gathering should include direct observation of the patient; communication
with the patient’s direct caregivers across all shifts; review of relevant information in the patient’s
clinical record; and if possible, consultation with family members who have direct knowledge of the
patient’s behavior in the observation period. If the person completing the SB-MDS did not
personally observe a behavior, but others report that it occurred, the behavior must be considered as
having occurred when completing the SB-MDS form. In addition, the patient’s clinical record
should support his/her status as reported on the SB-MDS.
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Communication With Direct Care Staff
Direct care staff (e.g., nursing assistants) have daily, intimate contact with patients and are often the
most knowledgeable source of information about the patient. Direct care staff talk with and listen to
the patient. They observe and assist the patient’s performance of ADLs and involvement in
activities. They observe the patient’s physical, cognitive and psychosocial status daily during all
shifts, seven days a week. Key considerations when communicating with direct care staff are:
•
Be sure to speak with a person who has first-hand knowledge of the patient. Plan for
sufficient time to talk with direct care staff.
•
Start by asking about the patient’s performance on ADLs and activities. What can the
patient do without assistance? What do staff members do for the patient? What might the
patient be able to do that he or she is not doing now? Continue by asking about
communication and memory skills, body control, and the presence of mood or other
behavioral symptoms.
•
Talk with direct care staff across all shifts, if possible. The information from other shifts
may also be obtained in other ways (e.g., from change-of-shift reports if direct care staff
comments are included).
Communication With Licensed Professionals, Patient’s Physician, and Family
Licensed practical nurses (LPNs), RNs, social workers, activities professionals, occupational
therapists, physical therapists, speech therapists, pharmacists, dietitians and other professionals who
have observed, evaluated, or treated the patient should be interviewed about their knowledge of
patient abilities, performance patterns and problems. Their special expertise will enhance the
accuracy of the patient assessment.
The physician’s role is central to the overall management and outcome of patient care. The SBMDS assessment process should include a review of the physician’s examination of the patient, plan
of care, acute care hospital discharge plan, goals of the swing bed care, and medication and
treatment orders. Review the SB-MDS with the patient’s attending physician to share and validate
pertinent information.
The patient’s family (or persons close to the patient) can be a valuable source of information about
the patient’s health history, history of strengths and problems in various functional areas, and
customary routine prior to the first swing bed admission. This information is particularly necessary
when the patient is cognitively impaired or has a great deal of difficulty communicating. Using this
source obviously depends on the presence of family members, their willingness to participate, and
the patient’s preferences. Facilities need to respect the cognitively intact patient’s right to privacy
and should have permission from the individual for staff to ask questions of family members. In
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most instances, family will not be the sole source of information, but will supplement information
from other sources. The assessment process provides an excellent opportunity for caregivers to
develop trusting, working relationships with the patient and the patient’s family.
1.6
CMS Clarification Regarding Documentation Requirements
CMS has always accepted the SB-MDS as a primary data source, and duplicative documentation is
not required. However, clinical documentation that furnishes a picture of the patient’s care needs
and response to treatment is an accepted standard of practice and is part of good patient care and
staff care planning. For this reason, it is always expected that information contained in the clinical
record supports rather than conflicts with the SB-MDS. Completion of the SB-MDS does not
remove the swing bed’s responsibility to document a more detailed assessment of particular issues of
relevance for the patient. In addition, for the Medicare prospective payment system, documentation
must substantiate the patient’s need for Part A SNF-level services and his/her response to those
services.
Swing bed hospitals are required to document the patient’s care and response to care during the
course of the stay, and it is expected that this documentation would be chronological, support and be
consistent with the findings of each SB-MDS assessment. Always keep in mind that government
requirements are not the only or even the major reason for clinical documentation. The SB-MDS
has simply codified some documentation requirements into a standard format.
Clinical documentation that contributes to identification and communication of patients’ problems,
needs and strengths, that monitors their condition on an on-going basis, and that records treatment
and response to treatment, is a matter of good clinical practice and is an expectation of trained and
licensed health care professionals. Good clinical practice has always dictated documentation of
certain treatments and conditions such as the amount of IV nutrient intake and the number of
minutes of therapy actually provided to a swing bed patient. For these types of services, the more
detailed documentation needed for good patient care also provides all the data needed to code the
SB-MDS. The SB-MDS does not require duplication of the more detailed treatment logs; the data
are simply summarized on the SB-MDS.
In addition, it is important to note that CMS does not impose specific documentation procedures to
swing bed facilities. Some facilities have developed tools to collect data across shifts or throughout
an assessment period; e.g., ADL support needs, type and duration of restorative nursing services, etc.
Some facilities have found flow sheets useful for this purpose. The form and format of such
documentation is determined by the facility. These tools may provide more accurate data for
SB-MDS reporting and planning care, and may provide real value to the facilities utilizing them.
However, these tools are not mandated by CMS or by Fiscal Intermediaries.
When available, State Agency and Fiscal Intermediary (FI) staff will utilize these data collection
tools as part of an SB-MDS validation review. In the absence of this type of documentation, the SBMDS can still be verified by a review of the entire record to verify that the medical record supports
and is consistent with the responses on the SB-MDS.
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Some states may have regulations that require supporting documentation elsewhere in the record to
substantiate the patient’s status on particular SB-MDS items used to calculate payment under the
State’s Medicaid system. If your state requires the SB-MDS to be completed for the Medicaid
program, they may have additional documentation requirements. Contact your State Agency’s
Resident Assessment Coordinator or your Medicaid program for state specific requirements. (See
Appendix B for a list of the State RAI Coordinators.)
1.7
Reproduction of the SB-MDS in the Patient’s Record and
Maintenance of the Assessments
SB-MDS records are subject to the same record retention requirements as all other hospital clinical
records. All SB-MDS assessments, and Discharge and Reentry tracking information must be kept in
the medical record for active patients. Active records must be accessible to all professional staff
(including consultants) who need to review the information in order to provide care to the patient. In
addition, all data from closed records, including the SB-MDS data, must be maintained to provide
access when needed for survey, medical review or other program purposes.
There is no requirement to maintain a hard copy and an electronic copy of the SB-MDS. It is
required that the record be completed, signed, and dated within the regulatory time frames. If
corrections are required after completion and submission of the SB-MDS to the national database,
CMS has specific procedures that must be followed. Refer to Chapter 4 for correction procedures.
It may be appropriate to update the patient’s care plan, based on the revised assessment record.
Patient assessment forms must accurately reflect the patient’s status, and agree with the record that is
submitted to the CMS national database.
When a discharged patient is admitted at a later date, the swing bed hospital must open a new record.
The swing bed hospital may transfer copies of previous SB-MDS assessments and other clinical
information to the new record, but is not required to do so. Swing bed hospitals should develop their
own specific medical record policies for readmissions.
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Chapter 2: Assessment Schedule for the Swing
Bed Minimum Data Set
2.1
Minimum Data Set Requirements for Swing Bed Hospitals
The SB-MDS assessment consists of the two-page Minimum Data Set for Swing Bed Hospitals, and
two subsets of SB-MDS items used to track patient readmissions and discharges.
•
Minimum Data Set for Swing Bed Hospitals - A core set of screening, clinical and
functional status elements used to classify Medicare patients into one of 53 Resource
Utilization Groups (RUG-III) that will be used to bill the fiscal intermediary for Part A
SNF-level services. Swing bed hospitals do not have to complete the SB-MDS once the
patient is no longer eligible for Part A SNF-level services. The SB-MDS can also be
completed for other swing bed patients if required by other payers, such as the State
Medicaid agency, health maintenance organizations or other secondary payers. The
SB-MDS completed for other payers can be submitted to the national database, as long as the
assessments were performed on patients in Medicare or Medicaid certified beds.
Clarification:
If the patient enrolls in the Medicare hospice program and Medicare hospice
benefits have been established, the patient’s care is no longer paid through
the Part A SNF-level PPS and the SB-MDS assessments are no longer
completed. However, the hospice organization may require the completion of
the assessments.
Swing bed providers using the SB-MDS will follow the same schedule used by skilled nursing
facilities for the SNF PPS. The admission day is day one of the stay. The assessment schedule
includes 5-Day, 14-Day, 30-Day, 60-Day and 90-Day assessments. Other off-cycle assessments are
completed to report a clinical change or that all therapies are discontinued. A Readmission/Return
assessment may be required after an inpatient acute hospital stay.
The SB-MDS must be completed within 14 days of the assessment reference date. The Assessment
Reference Date (ARD) establishes a common reference end-point for all items. Chapter 3,
Item 10a, provides more detail about the ARD.
Swing bed staff should make every effort to complete assessments in a timely manner. Each of the
SB-MDS scheduled assessments has defined days when the assessment reference date can be set.
For example, the Medicare 5-Day assessment, days one through five have been defined as the
optimal days for setting the assessment reference date. However, there may be situations when an
assessment might be delayed and CMS has allowed for these situations by defining a number of
grace days for each PPS assessment. Grace days for the Medicare 5-Day assessment reference date
can be extended one to three grace days.
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Grace days can be added to the assessment reference date in situations such as an absence/illness of
the RN assessor, reassignment of the assessor to other duties for a short period of time, or an
unusually large number of assessments due at approximately the same time. Grace days may also be
used to more fully capture therapy minutes or other treatments.
An SB-MDS assessment is considered complete on the day that the registered nurse (RN)
coordinating the assessment signs and dates the assessment. Each SB-MDS record must be encoded
and edited at the swing bed hospital. The SB-MDS records must then be submitted electronically to
the national database. It will be considered timely if transmitted and accepted into the database
within 14 days of completion. The SB-MDS assessment is used to classify patients into a RUG-III
Classification group for the purpose of Medicare reimbursement.
2.2
Types of SB-MDS Assessments and Timing of Assessments
5-Day - The first Medicare assessment completed upon admission to the swing bed hospital for
Part A SNF-level services; i.e. swing bed services. The 5-Day Medicare assessment usually will
have an ARD (Item 10a) established between days 1-5 of the swing bed stay. The ARD (Item 10a)
can be extended to day 8 if using the designated “Grace Days.” The 5-Day Medicare assessment
must be completed (Item 45b) within 14 days of the ARD. The 14-day calculation is based on
calendar days and includes weekends. The 5-Day assessment authorizes payment from days 1
through 14 of the stay, as long as the patient remains eligible for Part A SNF-level services. The
SB-MDS records must be submitted electronically to the national database and will be considered
timely if submitted and accepted into the database within 14 days of completion (Item 45b).
14-Day - Medicare assessment that usually will have an ARD (Item 10a) established between days
11-14 of the swing bed stay. The ARD (Item 10a) can be extended to day 19 if using the designated
“Grace Days.” The 14-Day assessment must be completed (Item 45b) within 14 days of the ARD.
The 14-Day assessment authorizes payment from days 15 through 30 of the stay, as long as the
patient remains eligible for Part A SNF-level services. The SB-MDS records must be submitted
electronically to the national database and will be considered timely if submitted and accepted into
the database within 14 days of completion (Item 45b).
30-Day - Medicare assessment that usually will have an ARD (Item 10a) established between days
21-29 of the swing bed stay. The ARD (Item 10a) can be extended to day 34 if using the designated
“Grace Days.” The 30-Day Medicare assessment must be completed (Item 45b) within 14 days of
the ARD. The 30-Day assessment authorizes payment from days 31 through 60 of the stay, as long as
the patient remains eligible for Part A SNF-level services. The SB-MDS records must be submitted
electronically to the national database and will be considered timely if submitted and accepted into
the database within 14 days of completion (Item 45b).
60-Day - Medicare assessment that usually will have an established ARD (Item 10a) between days
50-59 of the swing bed stay. The ARD (Item 10a) can be extended to day 64 if using the designated
“Grace Days.” The 60-Day Medicare assessment must be completed (Item 45b) within 14 days of
the ARD. The 60-Day assessment authorizes payment from days 61 through 90 of the stay, as long
as the patient remains eligible for Part A SNF-level services. The SB-MDS records must be
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submitted electronically to the national database and will be considered timely if submitted and
accepted into the database within 14 days of completion (Item 45b).
90-Day - Medicare assessment that usually will have an ARD (Item 10a) established between days
80-89 of the swing bed stay. The ARD (Item 10a) can be extended to day 94 if using the designated
“Grace Days.” The 90-Day Medicare assessment must be completed (Item 45b) within 14 days of
the ARD. The 90-Day assessment authorizes payment from days 91 through 100 of the stay, as long
as the patient remains eligible for Part A SNF-level services. The SB-MDS records must be
submitted electronically to the national database and will be considered timely if submitted and
accepted into the database within 14 days of completion (Item 45b).
Readmission/Return - Medicare assessment that is completed when a patient whose stay was being
reimbursed by SNF PPS was hospitalized for more than 24 hours or was discharged with return
anticipated and later readmitted to the swing bed. The Readmission/Return assessment, like the
5-Day assessment, must have an ARD (Item 10a) established between days 1-8 of the return. The
Readmission/Return assessment must be completed (Item 45b) within 14 days of the ARD. The
Readmission/Return assessment restarts the Medicare schedule and the next required assessment
would be the Medicare 14-Day assessment. The SB-MDS records must be submitted electronically
to the national database and will be considered timely if submitted and accepted into the database
within 14 days of completion (Item 45b).
Other Medicare Required Assessment (OMRA) - The OMRA must be completed only if the
patient was in a RUG-III Rehabilitation Plus Extensive Services or Rehabilitation classification and
will continue to need Part A SNF-level services after the discontinuation of therapy. The last day in
which therapy treatment was furnished is day zero. The OMRA ARD (Item 10a) must be set on day
eight, nine, or ten after the last day that all rehabilitation therapies have been discontinued. The
OMRA must be completed (Item 45b) within 14 days of the ARD. The OMRA will establish a new
non-therapy RUG-III group and Medicare payment rate. The SB-MDS records must be submitted
electronically to the national database and will be considered timely if submitted and accepted into
the database within 14 days of completion (Item 45b).
Clinical Change Assessment (CCA)- Staff are responsible for determining whether a change (either
an improvement or decline) in the patient’s condition constitutes a “clinical change” in the patient’s
status. When a clinical change has occurred, the Clinical Change Assessment is completed within
14 days of the determination that the clinical change has occurred. The SB-MDS records must be
submitted electronically into the national database within 14 days of completion (Item 45b).
A “clinical change” is a decline or improvement in a patient’s status that:
•
will not normally resolve itself without intervention by staff or by implementing standard
disease-related clinical interventions,
•
impacts more than one area of the patient’s health status, and
•
requires interdisciplinary review and/or revision of the plan of care.
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Document the initial identification of a clinical change in the progress notes. The following
guidelines indicate conditions under which a Clinical Change Assessment is required. This list is not
exhaustive, and other situations may also meet the clinical change definition.
Guidelines for Determining a Clinical Change in Patient Status
Decline
• Any decline in activities of daily living physical functioning in which a patient is newly
coded as 3, 4, or 8 (i.e., extensive assistance, total dependency, activity did not occur);
•
Patient’s decision-making changes from 0 or 1 to 2 or 3;
•
Emergence of an unplanned weight loss problem (5 percent change in 30 days or 10 percent
change in 180 days);
•
Emergence of a condition or disease in which a facility judges a patient to be unstable;
•
Emergence of a pressure ulcer at Stage II or higher, when no ulcers were previously present
at Stage II or higher; or
•
Overall deterioration of patient’s condition; patient receives more support (for example, in
activities of daily living or decision-making).
Improvement
• Any improvement in activities of daily living physical functioning where a patient is newly
coded as 0, 1 or 2, when previously scored as a 3, 4 or 8;
•
Patient’s decision-making changes from 2 or 3 to 0 or 1;
•
Overall improvement of patient’s condition; patient receives fewer supports.
A clinical change may occur at any point during the patient’s stay. The Clinical Change Assessment
will most likely establish a new RUG-III classification and a new payment rate.
The following chart summarizes completion requirements for the Medicare assessments, Discharge
and Reentry tracking information and the Correction Request form.
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SWING BED MINIMUM DATA SET (SB-MDS) Assessment Schedule
ASSESSMENT
REFERENCE DATE
(Item 10a-ARD)
Can be set on any of
the following days
GRACE
DAYS
ARD can
also be set
on these
days
Days 1 - 5
6-8
Days 1 - 5
6-8
Days 11 - 14
15 - 19
Days 21-29
NUMBER OF
DAYS
AUTHORIZED
FOR
COVERAGE
& PAYMENT
APPLICABLE MEDICARE
PAYMENT DAYS
Item 45b + 14
Days
14
1 - 14
Item 45b + 14
Days
14
1 - 14
Item 45b - Within 14
days of ARD
Item 45b + 14
Days
16
15 - 30
30 - 34
Item 45b - Within 14
days of ARD
Item 45b + 14
Days
30
31 - 60
Days 50 - 59
60 - 64
Item 45b - Within 14
days of ARD
Item 45b + 14
Days
30
61 - 90
Days 80 - 89
90 - 94
Item 45b - Within 14
days of ARD
Item 45b + 14
Days
10
91 - 100
• 8 - 10 Days after all
therapy (PT, OT, ST)
services are
discontinued and
patient continues to
require skilled care.
• The first non-therapy
day counts as day 1.
N/A
Item 45b - Within 14
days of ARD
Item 45b + 14
Days
N/A
Must be completed by
th
the end of the 14
calendar day following
determination that a
clinical change has
occurred.
N/A
Item 45b + 14
Item 45b - By the end
th
of the 14 calendar day Days
following determination
of a clinical change
N/A
• Could establish a new RUG-III
classification that may remain
effective until the next
assessment is completed.
Discharge
Tracking
Information
• Completed when
patient is discharged
from swing bed.
• Patient dies.
Item 11a = 06 or • Admitted to hospital.
07
• Hospital observation
greater than 24 hrs.
N/A
Date of Event at
Item 15 + 7 Days
Item 45b + 14
Days
N/A
N/A
Reentry Tracking • Patient reenters
Information
swing bed following
admission to hospital
Item 11a = 09
or other health care
setting.
N/A
Date of Event at
Item 16 + 7 Days
Item 45b + 14
Days
N/A
N/A
Correction
Request Form
N/A
Must be completed
Within 14 days of
within 14 days of
completion of the
identification of an error correction record
on an SB-MDS already
accepted into the
national database.
N/A
• If RUG-III changes due to the
error, a billing change must be
reported.
CODES FOR
ASSESSMENTS
5 Day
COMPLETION
Item 45b - Within 14
days of ARD
SUBMISSION
Item 11a = 00
Item 11b = 1
AND
Readmission/
Return
Item 45b - Within 14
days of ARD
Item 11a = 00
Item 11b = 5
14 Day
Item 11a = 00
Item 11b = 7
30 Day
Item 11a = 00
Item 11b = 2
60 Day
Item 11a = 00
Item 11b = 3
90 Day
Item 11a = 00
Item 11b = 4
Other Medicare
Required
Assessment/
OMRA
Item 11a = 00
Item 11b = 9
Item 11c = 1
Clinical Change
Assessment
(CCA)
Item 11a = 00
Item 11b = 9
Item 11d = 1
October 2003
N/A
• Not required if the patient has
been determined to no longer
meet Medicare skilled level of
care.
• Establishes a new non-therapy
RUG-III classification.
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2.3
Factors Impacting the Assessment Schedule
The following information further clarifies the SB-MDS assessment schedule.
Patient Expires or Transfers
If a patient expires or transfers to another facility before the 5-Day assessment is completed, the
swing bed hospital prepares an SB-MDS assessment as completely as possible to obtain the RUG-III
classification so the provider can bill for the appropriate days. If the SB-MDS assessment is not
completed then the swing bed provider will have to bill at the default rate.
Physician Hold Occurs
If a physician hold occurs or 30 days has elapsed since a level of care change, the swing bed
provider will start the Medicare assessment schedule on the first day that Part A SNF-level services
started. An example of when a physician hold may occur is when a patient is admitted to the swing
bed for rehabilitation services but is not ready for weight bearing exercises. The physician will write
an order to start therapy when the patient is able to do weight bearing. Once the patient is able to
start the therapy then the Medicare 5-Day assessment will be completed. Day “1” of the stay will be
the first day that the patient is able to start therapy services.
Combining Assessments
Off-cycle SB-MDS assessments, e.g., Clinical Change Assessment (CCA) or the Other Medicare
Required Assessment (OMRA), may be completed during the regularly scheduled PPS assessments.
If the assessment reference date of either off-cycle assessments (e.g. CCA and OMRA) coincides
with a regularly scheduled assessment, a single assessment may be completed and coded as a
regularly scheduled assessment (e.g., 5-Day, 14-Day, 30-Day, 60-Day, or 90-Day) and a CCA,
OMRA, or both.
The SB-MDS will be coded to indicate that a regularly scheduled assessment is being completed and
could also be a CCA, OMRA, or both. The new coding for Reason for Assessment (Item 11) for the
SB-MDS form allows for these combinations.
Early Assessment
An assessment should be completed according to the designated Medicare assessment schedule. If
an assessment is performed earlier than the schedule indicates, (the ARD is not in the defined
window), the provider will be paid at the default rate for the number of days the assessment was out
of compliance. For example, a Medicare-required 14-Day assessment with an ARD of day 10 (1 day
early) would be paid at the default rate for the first day of the payment period that begins on day 15.
Late or Missed Assessment Criteria
When the assessment has an ARD after the mandated grace period, payment will be made at the
default rate for covered services, from the first day of the coverage period to the ARD of the late
assessment. A late assessment cannot replace the next regularly scheduled assessment. Therefore, if
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the ARD of the 14-Day assessment was day 22, it cannot be used as both the Medicare 14-Day and
Medicare 30-Day assessments.
In this situation, the late 14-Day assessment would be used to support payment for days 22-30 of the
Part A stay. A new 30-Day assessment would need to be completed within the assessment window
for the Medicare 30-Day assessment.
Non-Compliance with the Assessment Schedule
According to the Code of Federal Regulation (CFR) section 413.343, assessments that fail to comply
with the assessment schedule will be paid at the default rate. Frequent early or late assessment
scheduling practices may result in an onsite review.
Default Rate
MDS assessments are completed according to an assessment schedule specifically designed for
Medicare payment, and each assessment applies to specific days within a patient’s SNF stay to
determine the appropriate reimbursement for the patient. Compliance with this assessment schedule
is critical to ensure that the appropriate level of payment is established. Accordingly, SNFs that fail
to perform assessments timely are to be paid a RUG-III default rate for the days of a patient’s care
for which they are not in compliance with this schedule. The RUG-III default rate takes the place of
the otherwise applicable Federal rate. The RUG-III default rate is equal to the rate paid for the
RUG-III group reflecting the lowest acuity level, and would generally be lower than the Medicare
rate payable if the SNF had submitted an assessment in accordance with the prescribed assessment
schedule.
Midnight Rule
When a beneficiary receives emergency room (ER) care during the swing bed stay and is in the ER
at midnight, there are special rules for Medicare payment. The day preceding the midnight on which
the beneficiary was absent becomes a non-covered day that cannot be billed to Medicare Part A.
We would not generally expect swing bed patients to require emergency room care within the swing
bed hospital. In rare instances, a patient may need to be transferred to another hospital for
emergency care.
However, for clinical purposes, as long as the beneficiary returns to the swing bed in less than 24
hours, was not admitted as a hospital inpatient, and was not discharged from the swing bed, this time
in the ER is considered a “leave of absence” and does not require any Discharge Tracking
information.
Likewise, from the perspective of Medicare payment under PPS, there is no requirement for any
additional assessment. The day preceding the midnight is NOT a covered Part A day and, therefore,
the Medicare assessment “clock” is adjusted by skipping that day in calculating when the next
Medicare assessment is due.
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Leave of Absence
In extremely rare instances, a patient may require a temporary leave of absence (e.g. attend funeral
for family member). These instances are considered a “therapeutic” leave of absence and do not
require Discharge tracking information. There is no requirement for an additional assessment. The
days the patient is out of the facility are not covered Part A days, and, therefore, the Medicare
assessment “clock” is adjusted by skipping those days in calculating when the next Medicare
assessment is due. However, the days the patient is on the temporary absence are included in the
observation period, as indicated. The swing bed may include services furnished during the patient’s
temporary absence when permitted under swing bed MDS coding guidelines.
2.4
Discharge and Reentry Tracking Information
Swing bed hospitals are required to complete discharge and reentry information to “track” the
discharges and reentries of the patients. Discharge and reentry tracking information provides key
information to identify and track the movement of patients in and out of the swing bed hospital.
The discharge and reentry information is a selected subset of SB-MDS items. When a clinician has
determined that a discharge or reentry needs to be reported, he/she will select either Item 11a = 06
(Discharged-Return Not Anticipated), Item 11a = 07 (Discharged-Return Anticipated), or Item 11a
= 09 (Reentry). Following the selection of Item 11a = 06, 07, or 09, the software program will
display the required SB-MDS items to report the discharge or reentry.
The Discharge Tracking Information Contains:
•
•
•
•
•
•
•
•
•
•
•
Item 1a-d
Item 2
Item 3
Item 6
Item 7a
Item 7b
Item 8
Item 9a
Item 9b
Item 10b
Item 11a
•
•
•
•
•
•
Item 11e
Item 11f
Item 13
Item 14a
Item 14b
Item 15
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Name
Gender
Birth Date
Zip Code
Social Security Number
Medicare or Railroad Insurance Number
Medicaid Number
Medicaid Provider Number
Medicare Provider Number
Correction Number
Primary Reason for Assessment:
Discharge Code = 06 (Discharged-Return Not Anticipated)
Discharge Code = 07 (Discharged-Return Anticipated)
State-Required Assessment
Assessment Needed for Other Reasons
Admission Date
Admitted From
Discharge Status Code
Discharge Date
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The following items are not submitted with the discharge information, but must be completed on a
hard copy and kept in the record:
•
•
Item 45a
Item 45b
Name/Signature of RN Coordinating Assessment, and
Date RN Assessment Coordinator signed that the assessment was
completed.
The Reentry Tracking Information Contains:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Item 1a-d
Item 2
Item 3
Item 6
Item 7a
Item 7b
Item 8
Item 9a
Item 9b
Item 10b
Item 11a
Item 11e
Item 11f
Item 13
Item 14a
Item 14c
Item 16
Name
Gender
Birth Date
Zip Code
Social Security Number
Medicare or Railroad Insurance Number
Medicaid Number
Medicaid Provider Number
Medicare Provider Number
Correction Number
Primary Reason for Assessment = Reentry Code 09
State-Required Assessment
Assessment Needed for Other Reasons
Admission Date
Admitted From
Reentered From
Reentry Date
The following items are not submitted with the reentry information, but must be completed on a hard
copy and kept in the record:
•
•
Item 45a
Item 45b
Name/Signature of RN Coordinating Assessment, and
Date RN Assessment Coordinator signed that the assessment was
completed.
In some situations, discharge and reentry tracking information is not completed:
•
When the patient leaves the swing bed on a temporary visit home, or on another type of
therapeutic or social leave.
•
When patients are in a hospital outpatient department for an observational stay of less than 24
hours and the patient is not admitted for acute care as an inpatient.
If the observational stay goes beyond 24 hours or if the patient is admitted for acute care, then
discharge tracking information must be completed within 7 days. The discharge date entered at
Item 15 would be the date that the patient actually left the swing bed, not the date he/she was
admitted to the hospital.
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The clinician must clearly understand the differences between the two types of discharges in order to
correctly select the appropriate response at Item 11a. They are:
•
Discharged-Return Not Anticipated (Reason for Assessment Item 11a = 06)
•
Discharged-Return Anticipated (Reason for Assessment Item 11a = 07)
A Discharged-Return Not Anticipated (Item 11a = 06) is completed when it is determined that the
patient is being discharged with no expectation of return after a Medicare PPS assessment has been
completed. A Discharged-Return Not Anticipated can be a formal discharge to home, to another
facility, or when the patient dies. The Discharge-Return Not Anticipated must be completed
(Item 45b) within 7 days of the discharge date (Item 15) and must be electronically submitted to
and accepted into the national database within 14 days of completion (Item 45b). If the patient is
formally discharged from the swing bed and returns at a later date, this will be a new admission and
requires a new 5-Day Medicare PPS assessment. The SB-MDS assessment schedule will start over
with the new 5-Day assessment.
The term “discharged” is also defined as the discontinuation of Part A SNF-level services.
Discharge tracking information is required when Medicare Part A SNF-level benefits have been
exhausted or when the patient no longer requires skilled services. The discharge tracking
information should be coded to indicate “return not anticipated.” If the patient remains in the swing
bed hospital after the end of the Part A SNF-level stay, the clinician is not required to perform
additional SB-MDS assessments. The swing bed hospital may choose to continue the SB-MDS
assessment process, if needed for other payers or for its own assessment and care planning purposes.
A Discharged-Return Anticipated (Item 11a = 07) reports a more temporary absence from the
swing bed after any Medicare assessment is completed, and when it is anticipated that the patient
will return for Medicare Part-A services. A Discharged-Return Anticipated would be coded when a
patient is temporarily admitted for acute care in the hospital or a hospital observation stay lasting
more than 24 hours and the patient is expected to return to the swing bed. The Discharge-Return
Anticipated must be completed (Item 45b) within 7 days of the discharge date (Item 15) and must
be electronically submitted to and accepted into the national database within 14 days of completion
(Item 45b).
It is possible that a patient would be Discharged-Return Anticipated and later the swing bed learns
that he/she will not be returning or has died. If this occurs, additional discharge tracking information
(Return Not Anticipated) is not required.
Clarification:
October 2003
The requirements for completion of discharge tracking information are not
associated with bedhold status. Discharge tracking information is required
whenever a patient is discharged, regardless of bedhold status. If the bed is
being held, it logically follows that return is anticipated, and Item 11a = 07
is coded Discharged-Return Anticipated.
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CMS’s SB Version 1.0 Manual
Reentry tracking information (Item 11a = 09) is completed whenever the patient reenters the swing
bed hospital following a temporary admission to any hospital, a hospital observation stay greater
than 24 hours, or is returning to Part A SNF-level services following a Discharged-Return
Anticipated (Item 11a = 07). The reentry tracking information is completed, even if the patient’s
clinical record was not formally closed and regardless of whether or not the patient was formally
discharged from the swing bed hospital. The Reentry must be completed (Item 45b) within 7 days
of the reentry date (Item 16) and must be electronically submitted to and accepted into the national
database within 14 days of completion (Item 45b).
A flow chart has been provided on Page 2-12 to diagram the discharge and reentry process.
October 2003
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CMS’s SB Version 1.0 Manual
SB-MDS DISCHARGE AND REENTRY FLOWCHART
PATIENT LEAVES SWING BED
• Temporary home visit
• Temporary therapeutic leave or
social leave
• Hospital outpatient observational
stay < 24 hr., where hospital does
not admit and swing bed does not
discharge
• Permanent discharge to private residence
• Patient dies in swing bed hospital
• Swing bed discharges to hospital or other
hospital
• Hospital observational stay > 24 hr.,
regardless of whether hospital admits or
swing bed discharges
• Part A SNF-level services are no longer
provided
Discharge or Reentry
tracking information
NOT APPROPRIATE
Yes
Return anticipated?
Yes
Discharge code = 07 on
discharge tracking information
Yes
Discharge tracking
information REQUIRED
Patient later returns to
swing bed
No
Discharge code = 06 on
discharge tracking information
No
Patient later returns to
swing bed
No
Yes
• Reentry tracking
information
REQUIRED
• Medicare Return/
Readmission
assmt.
REQUIRED if
Part A SNF-level
services continuing
October 2003
• Further tracking
information
NOT
REQUIRED by
Federal
regulations
• Subsequent
tracking may be
completed at the
swing bed’s
option or as
required by the
State
• Reentry tracking
information NOT
REQUIRED
• Medicare 5-Day
assmt.
REQUIRED if
starting Part A
SNF-level
services
• No further tracking
information is
required
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Chapter 3: Item-by-Item Guide to the Swing Bed
Minimum Data Set Assessment
3.1
Overview and Standard Format of the Item-by-Item Guide
The SB-MDS is a subset of the MDS 2.0 used by skilled nursing facilities. All clinical items are
coded in exactly the same way by swing bed and skilled nursing facility staff. The MDS 2.0 item
numbers are printed on the SB-MDS form to allow you to cross-reference to the complete Revised
Long-Term Care Resident Assessment Instrument User’s Manual.
Information contained in this chapter should facilitate completion of the SB-MDS assessment
through item-by-item instructions that focus on:
•
The intent of items included on the SB-MDS assessment.
•
Supplemental definitions and instructions for completing SB-MDS items.
•
SB-MDS items that require observation of the patient for other than the standard 7-day
observation period.
•
Sources of information to be consulted in completing specific SB-MDS items.
CMS recognizes that the publication of this revised manual will not preclude future questions or the
need for more clarification about SB-MDS items. Therefore, CMS has developed a procedure to
review, respond and distribute clarifications for the SB-MDS coding process.
STEP 1:
If clinicians have a question about a particular SB-MDS item, they should first review
the manual and then contact their State RAI Coordinator for a clarification. If
necessary, the State RAI Coordinator will contact the appropriate CMS staff if he/she is
not able to answer a specific question.
STEP 2:
CMS will determine if a clarification about an item is needed and will post new
clarifications on the CMS web site. If a clarification is posted on the official CMS web
site, then it can be considered policy. CMS will develop a process to periodically
update the manual and incorporate additional clarifications. Clinicians should monitor
the CMS web site at:
http:://www.cms.hhs.gov/providers/snfpps/snfpps_swingbed.asp.
October 2003
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To ensure consistent interpretation, the item-by-item instructions are organized in the
following standard format. Descriptions of each SB-MDS item in this chapter will include
some or all of these information categories:
Intent:
Reasons(s) for including the item (or set of items) in the SB-MDS and
discussions about how the information will be used by clinical staff to document
the services and treatments provided to the patient.
Definition:
Explanation of key terms.
Process:
Methods for determining the correct response for an item and sources of
information, including:
Coding:
•
Discussion with facility staff, both licensed and non-licensed
•
Patient interview and observation
•
Clinical records, facility records, transmittal records (at admission),
physician orders, laboratory data, medication records, treatment sheets, flow
sheets (e.g., vital signs, weights, intake and output), and other documents in
the facility record system
•
Discussion with the patient’s family
•
Discussion with attending physician
Explanations of individual response categories and the proper method of
recording each response.
Clarifications:
October 2003
Clarifications for SB-MDS items provided by CMS.
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3.2
How to Use This Chapter
Use this chapter alongside the SB-MDS assessment, keeping the form in front of you at all
times. The SB-MDS information in this chapter should facilitate successful completion of the
SB-MDS assessment. The items from the SB-MDS assessment are presented in the same order as on
the form.
Becoming Familiar with the SB-MDS
(A) Review the SB-MDS assessment.
•
Notice how items are organized and where information is to be recorded.
•
Work through each item.
•
Examine item definitions and response categories.
•
Review procedural instructions, time frames, and general coding conventions.
(B) Complete an SB-MDS assessment for a patient in your facility using only your
knowledge of this individual. Enter the appropriate codes on the SB-MDS assessment.
Note items that would benefit from additional information and where you might secure the
information.
(C) Complete an initial pass through this chapter after reviewing the SB-MDS assessment
and completing all items for a patient who is well known to you.
•
Read the instructions that apply to a single item of the SB-MDS assessment. Make sure
you understand this information before going on to another item. It will take time to
review all this material. Do it slowly, working through the manual one item at a time.
•
Review the test case you completed. Clarify questions you had as you completed the
SB-MDS assessment for the first time.
(continued on next page)
October 2003
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Becoming Familiar with the SB-MDS
(continued)
•
Are you surprised by any SB-MDS definitions, instructions, or case examples? Do
you understand how to code ADLs? Or Mood?
•
Do any definitions or instructions differ from what you thought you learned when you
reviewed the SB-MDS assessment?
•
Would you now complete your test case differently?
•
Are there definitions or instructions that differ from current practice patterns in your
facility?
•
Make notations of any questions next to any section(s) of this manual. Be prepared to
discuss these issues during any formal training program you attend, or contact your
State SB-MDS resource person (see Appendix B).
(D) Make a second pass through this chapter, focusing on difficult issues or ones that
were problematic in the first pass.
•
Make notes of any issues on the SB-MDS assessment.
•
Further familiarize yourself with definitions and procedures that differ from current
practice patterns or seem to raise questions.
•
Reread each of the case examples presented throughout this chapter.
(E) A third pass through this chapter may occur during formal SB-MDS training and
will provide you with another opportunity to review the material in this chapter. If you
have questions, raise them during the training session.
(F) Future use of information in this chapter:
•
Keep this manual at hand during the assessment process.
•
Where necessary, review the intent of each item in question.
•
Use it to increase the accuracy of your assessments.
October 2003
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SB-MDS CODING CONVENTIONS
Use the following coding conventions to enter information on the SB-MDS form:
•
Darkly shaded areas remain blank; they are on the form to set off boxes visually.
•
The convention of entering “0”: In assigning values for items that have an ordered set
of responses (e.g., from independent to dependent), zero (“0”) is used universally to
indicate the lack of a problem or that the patient is self-sufficient. For example, a patient
whose ADL codes are almost all coded “0” is a self-sufficient patient; the patient whose
ADLs have no “0” codes indicates a patient receives help from others.
•
When completing hard copy forms to be used for data entry, capital letters may be
easiest to read. Print legibly.
•
Dates - Where recording month, day, and year, enter two digits for the month and the day,
but four digits for the year. For example, the third day of January in the year 2003 is
recorded as:
0
1
Month
0
3
Day
2
0
0
3
Year
•
The standard no-information code is a dash (-). This code indicates that all available
sources of information have been exhausted; that is the information is not available, and
despite exhaustive probing, it remains unavailable. The no-information code entered on
the form manually or electronically may be any of the alternatives: circled dash,”NA”, or
plain dash.
•
“Skip” Patterns - There are a few instances where scoring on one item will govern
how scoring is completed for one or more additional items. The instructions direct the
assessor to “skip” over the next item (or several items) and go on to another (e.g.,
Item 17, Comatose, directs the assessor to “skip” to Item 23 if Item 17 is answered “1”
–“yes”. The intervening items would not be scored. If Item 17 was recorded as “0” “no”, then the assessor would continue with Item 18.).
A useful technique for visually checking the proper use of the “skip” pattern instructions
is to circle the “skip” instructions before going to the next appropriate item.
October 2003
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3.3
Item-by-Item Instructions for the SB-MDS Assessment
This section of item-by-item instructions follows the sequence of items on the CMS SB-MDS
assessment.
1.
Resident Name
(Key Field Item)
Definition:
Legal name in medical record.
Coding:
Use printed letters. Enter in the following order:
a.
b.
c.
d.
First Name
Middle Initial - If the patient has no middle initial, leave blank.
Last Name
Jr./Sr.
If the patient has no middle initial, leave Item (b) blank.
2.
3.
Gender
(Key Field Item)
Coding:
Enter “1” for Male or “2” for Female.
Birth Date
Coding:
(Key Field Item)
Fill in 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: January 2, 1918, should be entered as:
0
1
Month
4.
0
2
Day
1
9
1
8
Year
Marital Status
Coding:
Choose the answer that describes the current marital status of the patient.
1.
2.
3.
4.
5.
October 2003
Never Married
Married
Widowed
Separated
Divorced
Page 3-6
CMS’s SB Version 1.0 Manual
5.
Race/Ethnicity
Process:
Enter the race or ethnic category the patient uses to identify himself/herself.
Consult the patient, as necessary. For example, if parents are of two different
races, consult with patient to determine how he or she wishes to be classified.
Patients should be offered the option of selecting one or more racial designations.
Definition:
a. American Indian or Alaska Native - A person having origins in any of the
original peoples of North, Central, and South America, and who maintains
tribal affiliation or community attachment.
b. Asian - A person having origins in any of the original peoples of the Far East,
Southeast Asia, or the Indian subcontinent including, for example, Cambodia,
China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands,
Thailand, and Vietnam.
c. Black or African American - A person having origins in any of the black
racial groups of Africa. Terms such as “Haitian” or “Negro” can be used in
addition to “Black or African American.”
d. Hispanic or Latino - A person of Cuban, Mexican, Puerto Rican, South or
Central American, or other Spanish culture or origin, regardless of race. The
term, “Spanish origin” can be used in addition to “Hispanic or Latino.”
e. Native Hawaiian or Other Pacific Islander - A person having origins in any
of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
f. White - A person having origins in any of the original peoples of Europe, the
Middle East, or North Africa.
Coding:
6.
Check all that apply.
Zip Code
Definition:
Pre-Hospital Residence. The community address where the patient last resided
prior to swing bed admission. A primary residence includes a primary home,
apartment, board and care home, assisted living, or group home. If the patient
was admitted to your facility from another nursing facility or institutional setting,
the prior primary residence is the address of the patient’s primary home before
entering the other nursing facility or institutional setting.
Process:
Review patient’s admission records and transmittal records as necessary. Ask
patient and family members as appropriate. Check with your admissions office.
October 2003
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CMS’s SB Version 1.0 Manual
Examples
7.
•
Mr. T was admitted to the swing bed hospital from an acute hospital stay. Prior to the
hospital admission, he lived with his wife in a mobile home in Jensen Beach, Florida.
Enter the zip code for Jensen Beach.
•
Mrs. F was admitted to the swing bed hospital after spending 3 years living with her
daughter’s family in Newton, MA. Prior to moving in with her daughter, Mrs. F lived
in Boston, MA for 50 years with her husband until he died. Enter the Newton, MA
zip code. Rationale: Her daughter’s home was Mrs. F’s primary residence prior to
swing bed hospital admission.
•
Ms. J was admitted to the Missouri Valley swing bed hospital following an acute stay
in the hospital. Before coming to the hospital, she had been a patient at the Green
Acres Nursing Facility in Chicago, Illinois. Prior to the nursing facility, she had lived
in her own home in Aurora, Illinois. Enter the Aurora, Illinois zip code. Rationale:
Her home in Aurora, Illinois was her prior primary residence before entering the
nursing facility.
Social Security Number and Medicare Numbers
Intent:
To record patient identifier numbers.
Process:
Review the patient’s record. If these numbers are missing, consult with your
swing bed hospital’s admission office.
Coding:
Enter one number per box starting with the left most box. Recheck the number
to be sure you have entered the digits correctly.
Social Security Number (Key Field Item) - If no Social Security number is
available for the patient (e.g., if the patient is a recent immigrant or a child),
leave it blank or enter the standard “no information” code (-).
Medicare Number (or comparable railroad insurance number) - Enter a
Medicare number or railroad number exactly as it appears on the beneficiary
documents. A Medicare number always starts with a number and the first 9
characters must be digits (0-9). It is important to remember that the Medicare
Health Insurance number may be different from the patient’s social security
number (SSN). For example, many patients may be receiving Medicare benefits
based on a spouse’s Medicare eligibility.
October 2003
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CMS’s SB Version 1.0 Manual
In rare instances, the patient will have neither a Medicare number nor a social
security number. When this occurs, another type of basic identification number
(e.g., railroad retirement insurance number) may be substituted. Railroad
retirement numbers contain 12 characters. Enter the number itself, one digit per
box beginning with the left-most box.
8.
Medicaid Number (if applicable)
Coding:
Clarification:
9.
Record this number if the patient is a Medicaid recipient. Enter one number per
box beginning in the left-most box. Recheck the number to make sure you have
entered the digits correctly. Enter a “+” in the left-most box if the number is
pending. If you get notified later that the patient does have a Medicaid number,
just include it on the next assessment. It is not necessary to process an SB-MDS
correction to add the Medicaid number on a prior assessment. If not applicable
because the patient is not a Medicaid recipient, enter “N” in the left-most box.
The Medicaid number is a unique identifier assigned by the State Medicaid
office. Questions regarding the Medicaid number can be referred to the State
Medicaid office.
Facility Provider Numbers
Intent:
To record the facility identifier numbers.
Definition:
The identification numbers assigned to the swing bed hospital by the Medicare
and Medicaid programs. Some facilities will have only a Federal (Medicare)
identification number; i.e., Medicare-only facilities. Dually eligible facilities
(i.e., facilities participating in both the Medicare and Medicaid programs) will
have Federal (Medicare) and State (Medicaid) identification numbers.
Process:
You can obtain the swing bed’s Medicare and Medicaid numbers from the
admission office. Once you have these numbers, they apply to all patients in the
swing bed facility.
Coding:
The Medicare provider number is a 6-digit number. For Medicare and Medicaid
dually-certified facilities, the first two digits are the state identifier followed by a
numeric character that is either a “5” or “6” followed by three numeric
characters. For Medicaid-only facilities, the Federal ID number consists of a twodigit state identifier followed by one alpha character and three numeric
characters. Start with the left-most box. Enter one character per box. Do not
enter imbedded dashes. Recheck the number to be sure you have entered the
digits correctly. There must always be a Federal provider number. The State
Medicaid number is optional. Each state establishes the structure of its Medicaid
provider numbers.
October 2003
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10. Assessment Reference Date
(Key Field Item)
a. Last Day of SB-MDS Observation Period
Intent:
To establish a common reference point for all staff participating in the patient’s
assessment. As staff members may work on a patient’s SB-MDS assessment on
different days, establishing the Assessment Reference Date (ARD) 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 patient’s objective
performance and health status during the same period of time. See Chapter 2 for
completion timing requirements for each assessment type.
Definition:
Assessment Reference Date - This date refers to a specific end-point for a
common observation period in the SB-MDS assessment process. Almost all
SB-MDS items refer to the patient’s status over a designated time period
referring back in time from the Assessment Reference Date. The observation
period ends on this date. Most observation periods are 7 days, while others are
14 or 30.
Clarifications:
The ARD is the common date on which all SB-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 SB-MDS
assessment. The ARD is the last day of the observation period and controls
what care and services are captured on the SB-MDS assessment. Anything
that happens after the ARD will not be captured on that SB-MDS. For
example, for an SB-MDS item with a 7-day period of observation,
assessment information is collected for a 7 day period ending on and
including the ARD, which is the 7th day of this observation period. For an
item with a 14-day observation period, the information is collected for a 14day period ending on and including the ARD.
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., Clinical Change 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.
October 2003
When the patient 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 the assessment
after the patient’s discharge in order to bill for Medicare 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 patient’s condition prior
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CMS’s SB Version 1.0 Manual
to admission to the swing bed, CMS has established a second option that
allows the swing bed to establish a full observation period.
October 2003
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Option 1 - Change the ARD to the date of discharge, but complete the
SB-MDS using less than a full observation period. In this case,
the Assessment Reference Date had been set at Day 5, and the
patient was discharged after 4 days of the observation period. For
items with a 7-day observation period, the SB-MDS would be
completed using the data collected for the 4-day period in the
swing bed and the 2-day period prior to admission. NOTE:
Item 38b, Therapies, includes only medically necessary therapies
furnished after admission or readmission to the swing bed.
Therapies received in the acute care setting are not included in
Item 38b – a, b, c, and d.
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 patient was
discharged after 4 days, the SB-MDS would be completed using
the data collected for the 4-day period in the swing bed. For a
7-day assessment item, hospital data could be used for the 3-day
period prior to the swing bed admission. NOTE: Item 38b,
Therapies, includes only medically necessary therapies furnished
after admission or readmission to the swing bed. Therapies
received in the acute care setting are not included in Item 38b –
a, b, c, and d.
Swing bed providers must select one of these options and apply it
consistently in all cases where the patient 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.
Coding:
The observation period may not be extended simply because a patient 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. This procedure applies to
all assessments.
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:
0
8
Month
October 2003
0
2
Day
2
0
0
2
Year
Page 3-12
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b. Original (00) or Correction (enter number of correction)
Intent:
To be used in the correction process. Assessments can be corrected once they
have been submitted to the national database. Errors can be corrected following
the correction process detailed in Chapter 4.
Definition:
Original Record - The initial assessment submitted to the national database.
Correction Record - This is a new version of an existing assessment that has
already been accepted into the national database. The correction record must
have the same “key fields” as the existing active record. Key fields are defined
in Chapter 4, Section 4.6.
Coding:
Original Record - Code “00” in the correction counter.
Correction Record - Code a value exactly one greater than the existing record.
If this is the first correction following the submission of the original record, it
would be coded “01”. There is no penalty for submitting too many corrections.
However, providers exhibiting a pattern for multiple corrections may be subject
to stringent SB-MDS review during survey. If the surveyor identifies an error
pattern impacting Medicare reimbursement, we would expect the survey agency
to alert the FI of the problem.
11. Reasons for Assessment
a. Primary Reasons for Assessment (Key Field Item)
Intent:
To document the 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.
Definition:
00.
PPS Assessment for Medicare Payment - A code used to report an
SB-MDS assessment completed for any PPS requirement: 5-Day, 14-Day,
30-Day, 60-Day, 90-Day, Readmission/Return, OMRA, or Clinical Change
assessment.
06.
Discharged-Return Not Anticipated - A code used to report a discharge
from the swing bed when a patient is not expected to return. This is a
means of closing the record of any patient from the facility without an
anticipated return. Also completed when Part A SNF-level services are no
longer provided.
07. Discharged-Return Anticipated - A code used to report a discharge when
the patient is expected to return to the swing bed facility, such as a
temporary discharge to a hospital.
October 2003
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CMS’s SB Version 1.0 Manual
Coding:
09.
Reentry - A code used when a patient is readmitted to the swing bed from a
temporary discharge (Discharged-Return Anticipated).
11.
Assessment-Not for Medicare Payment - A code used when the SB-MDS
assessment is being completed for any reason other than a Medicare PPS
assessment, discharge or reentry, such as State-Required Assessment
(Item 11e) or Assessment Needed for Other Reasons (Item 11f).
A response is required in this subsection. Choose the one answer that applies.
There may be situations when a swing bed patient is admitted as a hospital
patient and stays in the same bed. Even though the patient has not physically
moved from the bed, discharge tracking must be completed.
b. Assessment Codes Used for the Medicare Prospective Payment System
Intent:
To document which SB-MDS assessment is being completed: 5-Day, 30-Day,
60-Day, 90-Day, Readmission/Return, 14-Day or Other.
Definition:
1.
5-Day - The first Medicare PPS assessment completed upon admission to
the swing bed hospital for Part A SNF-level services; i.e. swing bed
services. The 5-Day Medicare PPS assessment will usually have an ARD
(Item 10a) established between days 1-5 of the swing bed stay. The ARD
(Item 10a) can be extended to day 8 if using the designated “Grace Days.”
The 5-Day Medicare PPS assessment must be completed (Item 45b)
within 14 days of the ARD (Item 10a). The 14-day calculation is based on
calendar days and includes weekends. The 5-Day assessment authorizes
payment from days 1 through 14 of the stay, as long as the patient remains
eligible for Part A SNF-level services. The SB-MDS records must be
submitted electronically to the national database and will be considered
timely if submitted and accepted into the database within 14 days of
completion (Item 45b).
2.
30-Day - Medicare PPS assessment that will usually have an ARD
(Item 10a) established between days 21-29 of the swing bed stay. The
ARD (Item 10a) can be extended to day 34 if using the designated “Grace
Days.” The 30-Day Medicare PPS assessment must be completed
(Item 45b) within 14 days of the ARD (Item 10a). The 30-Day assessment
authorizes payment from days 31 through 60 of the stay as long as the
patient remains eligible for Part A SNF-level services. The SB-MDS
records must be submitted electronically to the national database and will
be considered timely if submitted and accepted into the database within 14
days of completion (Item 45b).
3.
60-Day - Medicare PPS assessment that will usually have an established
ARD (Item 10a) between days 50-59 of the swing bed stay. The ARD
(Item 10a) can be extended to day 64 if using the designated “Grace
October 2003
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CMS’s SB Version 1.0 Manual
Days.” The 60-Day Medicare PPS assessment must be completed (Item
45b) within 14 days of the ARD (Item 10a). The 60-Day assessment
authorizes payment from days 61 through 90 of the stay as long as the
patient remains eligible for Part A SNF-level services. The SB-MDS
records must be submitted electronically to the national database and will
be considered timely if submitted and accepted into the database within 14
days of completion (Item 45b).
October 2003
4.
90-Day - Medicare PPS assessment that will usually have an ARD (Item
10a) established between days 80-89 of the swing bed stay. The ARD
(Item 10a) can be extended to day 94 if using the designated “Grace
Days.” The 90-Day Medicare PPS assessment must be completed (Item
45b) within 14 days of the ARD (Item 10a). The 90-Day assessment
authorizes payment from days 91 through 100 of the stay as long as the
patient remains eligible for Part A SNF-level services. The SB-MDS
records must be submitted electronically to the national database and will
be considered timely if submitted and accepted into the database within 14
days of completion (Item 45b).
5.
Readmission/Return - Medicare PPS assessment that is completed when a
patient whose stay was being reimbursed by SNF PPS, was hospitalized for
more than 24 hours and was discharged return anticipated, then later
readmitted to the swing bed from the hospital. The Readmission/Return
assessment, like the 5-Day assessment, must have an ARD (Item 10a)
established between days 1-8 of the return. The Readmission/Return
assessment must be completed (Item 45b) within 14 days of the ARD
(Item 10a). The Readmission/Return assessment restarts the Medicare
PPS schedule and the next required assessment would be the Medicare 14Day assessment. The SB-MDS records must be submitted electronically to
the national database and will be considered timely if submitted and
accepted into the database within 14 days of completion (Item 45b).
7.
14-Day - Medicare PPS assessment that will usually have an ARD
(Item 10a) established between days 11-14 of the swing bed stay. The
ARD (Item 10a) can be extended to day 19 if using the designated “Grace
Days.” The 14-Day assessment must be completed (Item 45b) within 14
days of the ARD (Item 10a). The 14-Day assessment authorizes payment
from days 15 through 30 of the stay as long as the patient remains eligible
for Part A SNF-level services. The SB-MDS records must be submitted
electronically to the national database and will be considered timely if
submitted and accepted into the database within 14 days of completion
(Item 45b).
9.
Other - This code is used only when an OMRA (Item 11c) or a CCA
(Item 11d) is completed.
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Coding:
Choose the one answer that applies. If you are completing an OMRA on a
Medicare patient, you will enter a “9” indicating other and also code “1” to
Item-11c (OMRA assessment). If you are completing a Clinical Change
assessment on a Medicare patient, you will enter a “9” indicating other, and also
code a “1” in Item 11d (Clinical Change assessment). If you are completing a
State Required Assessment (Item 11e) or an Assessment Needed for Other
Reason (Item 11f), leave this item blank.
c. OMRA Assessment
Definition:
Other Medicare Required Assessment (OMRA) - Assessment that must be
completed only when the patient was in a RUG-III Rehabilitation Plus Extensive
Services or Rehabilitation classification and will continue to need Part A
SNF-level services after the discontinuation of therapy. The OMRA ARD (Item
10a) must be set on day eight, nine, or ten after the last day that all rehabilitation
therapies have been discontinued.
The OMRA must be completed (Item 45b) within 14 days of the ARD
(Item 10a). The OMRA will establish a new non-therapy payment rate. The SBMDS records must be submitted electronically to the national database and will
be considered timely if submitted and accepted into the database within 14 days
of completion (Item 45b).
Coding:
A response is required in this subsection. Code “1” if the assessment is an
OMRA.
d. Clinical Change Assessment
Definition:
Clinical Change Assessment (CCA) – An assessment performed when a decline
or improvement in a patient’s status that: 1) will not normally resolve itself
without intervention by staff or by implementing standard disease-related clinical
interventions, 2) impacts on more than one area of the patient’s health status and,
3) requires interdisciplinary review and/or revision of the plan of care. (See
Chapter 2, Section 2.2 for guidelines.)
Coding:
A response is required in this subsection. Code “1” if the assessment is a
Clinical Change Assessment.
Clarification:
October 2003
Adding therapy services to the treatments furnished to a patient in a Part A
SNF-level stay does not automatically require a new assessment. However,
if the therapy was added because the beneficiary experienced a clinical
change, a CCA must be completed.
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e. State-Required Assessment
Definition:
State Required Assessment - An assessment required by your State Medicaid
swing bed program.
Coding:
A response is required in this subsection. Code “1” if your state requires the SBMDS assessment for the Medicaid program.
f. Assessment Needed for Other Reasons
Definition:
Assessment Needed for Other Reasons – An assessment that is completed for
other payers, such as a Health Maintenance Organization (HMO) or other
Medicare Secondary Payer (MSP).
Coding:
A response is required in this subsection. Code “1” if you are required to
complete the SB-MDS assessment by an HMO or MSP or because of a sanction
situation.
12. Prior Acute Care Stay
Intent:
To document the admission date of the qualifying 3-day hospital stay that
occurred before admission to the swing bed for Part A SNF-level services.
Definition:
Date the patient was admitted as an inpatient for hospital acute care services.
Coding:
Fill in 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, February 7, 2003 should be entered as:
0
2
Month
0
7
Day
2
0
0
3
Year
13. Admission Date
Intent:
To document the date of the initial admission for swing bed services.
Definition:
Admission Date - The initial date of admission for Part A SNF-level services.
This date will not change on subsequent assessments until the patient is
discharged with a return not anticipated. If the patient is discharged as a return
not anticipated and is admitted again at a later date, the patient will be considered
a new admission and a new admission date will be entered on the 5-Day
assessment.
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Coding:
Fill in 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, February 7, 2003 should be entered as:
0
2
Month
0
7
Day
2
0
0
3
Year
Examples
Mr. Jones was first admitted to Green Oaks for swing bed services on March 3, 2002 for a Medicare
Part A covered stay. On the 5-Day assessment, the admission date of 03/03/2002 was recorded as
the admission date. On March 9, 2002 he became unstable and required acute care services at Green
Oaks Hospital for 2 days. The RN assessment coordinator completed a discharge return anticipated
on March 11, 2002. Mr. Jones returned to the swing bed on March 12, 2002. The nurse completed a
reentry document on March 12, 2002. A Return/Readmission assessment is required because he will
continue to be eligible for Medicare. The admission date would be coded 03/03/2002, because Mr.
Jones was discharged as a return anticipated and you would reflect the initial admission date.
Mrs. Smith was admitted to the Missouri Valley Hospital as a swing bed patient on December 10,
2002. The admission date of 12/10/2002 was recorded on the 5-Day and 14-Day assessments. On
day 18 of her stay, she was discharged to her home. A discharged-return not anticipated document
was completed and submitted to the national database. On December 31st, Mrs. Smith was admitted
to the hospital for a fractured hip and was transferred back to the swing bed for rehabilitation on
January 6, 2003. The January 6, 2003 swing bed admission is a new stay and the admission date
will be 01/06/2003.
14. Admission/Discharge Status Code
Definition:
October 2003
01.
Private Home/Apt With No Home Health Care - Any house,
condominium or apartment in the community, whether owned by the
patient or another person (may be a child, friend, sibling). Also included in
this category are retirement communities and independent housing for the
elderly. No health care services were provided to the resident.
02.
Private Home/Apt With Home Health Care - Services including 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 home
health services: homemaker/personal care services, home delivered meals,
telephone reassurance, transportation, respite services, or adult day care.
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03. Board and Care/Assisted Living/Group Home - A non-institutional
community residential setting that may include services of the following
types: home health services, homemaker/personal care services, or meal
services.
October 2003
04.
Another Nursing Facility - 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 of injured, disabled, or sick persons. Include
admissions from hospital swing beds here.
05.
Acute Unit at Own 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 in the hospital where the swing
bed services are currently being provided.
06.
Acute Unit at Another Hospital - An institution where acute care was
provided other than the hospital where the Part A SNF-level services are
currently being provided.
07.
Psychiatric Hospital - 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.
08.
Rehabilitation Hospital - An institution that is engaged in providing,
under the supervision of physicians, rehabilitation services for the
rehabilitation of injured, disabled, or sick persons.
09.
MR/DD Facility - 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.
10.
Hospice - A program that provides palliative and supportive care for the
terminally ill patients and their families.
11.
Deceased
12.
Other - Includes chronic disease hospitals. Also includes when a patient
has exhausted Part A SNF days or no longer meets criteria for Part A SNF
level services.
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a. Admitted From
Intent:
To document the patient’s living arrangement prior to admission and the presence
or absence of home health services.
Process:
Review admission records. Consult the patient and the patient’s family.
Coding:
Choose only one answer.
b. Discharge Status
Intent:
To document the type of living arrangement to which the patient is discharged or
to report the death of a patient.
Coding:
Choose only one answer.
Clarification:
Complete when Item 11a is coded as 06 or 07. Must also complete Item 15.
c. Reentered From
Intent:
To document the patient’s living arrangements prior to reentry for swing bed
services.
Process:
Review admission records. Consult the patient and the patient’s family.
Coding:
Choose only one answer. Complete only if previously discharged with return
anticipated.
Clarification:
Complete when Item 11a is coded as 09. Must also complete Item 16.
15. Discharge Date
(Key Field Item)
Intent:
To track the date that the patient was discharged from the swing bed or has died.
This includes when a patient has exhausted Part A SNF benefits or no longer
meets the criteria for Part A SNF services.
Coding:
Complete if Item 11a = 06 (Discharged-Return not Anticipated) or 07
(Discharged-Return Anticipated). Fill in 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, February 7,
2003 should be entered as:
0
2
Month
October 2003
0
7
Day
2
0
0
3
Year
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16. Reentry Date
(Key Field Item)
Intent:
To document the date the patient returns to the swing bed program from a
discharged-return anticipated status.
Coding:
Complete if Item 11a = 09 (Reentry). Fill in 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,
February 7, 2003 should be entered as:
0
2
Month
0
7
Day
2
0
0
3
Year
CLINICAL DATA
17. Comatose
(7-day look back)
Intent:
To record whether the patient’s clinical record includes a documented
neurological diagnosis of coma or persistent vegetative state.
Coding:
Enter the appropriate number in the box. If the patient has been diagnosed as
comatose or in a persistent vegetative state, code “1” and Skip to Item 23
(Activities of Daily Living). If the patient is not comatose or not in a persistent
vegetative state, code “0” and proceed to the next item (Item 18).
Clarification:
Comatose (coma) is a pathological state in which neither arousal
(wakefulness, alertness) nor awareness (cognition of self and environment) is
present. The comatose person is unresponsive and cannot be aroused; he/she
does not open his/her eyes, does not speak and does not move his/her
extremities on command or in response to noxious stimuli (e.g., pain).
Sometimes patients who were comatose for a period of time after an anoxicischemic injury (i.e., not enough oxygen to the brain), from a cardiac arrest,
head trauma or massive stroke, regain wakefulness but have no evidence of
any purposeful behavior or cognition. Their eyes are open and they seem to
be awake. They may grunt, yawn, pick with their fingers and have random
movements of their heads and extremities. A neurological exam shows that
they have extensive damage to both cerebral hemispheres. This state is
different from coma, and if it continues, is called a persistent vegetative state.
Both coma and vegetative state have serious consequences in terms of longterm clinical outcomes and care needs.
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Many other patients have severe impairments in cognition that are associated
with late stages of progressive neurological disorders such as Alzheimer’s
disease. Although such patients may be non-communicative, totally
dependent on others for care and nourishment, and sleep a great deal of time,
they are usually not comatose or in a persistent vegetative state as described
above.
To prevent any patient from being mislabeled, it is imperative that coding of
comatose reflects physician documentation of a diagnosis of either coma or
persistent vegetative state.
18. Short-Term Memory
(7-day look back)
Intent:
To determine the patient’s functional capacity to remember recent or short-term
events.
Process:
Ask the patient to describe a recent event that both of you had the opportunity to
remember. Or, you could use a more structured short-term memory test. For
patients with limited communication skills, ask staff and family about the
patient’s memory status. Remember, if there is no positive indication of memory
ability, (e.g., remembering multiple items over time or following through on a
direction given five minutes earlier) the correct response is “1”, Memory
Problem.
If the test cannot be conducted (patient will not cooperate, is non-responsive,
etc.) and the staff were unable to make a determination based on observation of
the patient, use the “-” response to indicate that the information is not available
because it could not be assessed.
Examples
Ask the patient to describe the breakfast meal or an activity just completed.
Ask the patient to remember three items (e.g., book, watch, table) for a few minutes.
After you have stated all three items, ask the patient to repeat them (to verify that you
were heard and understood). Then proceed to talk about something else - do not be
silent, do not leave the room. In five minutes, ask the patient to repeat the name of each
item. If the patient is unable to recall all three items, code “1.” For persons with verbal
communication deficits, non-verbal responses are acceptable (e.g., when asked how
many children they have, they can tap out a response of the appropriate number).
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Coding:
Enter the number that corresponds to the observed response. Remember, if there
is no positive indication of memory ability, (e.g., remembering multiple items
over time or following through on a direction given five minutes earlier) the
correct response is “1”, Memory Problem.
Clarifications:
Many persons with memory problems can learn to function successfully in a
structured, routine environment. Observing patient function in multiple daily
activities is only one aspect of evaluating short-term memory function. For
example, a patient may remember to come to lunch, but may not remember
what he/she ate. The short-term memory test described above is still an
important component of the overall evaluation.
When coding short-term memory, identify the most representative level of
function, not the highest. Therefore, a patient with short-term memory
problems 6 of the 7 days should be coded as “1”. For many patients,
performance varies. Staff must use clinical judgment to decide whether a
single observation provides sufficient information on the patient’s typical
level of function.
19. Cognitive Skills
Intent:
(7-day look back)
To record the patient’s actual performance in making everyday decisions about
tasks or activities of daily living.
Examples
Choosing items of clothing; knowing when to go to scheduled meals; using environmental
cues to organize and plan (e.g., clocks, calendars, posted listings of upcoming events); in
the absence of environmental cues, seeking information appropriately (i.e., not
repetitively) from others in order to plan the day; using awareness of one’s own strengths
and limitations in regulating the day’s events (e.g., asks for help when necessary); making
the correct decision concerning how to get to the dining room; acknowledging need to use
a walker, and using it faithfully.
Process:
October 2003
Review the clinical record. Consult family and nurse assistants. Observe the
patient. The inquiry should focus on whether the patient is actively making these
decisions, and not whether staff believe the patient might be capable of doing so
or not. Remember, the intent of this item is to record what the patient is doing
(performance). Where a staff member takes decision-making responsibility away
from the patient regarding tasks of everyday living or the patient does not
participate in decision making, whatever his or her level of capability may be, the
patient should be considered to have impaired performance in decision-making.
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This item is especially important for further assessment. It can alert staff to a
mismatch between a patient’s abilities and his or her current level of performance
or to an inadvertent fostering of the patient’s dependence.
Coding:
Enter one number that corresponds to the most correct response.
0. Independent - The patient’s decisions in organizing daily routine and making
decisions were consistent, reasonable, and organized reflecting lifestyle,
culture, values.
1. Modified Independence - The patient organized daily routine and made safe
decisions in familiar situations, but experienced some difficulty in decisionmaking when faced with new tasks or situations.
2. Moderately Impaired - The patient’s decisions were poor; the patient
required reminders, cues, and supervision in planning, organizing, and
correcting daily routines.
3. Severely Impaired - The patient never (or rarely) made decisions.
Clarifications:
If the patient “rarely or never” made decisions, despite being provided with
opportunities and appropriate cues, code as “3” for Severely Impaired. If
the patient attempts to make decisions, although poorly, code “2” for
Moderately Impaired.
Coding the following examples for “Cognitive Skills for Daily DecisionMaking:”
(1)
If a patient seems to have severe cognitive impairment and is nonverbal, but usually clamps his mouth shut when offered a bite of food,
would the patient be considered moderately or severely impaired?
(2)
If a patient does not generally make conversation or make his needs
known, but replies “yes” when asked if he would like to take a nap,
would the patient be considered moderately or severely impaired?
These examples are similar in that the patients are primarily non-verbal and
do not make their needs known, but they do make basic verbal or non-verbal
responses to simple gestures or questions regarding care routines (e.g.,
comfort). More information about how the patient functions in his
environment is needed to definitively answer the questions. From the limited
information provided about these patients, one would gather that their
communication is only focused on very particular circumstances, in which
case it would be regarded as “rarely/never” in the relative number of
decisions a person could make during the course of a week code as “3”,
Severely Impaired. The assessor should determine if the patient would
respond in a similar fashion to other requests made during the 7-day
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observation period. If such “decisions” are more frequent, the patient may be
only moderately impaired or better.
20. Making Self Understood
(7-day look back)
Intent:
To document the patient’s ability to express or communicate requests, needs,
opinions, urgent problems, and social conversation, whether in speech, writing,
sign language, gestures, sounds, communication board or a combination of these.
Process:
Interact with the patient. Observe and listen to the patient’s efforts to
communicate with you. Observe his or her interactions with others in different
settings (e.g., one-on-one, groups) and different circumstances (e.g., when calm,
when agitated). Consult with the primary nurse assistant (over all shifts), family
members (if available), and the speech-language pathologist.
Coding:
Enter the number corresponding to the most correct response.
0. Understood - The patient expresses ideas clearly.
1. Usually Understood - The patient has difficulty finding the right words or
finishing thoughts, resulting in delayed responses; or the patient requires
some prompting to make self understood.
2. Sometimes Understood - The patient has limited ability, but is able to
express concrete requests regarding at least basic needs (e.g., food, drink,
sleep, toilet).
3. Rarely/Never Understood - At best, understanding is limited to staff
interpretation of highly individual, patient-specific sounds or body language
(e.g., indicated presence of pain or need to toilet).
Clarification:
A patient assessed as “3” (Rarely/Never Understood), should not necessarily
be coded as severely impaired in daily decision making (Item 19, Cognitive
Skills). The two areas of function are not always associated. The ability to
be understood may not be a functional problem, but a different language
spoken by the patient. For example, a person who is rarely/never understood
may speak a language other than that spoken by caregivers, or he/she may be
profoundly hearing or vision impaired. A more thorough assessment must be
done to determine the actual level of cognitive function.
21. Indicators of Depression
(30-day look back)
It is important to note that coding the presence of indicators does not automatically mean that the
patient has a diagnosis of depression or anxiety. Assessors do not make or assign a diagnosis in this
section; they simply record the presence or absence of specific indicators and behaviors. It is
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important that facility staff recognizes these clinical indicators and consider them when developing
the patient’s plan of care.
Intent:
To record the frequency of indicators observed in the last 30 days, irrespective of
the assumed cause of the indicator (behavior).
Definition:
Feelings of distress may be expressed directly by the patient who is depressed,
anxious, or sad. Distress may also be expressed non-verbally and identified
through observation of the patient during usual daily routines. Statements such
as “I’m so depressed” are rare in the elderly. Rather, distress is more commonly
expressed in the following ways:
VERBAL EXPRESSIONS OF DISTRESS
a. Negative Statements - e.g., “Nothing matters”; “Would rather be dead”;
“What’s the use”; “Regrets having lived so long”; “Let me die.”
b. Repetitive Questions - e.g., “Where do I go?”; “What do I do?”
c. Repetitive Verbalizations - e.g., Calling out for help, “God help me”.
d. Persistent Anger with Self/Others - e.g., easily annoyed, anger at placement
in swing bed; anger at care received.
e. Self Deprecation - e.g., “I am nothing”; “I am of no use to anyone”.
f. Expression of Unrealistic Fears - e.g., fear of being abandoned, left alone,
being with others.
g. Recurrent Statements that Something Terrible is About to Happen - e.g.,
believes he or she is about to die, have a heart attack.
h. Repetitive Health Complaints - e.g., persistently seeks medical attention,
obsessive concern with body functions.
i. Repetitive Anxious Complaints/Concerns (non-health related) - e.g.,
persistently seeks attention/reassurance regarding schedules, meals, laundry,
clothing, relationship issues.
NON-VERBAL EXPRESSIONS OF DISTRESS
Sleep Cycle Patterns:
j. Unpleasant Mood in Morning – e.g., angry, irritable.
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k. Insomnia/Change in Usual Sleep Pattern - e.g., difficulty falling asleep,
fewer or more hours of sleep than usual, waking up too early and unable to
fall back to sleep.
Sad, Apathetic, Anxious Appearance:
l. Sad, Pained, Worried Facial Expressions - e.g., furrowed brows.
m. Crying, Tearfulness
n. Repetitive Physical Movements - e.g., pacing, hand wringing, restlessness,
fidgeting, picking.
Loss Of Interest:
o. Withdrawal from Activities of Interest - e.g., no interest in long standing
activities or being with family/friends. If the patient’s withdrawal from
activities of interest persists over time, it should continue to be coded,
regardless of the amount of time the patient has withdrawn from activities of
interest or has shown no interest in being with family/friends.
p. Reduced Social Interaction - e.g., less talkative, more isolated.
Process:
Initiate a conversation with the patient. Some patients are more verbal about
their feelings than others and will either tell someone about their distress, or tell
someone only when directly asked how they feel. Other patients may be unable
to articulate their feelings (i.e., cannot find the words to describe how they feel,
or lack insight or cognitive capacity). Observe patients carefully for any
indicator. Consult with direct care staff over all shifts, and family members, if
available, who have direct knowledge of the patient’s behavior. Relevant
information may also be found in the clinical record.
Coding:
For each indicator apply one of the following codes based on interactions with
and observations of the patient in the last 30 days. Remember, code regardless of
what you believe the cause to be.
0. Indicator not exhibited in last 30 days
1. Indicator of this type exhibited up to 5 days a week -exhibited at least
once during the last 30 days but less than 6 days a week
2. Indicator of this type exhibited daily or almost daily – exhibited 6, 7 days
a week
Clarifications:
October 2003
The keys to obtaining, tracking and recording accurate information are 1)
interviews with and observations of the patient, and 2) communication
between licensed and non-licensed staff and other caregivers.
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October 2003
•
Daily communication between nurses, nurse assistants and other direct
care providers is crucial for patient monitoring and care giving.
•
Educate all caregivers (including direct care staff and staff who routinely
come into contact with the patient, such as housekeepers, maintenance,
and dietary personnel) about the patient’s status in this area, and how to
observe mood and behavior patterns that are captured in this item. These
mood and behavior patterns are not part of normal aging. They are often
indicative of depression, anxiety, and other mental disorders. These
conditions are often under-identified and under-treated or untreated in
Part A SNF-level care. Part of the reason may be that staff tend to
perceive these conditions as the patient’s “normal” or “usual” behaviors.
•
Documentation of signs and symptoms of depression, anxiety and sad
mood, and of behavioral symptoms, is a matter of good clinical practice.
This information facilitates accurate diagnosis and identification of new
or worsening problems. This information facilitates communication to
the entire treatment team, across shifts, and is necessary in order to
monitor on an on-going basis, the patient’s status and response to
treatment. It is up to the facility to determine the form and format of such
documentation.
These items specify a 30-day observation period. Try a rule-out process to
make coding easier. For each indicator listed, think about whether it
occurred at all. If not, use code “0”. If the patient exhibited the behavior
almost daily (6 or 7 days a week), or multiple times daily, code “2”. If codes
“0” or “2” do not reflect the patient’s status, but the behavior occurred at
least once, use code “1”.
If an indicator of depression occurs twice in the last 30 days (not 2 times
each week), it should be coded as “1” to indicate that the indicator of
depression was exhibited up to five days a week (but less than 6 days a
week). It does not need to occur in each week to be coded. If an indicator of
depression occurs only in the beginning of the 30-day period, it should be
coded as an indicator of depression occurring up to 5 days a week (but less
than 6 days a week) in the last 30 days.
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Example
Mr. F is a new admission that becomes upset and angry when his daughter visits (3 times a
week). He complains to her and staff caregivers that “she put me in this terrible dump.”
He chastises her “for not taking him into her home,” and berates her “for being an
ungrateful daughter.” After she leaves, he becomes remorseful, sad looking, tearful, and
says, “What’s the use. I’m no good. I wish I died when my wife did.” Code a. (Negative
statements), d. (Persistent anger with self/others), e. (Self deprecation), m. (Crying,
tearfulness) as “1”; remaining Mood items would be coded “0”.
22. Behavioral Symptoms
Intent:
(7-day look back)
To identify the frequency of behavioral symptoms in the last seven days that
cause distress to the patient, or are distressing or disruptive to facility patients or
staff members. Such behaviors include those that are potentially harmful to the
patient himself or herself or disruptive in the environment, even if staff and other
patients appear to have adjusted to them (e.g., “Mrs. R’s calling out isn’t much
different than others on the unit. There are many noisy patients;” or “Mrs. L
doesn’t mean to hit me. She does it because she’s confused.”).
Acknowledging and documenting the patient’s behavioral symptom patterns on
the SB-MDS provide a basis for further evaluation, planning care, and delivery
of consistent, appropriate care towards ameliorating the behavioral symptoms.
Documentation in the clinical record of the patient’s current status may not
initially be detailed (and in some cases will not pinpoint the patient’s actual
problems) and it is not intended to be the one and only source of information (see
Process below). However, once the frequency of behavioral symptoms is
accurately determined, subsequent documentation should more accurately reflect
the patient’s status and response to interventions.
Definition:
a. Wandering - Locomotion with no discernible, rational purpose. A
wandering patient may be oblivious to his or her physical or safety needs.
Wandering behavior should be differentiated from purposeful movement
(e.g., a hungry person moving about the unit in search of food). Wandering
may be manifested by walking or by wheelchair.
Do not include pacing as wandering behavior. Pacing back and forth is not
considered wandering, and if it occurs, it should be documented in Item 21n,
“Repetitive physical movements”.
b. Verbally Abusive Behavioral Symptoms - Other patients or staff were
threatened, screamed at, or cursed at.
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c. Physically Abusive Behavioral Symptoms - Other patients or staff were hit,
shoved, scratched, or sexually abused.
d. Socially Inappropriate/Disruptive Behavioral Symptoms - Includes
disruptive sounds, excessive noise, screams, self-abusive acts, sexual
behavior or disrobing in public, smearing or throwing food or feces,
hoarding, rummaging through others’ belongings.
e. Resists Care - Resists taking medications/injections, ADL assistance or help
with eating. This category does not include instances where the patient has
made an informed choice not to follow a course of care (e.g., patient has
exercised his or her right to refuse treatment, and reacts negatively as staff try
to reinstitute treatment).
Signs of resistance may be verbal and/or physical (e.g., verbally refusing
care, pushing caregiver away, scratching caregiver). These behaviors are not
necessarily positive or negative, but are intended to provide information
about the patient’s responses to nursing interventions and to prompt further
investigation of causes (e.g., fear of pain, fear of falling, poor
comprehension, anger, poor relationships, eagerness for greater participation
in care decisions, past experience with medication errors and unacceptable
care, desire to modify care being provided).
Process:
Take an objective view of the patient’s behavioral symptoms. The coding for this
item focuses on the patient’s actions, not intent. It is often difficult to determine
the meaning behind a particular behavioral symptom. Therefore, it is important
to start the assessment by recording any behavioral symptoms. The fact that staff
have become used to the behavior and minimize the patient’s presumed intent
(“He doesn’t really mean to hurt anyone. He’s just frightened.”) is not pertinent
to this coding. Does the patient manifest the behavioral symptom or not? Is the
patient combative during personal care? Does the patient strike out at staff or
not?
Observe the patient. Observe how the patient responds to staff members’
attempts to deliver care to him or her. Consult with staff that provide direct care
on all shifts. A symptomatic behavior could be present only at specific times
through out the day, e.g., during evening care. Therefore, it is especially
important to solicit from all nurse assistants having contact with the patient.
Also, be alert to the possibility that staff might not think to report a behavioral
symptom if it is part of the unit norm (e.g., staff are working with cognitively
severe and functionally impaired patients and are used to patients’ wandering,
noisiness, etc.). Focus staff attention on what has been the individual patient’s
actual behavior over the last seven days. Finally, although it may not be
complete, review the clinical record for documentation.
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Coding:
0. Behavior NOT Exhibited in Last 7 Days - Code “0” if the patient did not
exhibit that type of symptom in the last seven days. This code applies to patients
who have never exhibited the behavioral symptom or those who have previously
exhibited the symptom but now no longer exhibit it, including those whose
behavioral symptoms are fully managed by psychotropic drugs, restraints, or a
behavior-management program. For example: A “wandering” patient who did
not wander in the last seven days because he was restricted to a geri-chair would
be coded “0” - Behavioral symptom not exhibited in last seven days.
1. Behavior Occurred 1 to 3 Days in Last 7 Days
2. Behavior Occurred 4 to 6 Days, but Less Than Daily
3. Behavior Occurred Daily - behavior symptom occurred daily or multiple
times each day.
Examples for Wandering
Frequency
Ms. T has dementia and is severely impaired in making
decisions about daily life on her unit. She is dependent
on others to guide her through each day. When she is not
involved in some type of activity (leisure, dining, ADLs,
etc.) she wanders about the unit on a daily basis.
3
Mr. W has dementia and is severely impaired in making
daily decisions. He wanders all around the unit
throughout each day. He is extremely hard of hearing and
refuses to wear his hearing aid. He is easily frightened by
others and cannot stay still for activities programs.
3
23. Activities of Daily Living (ADLs)
(7-day look back)
Most swing bed patients are at risk of physical decline. Most long-term and many short-term
patients also have multiple chronic illnesses and are subject to a variety of other factors that
can severely impact self-sufficiency. For example, cognitive deficits can limit ability or
willingness to initiate or participate in self-care or constrict understanding of the tasks required
to complete ADLs. A wide range of physical and neurological illnesses can adversely affect
physical factors important to self-care such as stamina, muscle tone, balance, and bone
strength. Side effects of medications and other treatments can also contribute to needless loss
of self-sufficiency.
Due to these many, possibly adverse influences, a patient’s potential for maximum
functionality is often greatly underestimated by family, staff, and the patient himself or herself.
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Thus, all patients are candidates for nursing-based rehabilitative care that focuses on
maintaining and expanding self-involvement in ADLs. Individualized plans of care can be
successfully developed only when the patient’s self-performance has been accurately assessed
and the amount and type of support being provided to the patient by others has been evaluated.
(A) ADL SELF-PERFORMANCE
Intent:
To record the patient’s self care performance in activities of daily living (i.e.,
what the patient actually did for himself or herself and/or how much verbal or
physical help was required by staff members) during the last seven days.
Definition:
ADL Self-Performance - Measures what the patient actually did (not what he
or she might be capable of doing) within each ADL category over the last seven
days according to a performance-based scale.
a. Bed Mobility - How the patient moves to and from a lying position, turns
side to side, and positions body while in bed, in a recliner, or other type of
furniture the patient sleeps in, rather than a bed.
b. Transfer - How the patient moves between surfaces - i.e., to/from bed, chair,
wheelchair, standing position. Exclude from this definition movement
to/from bath or toilet, which is covered under Toilet Use and Bathing.
c. Eating - How the patient eats and drinks, regardless of skill. Do not include
eating/drinking during medication pass. Includes intake of nourishment by
other means (e.g., tube feeding, total parenteral nutrition).
Even a patient who receives tube feedings and no food or fluids by mouth is
engaged in eating (receiving nourishment), and is not to be coded as an “8”.
The patient must be evaluated under the Eating ADL category for his/her
level of assistance in the process. A patient who is highly involved in giving
himself/herself a tube feeding is not totally dependent and should not be
coded as a “4”.
d. Toilet Use - How the patient uses the toilet room, commode, bedpan, or
urinal, transfers on/off toilet, cleanses, changes pad, manages ostomy or
catheter, and adjusts clothes. Do not limit assessment to bathroom use only.
Elimination occurs in many settings and includes transferring on/off the
toilet, cleansing, changing pads, managing an ostomy or catheter, and
clothing adjustment.
Process:
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In order to be able to promote the highest level of functioning among patients,
clinical staff must first identify what the patient actually does for himself or
herself, noting when assistance is received and clarifying the types of assistance
provided (verbal cueing, physical support, etc.).
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A patient’s ADL self-performance may vary from day to day, shift to shift, or
within shifts. There are many possible reasons for these variations, including
mood, medical condition, relationship issues (e.g., willing to perform for a nurse
assistant he or she likes), and medications. The responsibility of the person
completing the assessment, therefore, is to capture the total picture of the
patient’s ADL self-performance over the seven day period, 24 hours a day - i.e.,
not only how the evaluating clinician sees the patient, but how the patient
performs on other shifts as well.
In order to accomplish this, it is necessary to gather information from multiple
sources - i.e., interviews/discussion with the patient and direct care staff on all
shifts including weekends, and review of documentation used to communicate
with staff across shifts. Begin by reviewing the documentation in the clinical
record. Observe the care being provided to the patient. Ask questions pertaining
to all aspects of the ADL activity definitions. For example, when discussing Bed
Mobility with a nurse assistant, be sure to inquire specifically how the patient
moves to and from a lying position, how the patient turns from side to side, and
how the patient positions himself or herself while in bed. A patient can be
independent in one aspect of Bed Mobility yet, require extensive assistance in
another aspect. Since accurate coding is important as a basis for making
decisions on the type and amount of care to be provided, be sure to consider each
activity definition fully.
The wording used in each ADL performance coding option is intended to reflect
real-world situations where slight variations in performance are common. Where
small variations occur, the coding ensures that the patient is not assigned to an
excessively independent or dependent category. For example, by definition,
codes 0, 1, 2, and 3 (Independent, Supervision, Limited Assistance, and
Extensive Assistance) permit one or two exceptions or instances for the provision
of heavier care within the assessment period. For example, in scoring a patient
as independent in ADL Self-Performance, there can be one or two exceptions. As
soon as there are three exceptions, another code must be considered. While it is
not necessary to know the actual number of times the activity occurred, it is
necessary to know whether or not the activity occurred three or more times
within the last 7 days.
Because this section involves a two-part evaluation (Item 23A, ADL SelfPerformance, and Item 23B, ADL Support), each using its own scale, it is
recommended that you complete the Self-Performance evaluation for all ADL
activities before beginning the ADL Support evaluation.
Talk with clinical staff from each shift to ascertain what the patient does for
himself or herself in each ADL activity as well as the type and level of staff
assistance being provided. As previously noted, be alert to differences in patient
performance from shift to shift, and apply the ADL codes that capture these
differences. For example, a patient may be independent in Toilet Use during
daylight hours but receive non weight-bearing physical assistance every evening.
In this case, the patient would be coded as “2” (Limited assistance) in Toilet Use.
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Guidelines for Assessing ADL Self-Performance and ADL Support Provided
• The scales for ADL Self-Performance and ADL Support Provided are used to record the
patient’s actual level of involvement in self-care and the type and amount of support actually
received during the last seven days.
• Do not record your assessment of the patient’s capacity for involvement in self-care - i.e., what
you believe the patient might be able to do for himself or herself based on demonstrated skills
or physical attributes.
• Do not record the type and level of assistance that the patient “should” be receiving according
to the written plan of care. The type and level of assistance actually provided might be quite
different from what is indicated in the plan. Record what is actually happening.
• Engage direct care staff from all shifts that have cared for the patient over the last seven days
in discussions regarding the patient’s ADL functional performance. Remind staff that the
focus is on the last seven days only. To clarify your own understanding and observations about
each ADL activity (bed mobility, transfer, eating and toilet use), ask probing questions,
beginning with the general and proceeding to the more specific.
Here is a typical conversation between the RN and a nurse assistant regarding a patient’s Bed
Mobility assessment:
R.N.
“Describe to me how Mrs. L positions herself in bed. By that I mean once she is in bed,
how does she move from sitting up to lying down, lying down to sitting up, turning side to
side, and positioning herself?”
N.A.
“She can lay down and sit up by herself, but I help her turn on her side.”
R.N.
“She lays down and sits up without any verbal instructions or physical help?”
N.A.
“No, I have to remind her to use her trapeze every time. But once I tell her how to do
things, she can do it herself.”
R.N.
“How do you help her turn side to side?”
N.A.
“She can help turn herself by grabbing onto her side rail. I tell her what to do. But she
needs me to lift her bottom and guide her legs into a good position.”
R.N.
“Do you lift her by yourself or does someone help you?”
N.A.
“I do it by myself.”
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R.N.
“How many days during the last week did you give this type of help?”
N.A.
“Every day.”
Provided that ADL function in Bed Mobility was similar on all shifts, Mrs. L
would receive an ADL Self-Performance Code of “3” (Extensive Assistance) and
an ADL Support Provided Code of “2” (One Person Physical Assist).
Now review the first two exchanges in the conversation between the RN and
nurse assistant. If the RN did not probe further, he or she would not have
received enough information to make an accurate assessment of either the
patient’s skills or the nurse assistant’s actual workload, or whether or not the
current plan of care was being implemented.
Coding:
For each ADL category, code the appropriate response for the patient’s actual
performance during the past seven days. Enter the code in column (A). Consider
the patient’s performance during all shifts, as functionality may vary. In the
pages that follow, two types of supplemental instructional material are presented
to assist you in learning how to use this code: a series of case examples for each
ADL and a schematic flow chart for scoring ADL Self-Performance.
In your evaluations, you will also need to consider the type of assistance known
as “set-up help” (e.g., the nurse assistant positions wheelchair next to bed and
locks wheels). Set-up help is recorded under ADL Support Provided (Item 23B).
But in evaluating the patient’s ADL Self-Performance, include set-up help within
the context of the “0” (Independent) code. For example: If a patient transfers
independently once wheelchair is set up for him, code “0” (Independent) in
Transfer.
0. Independent - No help or staff oversight -OR- staff help/oversight provided
only one or two times during the last seven days.
1. Supervision - Oversight, encouragement, or cueing provided three or more
times during last seven days -OR- supervision (3 or more times) plus
physical assistance provided, but only one or two times during last seven
days.
2. Limited Assistance – Patient highly involved in activity, received physical
help in guided maneuvering of limbs or other non weight-bearing assistance
on three or more occasions -OR- limited assistance (3 or more times), plus
more weight-bearing support provided, but for only one or two times during
the last 7 days.
3. Extensive Assistance - While the patient performed part of activity over last
seven days, help of following type(s) was provided three or more times:
-- Weight-bearing support provided three or more times;
-- Full staff performance of activity (3 or more times) during part (but not
all) of last seven days.
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4. Total Dependence - Full staff performance of the activity during entire 7-day
period. There is complete non-participation by the patient in all aspects of
the ADL definition task. If staff performed an activity for the patient during
the entire observation period, but the patient performed part of the activity
himself/herself, it would not be coded as a “4” (Total Dependence).
Example: Eating is coded based on the patient’s ability to eat and drink,
regardless of skill, and includes intake of nourishment by other means (e.g.,
tube feeding, or total parenteral nutrition). For a patient to be coded as
totally dependent in Eating, he or she would be fed all food and liquids at all
meals and snacks (including tube feeding delivered totally by staff), and
never initiate any subtask of eating (e.g., picking up finger foods, giving self
tube feeding or assisting with procedure) at any meal.
8. Activity Did Not Occur During the Entire 7-Day Period - Over the last
seven days, the ADL activity was not performed by the patient or staff. In
other words, the particular activity did not occur at all.
•
A patient who was restricted to bed for the entire 7-day period and was
never transferred from bed would be coded for both Self-Performance
and Staff Support as “8”, since the activity (transfer) did not occur.
•
To code Eating as an “8”, consider if in the past 7 days the patient truly
did not receive any nourishment. It should go without saying that this is
a serious issue. Be careful not to confuse total dependence in eating
(coded “4”) with the activity itself (receiving nourishment and fluids).
Keep in mind that as a patient who receives nourishment via tube feeding
and manages the tube feeding independently is coded as ”0”
(Independent). In addition, the definition for Eating includes IV fluids.
Therefore, code this item “4” (Total Dependence) rather than “8” for a
patient who is receiving IV fluids or TPN.
However, do not confuse a patient who is totally dependent in an ADL
activity (code 4 - Total Dependence) with the activity itself not occurring.
For example: Even a patient who receives tube feedings and no food or
fluids by mouth is engaged in eating (receiving nourishment), and must
be evaluated under the Eating category for his or her level of assistance
in the process. A patient who is highly involved in giving himself a tube
feeding is not totally dependent and should not be coded as “4”.
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Clarification:
Each of these ADL Self-Performance codes is exclusive; there is no overlap
between categories. Changing from one Self-Performance category to
another demands an increase or decrease in the number of times that help is
provided. Thus, to move from Independent to Supervision to Limited
assistance, non weight-bearing supervision, or physical assistance must
increase from one or two times to three or more times during the last seven
days.
There will be times when no one type or level of assistance is provided to the
patient 3 or more times during a 7-day period. However, the sum total of
support of various types will be provided 3 or more times. In this case, code
for the least dependent Self-Performance category where the patient received
that level or more dependent support 3 or more times during the 7-day
period.
Examples
The patient received supervision for transferring on two occasions and non weight-bearing
assistance on two occasions. Code “1” for Supervision in Transferring. Rationale:
Supervision is the least dependent category.
The patient received supervision in toileting on one occasion, non weight-bearing
assistance (i.e., transferring to commode) on two occasions, and weight-bearing assistance
(i.e., transferring on commode) on one occasion during the last 7 days. Code “2” for
Limited assistance in Toileting. Rationale: There were 3 episodes of physical assistance
in the last 7 days: 2 non weight-bearing episodes, and 1 weight-bearing episode. Limited
assistance is the correct code because it reflects the least dependent support category that
encompasses 3 or more activities that were at least at that level of support.
Additional clarification and coding examples have been developed for this Manual update and are
presented below.
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Self-Performance - INDEPENDENT
ADLs - SELF-PERFORMANCE
INDEPENDENT
Bed Mobility
Mrs. D can easily turn and position herself in
bed and is able to sit up and lie down without
any staff assistance. She requires use of a
single side rail that staff place in the up
position when she is in bed.
Self-Performance = 0 Support Provided = 1
Coding rationale: Patient is independent in
task.
Transfer
When transferring to her chair, the patient is
able to stand up from a seated position
(without requiring any physical or verbal help)
and walk over to her reclining chair.
Self-Performance = 0 Support Provided = 0
Coding rationale: Patient is independent.
Eating
After staff delivered a lunch tray to Mr. K, he
is able to consume all food and fluids without
any cueing or physical help from staff.
Self-Performance = 0 Support Provided = 0
Coding rationale: Patient is independent.
Toilet Use
Mrs. L was able to transfer herself to the toilet,
adjust her clothing, and perform the necessary
personal hygiene after using the toilet without
any staff assistance.
Self-Performance = 0 Support Provided = 0
Coding rationale: Patient is independent.
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Self-Performance – SUPERVISION
ADLs - SELF-PERFORMANCE
SUPERVISION
Bed Mobility
Patient favors laying on right side. Since she
has had a history of skin breakdown, staff must
verbally remind her to reposition.
Self-Performance = 1 Support Provided = 0
Coding rationale: Patient requires staff
supervision, cueing and reminders.
Transfer
Staff must supervise the patient as she
transfers from her bed to wheelchair. Staff
must bring the chair next to the bed and then
remind her to hold on to the chair and position
her body slowly.
Self-Performance = 1 Support Provided = 1
Coding rationale: Patient requires staff
supervision, cueing and reminders.
Eating
One staff member had to verbally cue patient
to eat slowly, and drink throughout the meal.
Self-Performance = 1 Support Provided = 0
Coding rationale: Patient requires staff
supervision, cueing and reminders for safe
meal completion.
Toilet Use
Staff member must remind patient to unzip
pants and to wash his hands after using the
toilet.
Self-Performance = 1 Support Provided = 0
Coding rationale: Patient requires staff
supervision, cueing and reminders.
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Self-Performance - Limited Assistance
ADLs - SELF-PERFORMANCE
LIMITED ASSISTANCE
Bed Mobility
Patient favors laying on right side. Since she
has had a history of skin breakdown, staff must
sometimes help the patient place her hands on
the side rail and encourage her to change her
position when in bed.
Self-Performance = 2 Support Provided = 2
Coding rationale: Patient requires cueing and
encouragement with set up or minor physical
help.
Transfer
Mrs. H is able to transfer from the bed to chair
when she uses her walker. Staff place the
walker near her bed and then help to steady the
patient as she transfers.
Self-Performance = 2 Support Provided = 2
Coding rationale: Patient requires staff to set
up her walker and provide help when she is
ready to transfer.
Eating
Mr. V is able to feed himself. Staff must set up
the tray, cut the meat, open containers and
hand him the utensils. Mr. V requires more
help during dinner with guiding of utensils as
he is tired and less interested in completing his
meals. In addition to encouraging him to
continue eating and frequently handing him his
utensils and cups to complete the meal, at
these times a staff member also must assist
guiding his hand in order to get the utensil to
his mouth.
Self-Performance = 2 Support Provided = 1
Coding rationale: Patient is unable to
complete the meal without staff providing him
non-weight bearing assistance (3 or more
times in the observation period).
Toilet Use
Staff must assist Mr. P to zip pants, hand him a
washcloth and remind him to wash his hands
after using the toilet.
Self-Performance = 2 Support Provided = 2
Coding rationale: Patient requires staff to
perform non-weight bearing activities to
complete the task.
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Self-Performance – EXTENSIVE ASSISTANCE
ADLs - SELF-PERFORMANCE
EXTENSIVE ASSISTANCE
Bed Mobility
Mr. Q has slid to the foot of the bed. Two staff
members must physically lift and reposition
him toward the head of the bed. Mr. Q was
able to assist by bending his knees and push
with legs when reminded by staff.
Self-Performance = 3 Support Provided = 3
Coding rationale: Patient partially
participates in the task. 2 staff members are
required.
Transfer
Patient always had a difficult time standing
from her chair. One staff member had to
partially physically lift and support the patient
as she stands up.
Self-Performance = 3 Support Provided = 2
Coding rationale: Patient partially
participates in the task. 1 staff member is
required.
Eating
Mr. F begins eating a meal by himself. After
he has only eaten the bread, he states he is
tired and is unable to complete the meal. One
staff member physically supports his hand and
provides verbal cues to swallow the food in his
mouth. The patient is able to complete the
meal.
Self-Performance = 3 Support Provided = 2
Coding rationale: Patient partially
participates in the task. 1 staff member is
required.
Toilet Use
Mrs. M has had recent bouts of vertigo. One
staff member must assist and support her as she
transfers to the bedside commode.
Self-Performance = 3 Support Provided = 2
Coding rationale: Patient partially
participates in the task. 1 staff member is
required.
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Self-Performance - Total Dependence
ADLs - SELF-PERFORMANCE
TOTAL DEPENDENCE
Bed Mobility
Mrs. S is unable to physically turn, sit up or lay
down in bed. Two staff members must physically
turn her every 2 hours. She must be physically
supported to a seated position in bed when
reading.
Self-Performance = 4 Support Provided =3
Coding rationale: Patient did not participate and
required 2 staff to position her in bed.
Transfer
Mr. T is in a physically debilitated state due to
surgery. Two staff members must physically lift
and transfer him to a reclining chair daily. Mr. T.
is unable to assist or participate in any way.
Self-Performance = 4 Support Provided =3
Coding rationale: Patient did not participate and
required 2 staff to transfer him out of his bed.
Mrs. U is severely cognitively impaired. She is
unable to consume any of her meals or liquids
served to her. One staff member is responsible to
feed her all food and fluids.
Self-Performance = 4 Support Provided =2
Coding rationale: Patient did not participate and
required 1 staff person to feed her all of her meal.
Eating
Toilet Use
October 2003
Mr. B recently had a stroke. He is currently
receiving 100% of his nutrition via a G-tube due
to dysphagia. He does not assist in any part of the
tube feeding process.
Self-Performance = 4 Support Provided =2
Coding rationale: Patient did not participate and
required 1 staff person to provide total nutritional
support.
Miss W is cognitively and physically impaired;
she is on strict bed rest. Staff are unable to
physically transfer patient to toilet at this time.
Miss W is incontinent of both bowel and bladder.
One staff member must provide all care for her
elimination and personal hygiene needs every 2
hours.
Self-Performance = 4 Support Provided =2
Coding rationale: Patient did not participate and
required 1 staff person to provide total care for
toileting and personal hygiene.
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Examples – ADL ACTIVITY DID NOT OCCUR
ADLs - SELF-PERFORMANCE
8/8 - ADL ACTIVITY DID NOT OCCUR
Transfer
Mrs. D is post-operative for extensive surgical
procedures. Due to her ventilator dependent
status in addition to multiple surgical sites, her
physician has determined that she must remain
on total bed rest and not be moved from the
bed.
Self-Performance = 8 Support Provided = 8
Coding rationale: Activity did not occur.
Examples - WHEN NOT TO CODE 8/8-ACTIVITY DID NOT OCCUR
ADLs - SELF-PERFORMANCE
WHEN NOT TO CODE 8/8 –
ADL ACTIVITY DID NOT OCCUR
Bed Mobility
Mrs. P is unable to physically turn, sit up or
lay down in bed for the past week. Two staff
members must physically turn her every 2 hrs.
She must be physically supported to a seated
position in bed.
Self-Performance = 4 Support Provided =3
Coding rationale: Although the patient did
not move herself, staff performed the activity
for her. Self-Performance code for the patient
is total/did not participate; required 2 staff to
position her in bed.
Eating
Mrs. D is fed by feeding tube. No food or
fluids are consumed thru her mouth. She does
not assist with her tube feedings.
Self-Performance = 4 Support Provided =2
Coding rationale: Patient does not
participate in eating and receives nutrition
and hydration thru a tube.
Toileting
Mr. J has a catheter for urine. Adult briefs are
utilized, checked, and changed every 3 hours.
Self-Performance = 4 Support Provided =2
Coding rationale: Patient requires total care
and staff support in toileting.
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SCORING ADL SELF-PERFORMANCE
START
0
INDEPENDENT
Does on own OR
Aided 1 or 2
times only a
Frequency of
Help
or
Supervision
8
Activity never performed
ACTIVITY DID
NOT OCCUR
By resident or other
4
Weight-Bearing
Assistance or Full
Staff Performance
Full Staff
TOTAL
DEPENDENCE
Performance
Every Time Over
7-Day Period
Non
Weight-Bearing
Physical
Assistance b
3
EXTENSIVE
ASSISTANCE
2
c
Supervision
(oversight, cueing)
LIMITED
ASSISTANCE
1
SUPERVISION
a. Can include one or two events where received supervision, non weight-bearing assistance, or weightbearing assistance.
b. Can include one or two episodes of weight-bearing assistance, e.g., two events with non weight-bearing
assistance plus two of weight-bearing assistance would be coded as a “2”.
c.
Can include one or two episodes where physical help received, e.g., two episodes of supervision, one of
weight-bearing assistance and one of non weight-bearing assistance would be coded as a “1”.
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(B) ADL Support Provided
Intent:
To record the type and highest level of support the patient received in each ADL
activity over the last seven days.
Definition:
ADL Support Provided - Measures the highest level of support provided by
staff over the last seven days, even if that level of support only occurred once.
This is a different scale and is entirely separate from the ADL Self-Performance
assessment.
Set-Up Help: The type of help characterized by providing the patient with
articles, devices, or preparation necessary for greater patient self-performance in
an activity. This can include giving or holding out an item that the patient takes
from the caregiver.
Process:
For each ADL category, code the maximum amount of support the patient
received over the last seven days, irrespective of frequency, and enter in the
“SUPPORT” column. Be sure your evaluation considers all nursing shifts, 24
hours per day, including weekends. Code independently of the patient’s SelfPerformance evaluation. For example, a patient could have been Independent in
ADL Self-Performance in Transfer but received a one-person physical assist one
or two times during the 7-day period. Therefore, the ADL Self-Performance
Coding for Transfer would be “0” (Independent), and the ADL Support coding
“2” (One person physical assist).
Coding:
NOTE: The highest code of physical assistance in this category (other than the
“8” code) is a code of “3”, not “4” as in Self-Performance.
0. No Setup or Physical Help From Staff
1. Setup Help Only - The patient is provided with materials or devices
necessary to perform the activity of daily living independently.
Examples of Setup Help
•
For bed mobility - handing the patient the bar or a trapeze, staff applies ½ rails and then
provides no further help.
•
For transfer - giving the patient a transfer board or locking the wheels on a wheelchair for
safe transfer.
•
For eating - cutting meat and opening containers at meals; giving one food category at a
time.
•
For toilet use - handing the patient a bedpan or placing articles necessary for changing
ostomy appliance within reach.
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2. One Person Physical Assist
3. Two+ Persons Physical Assist
8. ADL Activity Itself Did Not Occur During the Entire 7 Days - When an
“8” code is entered for an ADL Support Provided category, enter an “8” code
for ADL Self-Performance in the same category.
Clarifications:
General supervision of a dining room is not the same as individual
supervision of a patient. If the patient ate independently, then code as “0”
(Independent). If the individual patient needed oversight, encouragement, or
cueing during the last 7 days, the item is coded as a “1” (Supervision). For a
patient who has received oversight, encouragement, or cueing and also
received more help, such as physical assistance provided one or two times
during the 7-Day assessment period, the patient would still be coded as a “1”
(Supervision). Patients who are in “feeding” or “eating” groups and who are
individually supervised during the meal would be coded as “1” (Supervision)
for Self-Performance in Eating.
The key to the differentiation between guided maneuvering and weightbearing assistance is determining who is supporting the weight of the
patient’s hand. If the staff member supports some of the weight of the
patient’s hand while helping the patient to eat (e.g., lifting a spoon or a cup to
mouth), this is “weight-bearing” assistance for this activity. If the patient can
lift the utensil or cup, but staff assistance is needed to guide the patient’s
hand to his/her mouth, this is guided maneuvering.
If therapists are involved with the patient, their input should be included
either by way of an interview or by the assessor reviewing the therapy
documentation. The patient may perform differently in therapy than on the
unit. Also focus on occurrences of exceptions in the patient’s performance.
When discussing a patient’s ADL performance with a therapist, make sure the
therapist’s information can be expressed in SB-MDS terminology.
CLARIFICATIONS USING THE CODE “8” (ACTIVITY DID NOT OCCUR):
•
October 2003
The Eating item is a little more complex. If in the past seven days the patient
truly did not receive any nourishment, the item would be coded 8. It should
go without saying that this is a serious issue. Be careful not to confuse total
dependence with eating (code 4) with the activity itself (in this case,
receiving nourishment and fluids). Keep in mind that a patient who is fed via
tube, and manages the tube feeding independently is coded as independent
(code 0). G1h includes receiving IV fluids. For a patient who is receiving
fluids for hydration, and is totally dependent, this is coded as “4”, rather than
"8”.
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•
Toilet use focuses on whether or not elimination occurs, rather than the
process. The elimination may be in the toilet room, commode, in the
bedroom on a bedpan or urinal. It includes transferring on/off the toilet,
cleansing, changing pads, managing an ostomy or catheter, and clothing
adjustment. The “8” code is rarely used in this section, as it would indicate
that elimination did not occur.
The examples that follow clarify coding for both Self-Performance and Support. The answers
appear to the right of the patient descriptions. Cover the answers, read and score the example,
then compare your answers with those provided. For the purpose of this exercise, the clinician
should assume that the patient has performed at the same level for the last 7 days.
Examples: ADL Self-Performance and Support
Self-Perf.
Support
Patient was physically able to reposition self in bed but had a tendency to
favor and remain on his left side. He received frequent reminders and
monitoring to reposition self while in bed.
1
0
Patient received supervision and verbal cueing for using a trapeze for all
bed mobility. On two occasions when arms were fatigued, he received
heavier physical assistance of two persons.
1
3
Patient usually repositioned himself in bed. However, because he sleeps
with the head of the bed raised 30 degrees, he occasionally slides down
towards the foot of the bed. On 3 occasions the night nurse assistant
helped him to reposition by providing weight-bearing support as he bent
his knees and pushed up off the footboard.
3
2
To turn over, the patient always began by reaching for a side rail for
support. He received physical assistance of one person to guide his legs
into position and complete the turn by guiding him with a turn sheet
(using weight-bearing assistance).
3
2
Patient independently turned on his left side whenever he wanted.
Because of left-sided weakness he received physical weight bearing help
of 1-2 persons to turn to his right side or sit up in bed.
3
3
Because of severe, painful joint deformities, patient was totally dependent
on two persons for all bed mobility. Although unable to contribute
physically to positioning process, she was able to cue staff for the position
she wanted to assume and at what point she felt comfortable.
4
3
Bed Mobility
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Examples: ADL Self-Performance and Support
Self-Perf.
Support
Despite bilateral above-the-knee amputations, patient almost always
moved independently from bed to wheelchair (and back to bed) using a
transfer board he retrieves independently from his bedside table. On one
occasion in the past week, staff had to remind patient to retrieve the
transfer board. On one other occasion, the patient was lifted by a staff
member from the wheelchair back into the bed.
0
2
Patient was physically independent for all transfers. However, he would
not get up in the morning until the nurse assistant rearranged his bed
covers and released the half side rail on his bed.
0
1
Once someone correctly positioned the wheelchair in place and locked the
wheels, the patient transferred independently to and from the bed.
0
1
Patient moved independently in and out of armchairs but always received
light physical guidance of one person to get in and out of bed safely.
2
2
Transferring ability varied throughout each day. Patient received no
assistance at some times and heavy weight-bearing assistance of one
person at other times.
3
2
Transfer
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Examples: ADL Self-Performance and Support
Self-Perf.
Support
Patient arose daily after 9:00 am, preferring to skip breakfast and just
munch on fresh fruit later in the morning. She ate lunch and dinner
independently in the facility’s main dining room.
0
0
Patient on long standing tube feedings via gastrostomy tube was
completely independent in self-administration including self-medication
via the tube once set up by staff.
0
1
Patient with a history of dysphagia and choking, ate independently as long
as a staff member sat with him during every meal (stand-by assistance if
necessary).
1
0
Patient is blind and confused. He ate independently once staff oriented
him to types and whereabouts of food on his tray and instructed him to eat.
1
1
Cognitively impaired patient ate independently when given one food item
at a time and monitored to assure adequate intake of each item.
1
1
Patient fed self solid foods independently at all meals and snacks. Selfadministered all fluids and medications via G-tube with supervision once
set up appropriately.
1
1
Patient, with difficulty initiating activity, always ate independently after
someone guided her hand with the first few bites and then offered
encouragement to continue.
3
2
Patient with fine motor tremors fed self finger foods (e.g., sandwiches,
raw vegetables and fruit slices, crackers) but always received supervision
and total physical assistance with liquids and foods requiring utensils.
3
2
Patient fed self with staff monitoring at breakfast and lunch but tired later
in day. She was fed totally by nursing assistant at supper meal.
3
2
Patient who was being weaned from gastrostomy tube feedings continued
to receive total care for twice daily tube feedings. Additionally, she ate
small amounts of food by mouth with staff supervision.
3
2
Patient received tube feedings via a jejunostomy for all nutritional intake.
Feedings were given by a nurse.
4
2
Eating
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Examples: ADL Self-Performance and Support
Self-Perf.
Support
Patient used bathroom independently once up in a wheelchair; used
bedpan independently at night after it was set up on bedside table.
0
1
In the toilet room patient is independent. As a safety measure, the nurse
assistant stays just outside the door, checking with her periodically.
1
0
Patient uses the toilet independently but occasionally required minor
physical assistance for hygiene and straightening clothes afterwards. She
received such help twice during the last week.
0
2
When awake, patient was toileted every two hours with minor assistance
of one person for all toileting activities (e.g., contact guard for transfers
to/from toilet, drying hands, zipping/buttoning pants). She required total
care of one person several times each night after incontinence episodes.
3
2
Patient received heavy assistance of two persons to transfer on/off toilet.
He was able to bear weight partially, and required only standby assistance
with hygiene (e.g., being handed toilet tissue or incontinence pads).
3
3
Obese, severely physically and cognitively impaired patient receives a
hoyer lift for all transfers to and from her bed. It is impossible to toilet her
and she is incontinent. Complete personal hygiene is provided at least
every two hours by two persons.
4
3
Toilet Use
24. Toileting Programs
(14-day look back)
Intent:
To record if the patient is participating in a bladder program.
Definition:
Any Scheduled Toileting Plan - A plan whereby staff members at scheduled
times each day either take the patient to the toilet room, or give the patient a
urinal, or remind the patient to go to the toilet. Includes habit training and/or
prompted voiding.
Bladder Retraining Program - A retraining program where the patient is taught
to consciously delay urinating (voiding) or resist the urgency to void. Patients
are encouraged to void on a schedule rather than according to their urge to void.
This form of training is used to manage urinary incontinence due to bladder
instability.
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Process:
Check the clinical record. Consult with the nurse assistant and the patient. Be
sure to ask about any items that are hidden from view because they are worn
under clothing (e.g., pads or briefs).
Coding:
Check all that apply.
Clarifications:
A bladder retraining program is different from a toileting plan and should not
be checked in Item 24a but should be checked in Item 24b.
There are 3 key ideas captured in Item 24a: 1) scheduled, 2) toileting, and
3) program. The word “scheduled” refers to performing the activity
according to a specific, routine time that has been clearly communicated to
the patient (as appropriate) and caregivers. The concept of “toileting” refers
to voiding in a bathroom or commode, or voiding into another appropriate
receptacle (i.e., urinal, bedpan). A “program” refers to a specific approach
that is organized, planned, documented, monitored and evaluated. A
scheduled toileting program could include taking the patient to the toilet,
providing a bedpan at scheduled times, or verbally prompting to void.
Changing wet garments is not included in this concept.
If the scheduled plan is recorded in the plan of care and staff are actually
toileting the patient according to the multiple specified times, check
Item 24a. If the patient also experiences breakthrough incontinence, this
would be a good time to reevaluate the effectiveness of the current plan by
assessing if the patient has a new, reversible condition causing a decline in
continence (e.g., UTI, mobility problem, etc.), and treating the underlying
cause. Also determine whether or not there is a pattern to the extra times the
patient is incontinent and consider adjusting the scheduled toileting plan
accordingly.
For patients on a scheduled toileting plan, the plan of care should at least
note that the patient is on a routine toileting schedule. A patient’s specific
toileting schedule must be in a place where it is clearly communicated and
available and easily accessible to all direct care staff. Facility staff may list a
patient’s toileting schedule by specific hours of the day or by timing of
specific routines, as long as those routines occur around the same time each
day. If the timing of such routines is not fairly standardized, specific times
should then be noted. Documentation in the clinical record should evaluate
the patient’s response to the toileting program.
25. Diseases
Intent:
October 2003
(7-day look back)
To code those diseases or conditions which have a relationship to the patient’s
current ADL status, cognitive status, mood or behavior status, medical
treatments, nursing monitoring, or risk of death. Nursing monitoring includes
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clinical monitoring by a licensed nurse (e.g., serial blood pressure evaluation,
medication management, etc.).
Definition:
•
The disease and conditions in this section require a physician-documented
diagnosis in the clinical record. It is good clinical practice to have the
patient’s physician provide supporting documentation for any diagnosis.
•
Do not include conditions that have been resolved or no longer affect the
patient’s functioning or plan of care. In many facilities, clinical staff and
physicians neglect to update the list of patient’s “active” diagnoses. There
may also be a tendency to continue old diagnoses that are either resolved or
no longer relevant to the patient’s plan of care.
a. Diabetes Mellitus - Includes insulin-dependent diabetes mellitus (IDDM)
and diet-controlled diabetes mellitus (NIDDM or AODM).
b. Aphasia - A speech or language disorder caused by disease or injury to the
brain resulting in difficulty expressing thoughts (i.e., speaking, writing), or
understanding spoken or written language. Include aphasia due to CVA.
c. Cerebral Palsy - Paralysis related to developmental brain defects or birth
trauma.
d. Hemiplegia/Hemiparesis - Paralysis/partial paralysis (temporary or
permanent impairment of sensation, function, motion) of both limbs on one
side of the body. Usually caused by cerebral hemorrhage, thrombosis,
embolism, or tumor.
e. Multiple Sclerosis - Chronic disease affecting the central nervous system
with remissions and relapses of weakness, incoordination, paresthesis, speech
disturbances and visual disturbances.
f. Quadriplegia - Paralysis (temporary or permanent impairment of sensation,
function, motion) of all four limbs. Usually caused by cerebral hemorrhage,
thrombosis, embolism, tumor, or spinal cord injury. (Spastic quadriplegia,
secondary to cerebral palsy, should not be coded as quadriplegia.) Do not
code quadriparesis here.
Process:
October 2003
Consult transfer documentation and the patient’s clinical record (including
current physician treatment orders and nursing plans of care). If the patient was
admitted from an acute care or rehabilitation hospital, the discharge forms often
list diagnoses and corresponding ICD-9-CM codes that were current during the
hospital stay. If these diagnoses are still active, record them on the SB-MDS
assessment. Also, accept statements by the patient that seem to have clinical
validity. Consult with the physician for confirmation. A physician diagnosis is
required to code the MDS.
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Check a disease item only if the disease has a relationship to current ADL status,
cognitive status, behavior status, medical treatment, nursing monitoring, or risk
of death. For example, it is not necessary to check “diabetes mellitus” if the
patient was diagnosed with latent diabetes mellitus during a pregnancy several
years ago and is no longer being treated for the illness. However, if the patient
later developed overt diabetes mellitus and the diabetes is currently being
controlled by medications, diet, exercise, etc., then check the disease.
Physician involvement in this part of the assessment process is crucial. The
physician should be asked to review the items in this section at the time of the
visit closest to the scheduled SB-MDS assessment. Use this scheduled visit as an
opportunity to ensure that active diagnoses are noted and “inactive” diagnoses
are designated as resolved. This is also an important opportunity to share the
entire SB-MDS assessment with the physician. In many facilities, physicians are
not brought into the SB-MDS review and assessment process. It is the
responsibility of facility staff to aggressively solicit physician input.
Full physician review of the most recent SB-MDS assessment or ongoing input
into the assessment currently being completed can be very useful. For the
physician, the SB-MDS assessment completed by facility staff can provide
insights that would have otherwise not been possible. For staff, the informed
comments of the physician may suggest new avenues of inquiry, or help to
confirm existing observations, or suggest the need for additional follow-up.
Coding:
Check all that apply. Do not record any conditions that have been resolved and
no longer affect the patient’s status.
Consult the patient’s transfer documentation (in the case of new admissions or readmissions) and current medical record including current nursing plans of care.
There will be times when a particular diagnosis will not be documented in the
medical record. If that is the case, as indicated above, accept statements by the
patient that seem to have clinical validity, consult with the physician for
confirmation, and initiate necessary physician documentation.
Clarification:
26. Infections
Intent:
October 2003
Patients with communication problems as a result of Alzheimer’s,
Parkinson’s or multi-infarct dementia need to be carefully assessed. These
diagnoses may result in impairment in the ability to comprehend or express
language that may affect some or all channels of communication, including
listening, reading, speaking, writing and gesturing.
(7-day look back)
To code those infections which have a relationship to the patient’s current ADL
status, cognitive status, mood or behavior status, medical treatments, nursing
monitoring, or risk of death. Nursing monitoring includes clinical monitoring by
a licensed nurse (e.g., serial blood pressure evaluation, medication management,
etc.).
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Definition:
a. Pneumonia - Inflammation of the lungs; most commonly of bacterial or viral
origin.
b. Septicemia - Morbid condition associated with bacterial growth in the blood.
Septicemia can be indicated once a blood culture has been ordered and
drawn. A physician’s working diagnosis of septicemia can be accepted,
provided the physician has documented the septicemia diagnosis in the
patient’s clinical record.
Process:
Consult transfer documentation and the patient’s clinical record (including
current physician treatment orders and nursing plans of care). Accept statements
by the patient that seem to have clinical validity. Consult with physician for
confirmation. A physician diagnosis is required to code the MDS.
Physician involvement in this part of the assessment process is crucial.
Coding:
Check all that apply.
Check an infection item only if the infection has a relationship to current ADL
status, cognitive status, mood and behavior status, medical treatment, nursing
monitoring, or risk of death. Do not record any conditions that have been
resolved and no longer affect the patient’s functional status or plan of care.
27. Problem Conditions
(7-day look back)
Intent:
To record specific problems or symptoms which affect or could affect the
patient’s health or functional status and to identify risk factors for illness,
accident, and functional decline.
Definition:
a. Dehydrated, Output Exceeds Intake – Check this item if the patient has 2
or more of the following indicators.
1. Patient usually takes in less than the recommended 1500 ml of fluids
daily (water or liquids in beverages, and water in high fluid content foods
such as gelatin and soups). NOTE: The recommended intake level has
been changed from 2500 ml to 1500 ml to reflect current practice
standards.
2. Patient has one or more clinical signs of dehydration, including but not
limited to dry mucous membranes, poor skin turgor, cracked lips, thirst,
sunken eyes, dark urine, new onset or increased confusion, fever,
abnormal laboratory values (e.g., elevated hemoglobin and hematocrit,
potassium chloride, sodium albumin, blood urea nitrogen, or urine
specific gravity).
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3. Patient’s fluid loss exceeds the amount of fluids he or she takes in (e.g.,
loss from vomiting, fever, diarrhea that exceeds fluid replacement).
b. Delusions - Fixed, false beliefs not shared by others that the patient holds
even when there is obvious proof or evidence to the contrary (e.g., belief he
or she is terminally ill; belief that spouse is having an affair; belief that food
served by the facility is poisoned).
c. Fever - A fever is present when the patient’s temperature (°F) is 2.4 degrees
greater than the baseline temperature. The baseline temperature may have
been established prior to the Assessment Reference Date.
d. Hallucinations - False sensory perceptions that occur in the absence of any
real stimuli. A hallucination may be auditory (e.g., hearing voices), visual
(e.g., seeing people, animals), tactile (e.g., feeling bugs crawling over skin),
olfactory (e.g., smelling poisonous fumes), or gustatory (e.g., having strange
tastes).
e. Internal Bleeding - Bleeding may be frank (such as bright red blood) or
occult (such as guaiac positive stools). Clinical indicators include black,
tarry stools, vomiting “coffee grounds”, hematuria (blood in urine),
hemoptysis (coughing up blood), and severe epistaxis (nosebleed) that
requires packing. However, nose bleeds that are easily controlled should not
be coded as internal bleeding.
f. Vomiting - Regurgitation of stomach contents; may be caused by any
etiology (e.g., drug toxicity; influenza; psychogenic).
Process:
It is often difficult to recognize when a frail, chronically ill elder is experiencing
dehydration or alternatively fluid overload that could precipitate congestive heart
failure. Ways to monitor the problem, particularly in patients who are unable to
recognize or report the common symptoms of fluid variation, are as follows: Ask
the patient if he or she has experienced any of the listed symptoms in the last
seven days. Review the clinical records (including current nursing care plan) and
consult with facility staff members and the patient’s family if the patient is
unable to respond. A patient may not complain to staff members or others,
attributing such symptoms to “old age.” Therefore, it is important to ask and
observe the patient directly, if possible, since the health problems being
experienced by the patient can often be remedied.
Coding:
Check all conditions that occurred within the past seven days.
28. Weight Loss
Intent:
October 2003
(30-day and 180-day look back)
To record variations in the patient’s weight over time.
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Definition:
Weight Loss in Percentages – Decline in weight of 5% or more in last 30 days,
or 10% or more in last 180 days.
Process:
New Admission - Ask the patient or family about weight changes over the last 30
and 180 days. Consult physician, review transfer documentation and compare
with admission weight. Calculate weight loss in percentages during the specified
time periods.
Current Patient - Review the clinical records and compare current weight with
weights of 30 and 180 days ago. Calculate weight loss in percentages during the
specified time periods.
Coding:
Code “0” for No or “1” for Yes. If there is no weight to compare to, enter the
unknown code (-).
Clarifications:
The first step in calculating percent weight loss is to obtain the actual weights
for the 30-day and 180-day time periods from the patient’s clinical record.
Calculate percentage for weight loss based on the patient’s actual weights.
Do not round the weights. The calculation is as follows:
1. Start with the patient’s weight from 30 days ago and multiply it by the
proportion (0.05). If the patient has lost this amount or more, then code a
“1” for Yes.
2. Start with the patient’s weight from 180 days ago and multiply it by the
proportion (0.10). If the patient has lost this amount or more, then code a
“1” for Yes.
29.
Patients experiencing a 7½ percent weight change 90 days ago must be
evaluated to determine how much of the 7½ percent weight change occurred
over the last 30 days.
Nutritional Approaches
(7-day look back)
Intent:
To record when the patient receives nutrition through alternative means.
Definition:
a. Parenteral/IV - Include only fluids administered for nutrition or hydration,
such as:
• IV fluids or hyperalimentation, including total parenteral nutrition (TPN),
administered continuously or intermittently
• IV fluids running at KVO (Keep Vein Open)
• IV fluids administered via heparin lock
• IV fluids contained in IV piggybacks
• IV fluids used to reconstitute medications for IV administration
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Do NOT include:
• IV medications (code in 38A)
• IV fluids administered as a routine part of an operative or diagnostic
procedure or recovery room stay
• IV fluids administered solely as flushes
• Parenteral/IV fluids administered during chemotherapy or dialysis
b. Feeding Tube - Presence of any type of tube that can deliver food/nutritional
substances/fluids/medications directly into the gastrointestinal system.
Examples include, but are not limited to, nasogastric tubes, gastrostomy
tubes, jejunostomy tubes, and percutaneous endoscopic gastrostomy (PEG)
tubes.
Coding:
Clarification:
Check all that apply.
If the patient receives fluids by hypodermoclysis and subcutaneous ports in
hydration therapy, code these nutritional approaches as Parenteral/IV. The
term parenteral therapy means “introduction of a substance (especially
nutritive material) into the body by means other than the intestinal tract (e.g.,
subcutaneous, intravenous).” If the patient receives fluids via these
modalities also code Items 30a and 30b, which refer to the caloric and fluid
intake the patient received in the last 7 days. Additives such as electrolytes
and insulin, which are added to the patient’s TPN or IV fluids, should be
documented in Item 38ac (IV medications).
Skip to Item 31 if neither 29a nor 29b is coded.
30. Parenteral or Enteral Intake
Intent:
a.
(7-day look back)
To record the proportion of calories received and the average fluid intake through
parenteral or tube feeding in the last seven days.
PROPORTION OF TOTAL CALORIES
Definition:
Proportion of Total Calories Received - The proportion of all calories ingested
during the last seven days that the patient actually received (not ordered) by
parenteral or tube feedings. Determined by calorie count.
Process:
Review Intake record. If the patient took no food or fluids by mouth, or took just
sips of fluid, stop here and code “4” (76%-100%). If the patient had more
substantial oral intake than this, consult with the dietitian who can derive a
calorie count received from parenteral or tube feedings.
Coding:
Code for the correct response:
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0.
1.
2.
3.
4.
None
1% to 25%
26% to 50%
51% to 75%
76% to 100%
Example of Calculation for Proportion of Total Calories
from IV or Tube Feeding
Mr. H has had a feeding tube since his surgery. He is currently more alert and feeling much
better. He is very motivated to have the tube removed. He has been taking soft solids by mouth,
but only in small to medium amounts. For the past week he has been receiving tube feedings for
nutritional supplementation. As his oral intake improves, the amount received by tube will
decrease. The dietitian has totaled his calories per day as follows:
Step #1:
Oral
Sun.
Mon.
Tues.
Wed.
Thurs.
Fri.
Sat.
TOTAL
500
250
250
350
500
800
800
3450
Tube
+
+
+
+
+
+
+
+
2000
2250
2250
2250
2000
800
1800
14350
Step #2:
Total calories = 3450 + 14350 = 17800
Step #3:
Calculate percentage of total calories by tube feeding.
14350/17800 = .806 X 100 = 80.6%
Step #4:
b.
Code “4” for 76% to 100%
AVERAGE FLUID INTAKE
Definition:
Average fluid intake per day by IV or tube feeding in last seven days refers to
the actual amount of fluid the patient received by these modes (not the amount
ordered).
Process:
Review the Intake and Output record from the last seven days. Add up the total
amount of fluid received each day by IV and/or tube feedings only. Also include
the water used to flush, as well as the “free water” in the tube feeding (based
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upon the percent of water in the specific enteral formula). The amount of
heparinized saline solution used to flush a heparin lock is not included in the
average fluid intake calculation, while the amount of fluid in an IV piggyback
solution is included in the calculation. Divide the week’s total fluid intake by 7.
This will give you the average of fluid intake per day.
Coding:
Code for the average number of cc’s of fluid the patient received per day by IV or
tube feeding. Record what was actually received by the patient, not what was
ordered.
Codes:
Code the correct response.
0.
1.
2.
3.
4.
5.
None
1
501
1001
1501
2001
to
to
to
to
to
500 cc/day
1000 cc/day
1500 cc/day
2000 cc/day
or more cc/day
Example of Calculation for Average Daily Fluid Intake
Ms. A has swallowing difficulties secondary to Huntington’s disease. She is able to
take oral fluids by mouth with supervision, but not enough to maintain hydration. She
received the following daily fluid totals by supplemental tube feedings (including water,
prepared nutritional supplements, juices) during the last 7 days.
Step #1:
1250 cc
775 cc
925 cc
1200 cc
1200 cc
1200 cc
1000 cc
7550 cc
Step #2:
7550 divided by 7 = 1078.6 cc
Step #3:
Code “3” for 1001 to 1500 cc/day
Clarifications:
October 2003
Sun.
Mon.
Tues.
Wed.
Thurs.
Fri.
Sat.
TOTAL
The basic TPN solution itself (that is, the protein/carbohydrate mixture or a
fat emulsion) is not counted as a medication. The use of TPN is coded here.
When medications such as electrolytes, vitamins, or insulin have been added
to the TPN solution, they are considered medications.
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The amount of heparinized saline solution used to flush a heparin lock is not
included in the average fluid intake calculation.
31. Ulcers (7-day look back)
Intent:
To record the number of skin ulcers at each ulcer stage, on any part of the body.
Definition:
Skin ulcer - A local loss of epidermis and variable levels of dermis and
subcutaneous tissue, or in the case of Stage 1 pressure ulcers, persistent area of
skin redness (without a break in the skin) that does not disappear when pressure
is relieved. Skin ulcers that develop because of circulatory problems or pressure
are coded here. Rashes without open areas, burns, desensitized skin ulcers
related to diseases, such as syphilis and cancer, and surgical wounds are NOT
coded here. Surgical wounds are coded in Item 34f. Skin tears/shears NOT
caused by pressure are NOT coded here.
Process:
a. Stage 1.
A persistent area of skin redness (without a break in the skin) that
does not disappear when pressure is relieved.
b. Stage 2.
A partial thickness loss of skin layers that presents clinically as an
abrasion, blister, scab, or shallow crater.
c. Stage 3.
A full thickness of skin is lost, exposing the subcutaneous tissues.
Presents as a deep crater with or without undermining adjacent
tissue.
d. Stage 4.
A full thickness of skin and subcutaneous tissue is lost, exposing
muscle or bone.
Review the patient’s record and consult with the nurse assistant about the
presence of any skin ulcers. Examine the patient and determine the stage and
number of any ulcers present. Without a full body check, a skin ulcer can be
missed.
Assessing a Stage 1 skin ulcer requires a specially focused assessment for
patients with darker skin tones to take into account variations in ebony-colored
skin. To recognize Stage 1 ulcers in ebony complexions, look for: (1) any
change in the feel of the tissue in a high-risk area; (2) any change in the
appearance of the skin in high-risk areas, such as the “orange-peel” look; (3) a
subtle purplish hue; and (4) extremely dry, crust-like areas that, upon closer
examination, are found to cover a tissue break.
Coding:
Record the number of skin ulcers at each stage on the patient’s body in the last 7
days. If necrotic eschar is present, prohibiting accurate staging, code the skin
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ulcer as Stage “4”. If there are no skin ulcers at a particular stage, record “0”
(zero) in the box provided. If there are more than 9 skin ulcers at any one stage,
enter “9” in the appropriate box.
Clarifications:
All skin ulcers present during the current observation period should be
documented on the SB-MDS assessment. These items refer to the objective
presence of skin ulcers as observed during the assessment period.
For the SB-MDS assessment, pressure ulcers should be coded in terms of
what is seen (i.e., visible tissue) during the look-back period. For example, a
healing Stage 3 pressure ulcer that has the appearance (i.e., presence of
granulation tissue, size, depth, and color) of a Stage 2 pressure ulcer must be
coded as a “2” for purposes of the SB-MDS assessment. Facilities certainly
may adopt the National Pressure Ulcer Advisory Panel (NPUAP) standards in
their clinical practice. However, the NPUAP standards cannot be used for
coding on the SB-MDS.
Debridement of an ulcer merely removes necrotic and decayed tissue to
promote healing. The skin ulcer still exists and may or may not be at the
same stage as it was prior to debridement. Good clinical practice dictates
that the ulcer be re-examined and re-staged after debridement. Also code
treatments as appropriate in Item 34 (Skin Treatments). Do not code the
debrided skin ulcer as a surgical wound.
If a skin ulcer is repaired with a flap graft, it should be coded as a surgical
wound and not as a skin ulcer. If the graft fails, continue to code it as a
surgical wound until healed.
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Example
Mrs. L has end-stage metastatic cancer and weighs 75 pounds. She has a Stage 3 ulcer
over her sacrum and two Stage 1 pressure ulcers over her heels.
Item 31, Ulcers
Stage
a. 1
b. 2
c. 3
d. 4
Code
2
0
1
0
Mr. A has five open wounds as a result of frostbite that are not pressure or venous stasis
ulcers. Upon examination, these wounds do not meet the criteria provided in Item 31
(Ulcers) coding definitions. Code the patient’s condition as follows:
Item 31, Ulcers
Stage
a. 1
b. 2
c. 3
d. 4
Code
0
0
0
0
Item 32, Type of Ulcer:
Code “0” (highest stage ulcer is not a pressure ulcer).
Include coding for treatments provided in Items 34 and 35, (Foot Problems and Care) as
appropriate.
32. Pressure Ulcers
(7-day look back)
Intent:
To record the highest stage for pressure ulcers that were present in the last 7
days.
Definition:
Pressure Ulcer - Any skin ulcer caused by pressure resulting in damage of
underlying tissues. Other terms used to indicate this condition include bedsores
and decubitus ulcers.
Process:
Review the patient’s record. Examine the patient. Consult with the physician
regarding the cause of the ulcer(s).
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Coding:
Using the ulcer staging scale in Item 31, record the highest ulcer stage for
pressure ulcers present in the last 7 days.
More definitive information concerning pressure ulcers is provided in the AHRQ Guidelines for
pressure ulcers in adults at: http://www.ahrq.gov/consumer/bodysys/edbody6.htm.
What are Pressure Ulcers?
A pressure ulcer is an injury usually caused by unrelieved pressure that damages the skin and
underlying tissue. Pressure ulcers are also called decubitus ulcers or bedsores and range in severity
from mild (minor skin reddening) to severe (deep craters down to muscle and bone).
Unrelieved pressure on the skin squeezes tiny blood vessels, which supply the skin with nutrients
and oxygen. When skin is starved of nutrients and oxygen for too long, the tissue dies and a
pressure ulcer forms. The affected area may feel warmer than surrounding tissue. Skin reddening
that disappears after pressure is removed is normal and not a pressure ulcer.
Other factors cause pressure ulcers, too. If a person slides down in the bed or chair, blood vessels
can stretch or bend and cause pressure ulcers. Even slight rubbing or friction on the skin may cause
minor pressure ulcers.
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Where Pressure Ulcers Form
Pressure ulcers form where bone causes the greatest force
on the skin and tissue, and squeezes them against an outside
surface. This may be where bony parts of the body press
against other body parts, a mattress, or a chair. In persons
who must stay in bed, most pressure ulcers form on the
lower back below the waist (sacrum), the hip bone
(trochanter), and on the heels. In people in chairs or
wheelchairs, the exact spot where pressure ulcers form
depends on the sitting position. Pressure ulcers can also
form on the knees, ankles, shoulder blades, back of the
head, and spine.
Nerves normally tell the body when to move to relieve
pressure on the skin. Persons in bed who are unable to
move may get pressure ulcers after as little as 1-2 hours.
Persons who sit in chairs and who cannot move can get
pressure ulcers in even less time because the force on the
skin is greater.
NOTE: It is also common for pressure ulcers to form on the ears and scrotum.
The full AHCRP guideline for clinicians can be found at:
http://www.ahcpr.gov/clinic/cpgonline.htm.
Clarification:
October 2003
In order to code Pressure Ulcers in the case of a blister, the key is to
determine if there was a source of pressure that caused the blister. In the
presence of moisture, less pressure may be required to develop a pressure
ulcer. If, for example, a blister was found in the area of the incontinence
brief waist or leg band, pressure from the band may be a likely cause of the
blister and the assessor would record the blister as a pressure ulcer. If no
source of pressure could be identified, the blister may be evidence of perineal
dermatitis caused by excessive urine or stool eroding the epidermis. No
pressure is required for perineal dermatitis to occur. If this is the case, the
blister would not be recorded as a pressure ulcer, but would be considered a
rash. For additional information, refer to: Lyder, C. (1997). Perineal
dermatitis in the elderly: A critical review of the literature. Journal of
Gerontological Nursing 23(12), 5-10.
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Example
Mr. C has diabetes and poor circulation to his lower extremities. Last month Mr. C spent 2
weeks in the hospital where he had a left below the knee amputation (BKA) for treatment of a
gangrenous foot. He was readmitted to the swing bed 3 days ago with a Stage II pressure
ulcer over his sacrum and a Stage I pressure ulcer over his right heel and both elbows. No
other ulcers were present.
Item 31, Ulcers
a. Stage 1
b. Stage 2
c. Stage 3
d. Stage 4
Code (# at stage)
3
1
0
0
Item 32, Type of Ulcer
a. Pressure Ulcer
Code (highest stage)
2
Rationale for coding: Mr. C has 4 pressure ulcers, the highest stage of which is Stage 2.
Mrs. B has a blockage in the arteries of her right leg causing impaired arterial circulation to
her right foot (ischemia). She has 1 ulcer, a Stage 3 ulcer on the dorsal surface (top) of her
right foot.
Item 31, Ulcer
a. Stage 1
b. Stage 2
c. Stage 3
d. Stage 4
Code (# at Stage)
0
0
1
0
Items 32, Type of Ulcer
a. Pressure ulcer
Code (highest stage)
0
Rationale for coding: Mrs. B’s ulcer is an ischemic ulcer rather than caused by pressure.
33. Other Skin Problems or Lesions
Intent:
October 2003
(7-day look back)
To document the presence of skin problems other than pressure or circulatory
ulcers, and conditions that are risk factors for more serious problems.
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Definition:
a. Burns (second or third degree) - Includes burns from any cause (e.g., heat,
chemicals) in any stage of healing. This category does not include first
degree burns (changes in skin color only).
b. Open Lesions/Sores (e.g., cancer lesions) – Include skin ulcers that
developed as a result of diseases and conditions such as syphilis and cancer.
Do NOT code skin tears or cuts, abrasions or bruises, burns (from any cause),
and rashes here.
c. Surgical Wounds - Includes healing and non-healing, open or closed
surgical incisions, skin grafts or drainage sites on any part of the body. This
category does not include healed surgical sites or stomas, or lacerations that
require suturing or butterfly closures.
Process:
Ask the patient if he or she has any problem areas. Examine the patient. Ask the
nurse assistant. Review the patient’s record.
Coding:
Check all that apply.
Clarification:
PICC sites, central line sites, and peripheral sites are not coded as surgical
wounds.
34. Skin Treatments
(7-day look back)
Intent:
To document any specific or generic skin treatments the patient has received in
the past seven days.
Definition:
a. Pressure Relieving Device(s) for Chair - Includes gel, air (e.g., Roho), or
other cushioning placed on a chair or wheelchair. Include pressure relieving,
pressure reducing, and pressure redistributing devices. Do not include egg
crate cushions in this category.
b. Pressure Relieving Device(s) for Bed - Includes air fluidized, low air loss
therapy beds, flotation, water, or bubble mattress or pad placed on the bed.
Include pressure relieving, pressure reducing, and pressure redistributing
devices. Do not include egg crate mattresses in this category.
c. Turning/Repositioning Program - Includes a continuous, consistent
program for changing the patient’s position and realigning the body.
“Program” is defined as “a specific approach that is organized, planned,
documented, monitored and evaluated.”
d. Nutrition or Hydration Intervention to Manage Skin Problems - Dietary
measures received by the patient for the purpose of preventing or treating
specific skin conditions - e.g., wheat-free diet to prevent allergic dermatitis,
high calorie diet with added supplements to prevent skin breakdown, high
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protein supplements for wound healing. Vitamins and minerals, such as
Vitamin C and Zinc, which are used to manage a potential or active skin
problem, should be coded here.
e. Ulcer Care - Includes any intervention for treating skin problems coded in
Items 31, 32, and 33b. Examples include: use of dressings, chemical or
surgical debridement, wound irrigations, and hydrotherapy.
f. Surgical Wound Care - Includes any intervention for treating or protecting
any type of surgical wound. Examples of care include: topical cleansing,
wound irrigation, application of antimicrobial ointments, dressings of any
type, suture removal, and warm soaks or heat application.
g. Application of Dressings (with or without topical medications) Other
Than to Feet - Includes dry gauze dressings, dressings moistened with saline
or other solutions, transparent dressings, hydrogel dressings, and dressings
with hydrocolloid or hydroactive particles.
h. Application of Ointments/Medications (other than to feet) - Includes
ointments or medications used to treat a skin condition (e.g., cortisone,
antifungal preparations, chemotherapeutic agents, etc.). This definition does
not include ointments used to treat non-skin conditions (e.g., nitropaste for
chest pain).
Process:
Review the patient’s records. Ask the patient and the nurse assistant. Examine
the patient.
Coding:
Check all that apply.
Clarifications:
Good clinical practice dictates that staff should document treatments
provided. Flow sheets could be useful for this purpose, but the form and
format of such documentation is determined by the facility.
Do not code an egg crate cushion or mattress as pressure relieving devices.
These are specifically excluded from coding.
Dressings do not have to be applied daily in order to be coded. If any
dressing was applied even once during the 7-day period, the assessor would
check the appropriate item.
35. Foot Care Problems
Intent:
October 2003
(7-day look back)
To document the presence of foot problems and care to the feet during the last
seven days.
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Definition:
a. Infection of the foot - e.g., cellulitis, purulent drainage
b. Open lesions on the foot - Includes cuts, ulcers, and fissures.
c. Application of dressings (with or without topical medications) - Includes
dry gauze dressings, dressings moistened with saline or other solutions,
transparent dressings, hydrogel dressings, and dressings with hydrocolloid or
hydroactive particles.
Process:
Ask the patient and the nurse assistant. Inspect the patient’s feet. Review the
patient’s clinical records.
Coding:
Check all that apply.
Clarifications:
For SB-MDS coding, ankle problems are not considered foot problems and
should be coded in Item 34.
Good clinical practice dictates that staff should document treatments
provided. Flow sheets could be useful for this purpose, but the form and
format of such documentation is determined by the facility.
36. Time Awake
(7-day look back)
Intent:
To identify those periods of a typical day (over the last seven days) when the
patient was awake all or most of the time (i.e., no more than one hour nap during
any such period).
Definition:
a. Morning – From 7 a.m. (or when the patient wakes up) until noon.
b. Afternoon – From noon until 5 p.m.
c.
Evening – From 5 p.m. until 10 p.m. (or bedtime, if earlier).
Process:
Consult with direct care staff, the patient, and the patient’s family. Review the
chart. Observe patient.
Coding:
Check all periods when patient was awake all or most of the time.
Clarifications:
When coding this item, check each time period, as defined for that patient,
during which he or she did not nap for more than one hour. Some examples
of coding are as follows:
•
October 2003
A patient wakes up every morning at 7 a.m. He typically eats breakfast,
has a shower, gets dressed and goes back to bed for a late morning nap
from 10 a.m. until 11:30 a.m. Morning should NOT be checked, since
this patient typically naps for more than 1 hour during the morning.
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•
A patient typically wakes up at 6 a.m. She is busy with therapy and
activities most of the day, and does not take naps. She goes to bed by
7 p.m. every evening. Morning, Afternoon and Evening should all be
checked, since this patient does not take naps.
•
A patient who is bedfast and has end-stage Alzheimer’s disease wakes up
at 6 a.m. daily. She typically dozes off throughout day, napping for more
than 1 hour before noon, and again from 3:30 pm to 5:30 pm every
afternoon. She is typically awake from 5:30 until 9 p.m. After that, she’s
asleep for the night. Morning and Afternoon should NOT be checked,
since this patient naps for more than one hour during each of these
periods. Evening should be checked as time awake. Although this
patient sleeps until 5:30 pm, that is only a 30-minute naptime in the
evening period (5 p.m. until 5:30 p.m.).
Accurate coding relies on the use of appropriate information-gathering
techniques. Coding based on only the assessor’s personal knowledge of a
patient’s typical day may result in an inaccurate response to this item.
Documentation review is important. However, we would generally not
expect facility staff to maintain flowcharts for information such as sleep and
awake times.
It is important to observe the patient across all shifts. In addition, the same
individual staff member is generally not on duty and available to observe a
patient across a 24-hour period. It’s important to supplement observation
with interviews of the patient, his/her family members, other staff across
shifts, and in particular, the nursing assistants caring for the patient.
37. Injections
(7-day look back)
Intent:
To determine the number of days during the past seven days that the patient
received any type of medication, antigen, vaccine, by subcutaneous,
intramuscular or intradermal injection. Although antigens and vaccines are
considered “biologicals” and not medication per se, it is important to track when
they are given to monitor for localized or systemic reactions.
Coding:
Record the number of DAYS in the answer box.
Clarifications:
Subcutaneous pumps would be coded for only the number of days that the
patient actually required a subcutaneous injection to restart the pump.
This category does not include intravenous (IV) fluids or medications. If the
patient received IV fluids, record in Item 29a (Parenteral/IV). If IV
medications were given, record in Item 38ac (IV Medication).
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If a test or vaccination is provided on one day and another vaccine provided
on the next day, code “2” for the number of days where the patient received
injections. If both injections were administered on the same day, code “1”.
Example
During the last seven days, Mr. T received a flu shot on Monday, a PPD test (for
tuberculosis) on Tuesday, and a Vitamin B12 injection on Wednesday. Code “3” as the
patient received injections on three days during the last seven days.
During the last 7 days, Miss C received a flu shot and her Vitamin B12 injection on
Thursday. Code “1” for patient received 2 injections on the same day in the last 7 days.
38.
Special Treatments and Procedures
Intent:
To identify any special treatments, therapies, or programs that the patient
received in the specified time period. Do not code services that were provided
solely in conjunction with a surgical or diagnostic procedure and the
immediate post-operative or post-procedure recovery period.
a. SPECIAL CARE (14-day look back)
TREATMENTS - The following treatments may be received by a swing bed patient either
at the facility, as a hospital outpatient, or as an inpatient, etc.
Definition:
a. Chemotherapy - Includes any type of chemotherapy (anticancer drug) given
by any route. The drugs coded here are those actually used for cancer
treatment. For example, Megace (megestrol ascetate) is classified in the
Physician’s Desk Reference (PDR) as an anti-neoplastic drug. One of its side
effects is appetite stimulation and weight gain. If Megace is being given only
for appetite stimulation, do not code it as chemotherapy in this item. The
patient is not receiving chemotherapy in these situations. Each drug should
be evaluated to determine its reason for use before coding it here. IVs, IV
medications and blood transfusions provided only during chemotherapy are
not coded under the respective Items 29a (Parentral/IV), 38c (IV
Medications), and 38h (Transfusions).
b. Dialysis - Includes peritoneal or renal dialysis that occurs at the swing bed
facility or at another facility. Record treatments of hemofiltration, Slow
Continuous Ultrafiltration (SCUF), Continuous Arteriovenous Hemofiltration
(CAVH) and Continuous Ambulatory Peritoneal Dialysis (CAPD) in this
item. IVs, IV medications, and blood transfusions administered only during
dialysis are not coded under the respective Items 29a (Parenteral/IV), 38c
(IV Medications) and 38h (Transfusions).
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c. IV Medication - Includes any drug or biological (e.g., contrast material)
given by intravenous push or drip through a central or peripheral port. Does
not include a saline or heparin flush to keep a heparin lock patent, or IV
fluids without medication. Record the use of an epidural pump in this item.
Epidurals, intrathecal, and baclofen pumps may be coded, as they are similar
to IV medications in that they must be monitored frequently and they involve
continuous administration of a substance. Do not include IV medications
that were administered only during dialysis or chemotherapy when treatment
was rendered only off-site.
d. Oxygen Therapy - Includes continuous or intermittent oxygen via mask,
cannula, etc. (does not include hyperbaric oxygen for wound therapy).
e. Radiation - Includes radiation therapy or having a radiation implant.
f. Suctioning - Includes nasopharyngeal or tracheal aspiration only. Oral
suctioning should not be coded here.
g. Tracheostomy Care - Includes cleansing of tracheostomy and cannula.
h. Transfusions - Includes transfusions of blood or any blood products (e.g.,
platelets), which are administered directly into the bloodstream. Do not
include transfusions that were administered only during dialysis or
chemotherapy when treatment was rendered only off-site.
i. Ventilator or Respirator - Assures adequate ventilation in patients who are,
or who may become, unable to support their own respiration. Includes any
type of electrically or pneumatically powered closed system mechanical
ventilatory support devices. Any patient who was in the process of being
weaned off of the ventilator or respirator in the last 14 days should be coded
under this definition. Does not include Continuous Positive Airway Pressure
(CPAP) or Bi-level Positive Airway Pressure (BIPAP) devices.
Coding:
Check all treatments received during the last 14 days.
Clarifications:
October 2003
Patients with sleep apnea may undergo treatments with a mask-like device
that is used to keep the airway open during sleep. This service cannot be
coded as a ventilator or a respirator. According to the American Academy of
Otolaryngology-Head and Neck Surgery, Inc., a CPAP (Continuous Positive
Airway Pressure) device delivers air into your airway through a specially
designed mask or pillows. The mask does not breathe for you; the flow of air
creates enough pressure when you inhale to keep your airway open.
Ventilators are sometimes used to deliver this type of non-invasive
ventilation when CPAP or BIPAP machines are not available. In these cases,
the ventilator is merely providing air, not traditional life support via invasive
measures and does not require the same level of intensity of care that life
support ventilation demands.
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Do not code services that were provided solely in conjunction with a surgical
procedure, such as IV medications or ventilators. Surgical procedures
include routine pre- and post-operative procedures.
b. THERAPIES (7-day look back)
Therapies that occurred after admission/readmission to the swing bed, were
ordered by a physician, and were performed by a qualified therapist (i.e., one
who meets State credentialing requirements or in some instances, under such a
person’s direct supervision).
The licensed therapist, in conjunction with the physician and nursing
administration, is responsible for determining the necessity for, and the frequency
and duration of, the therapy services provided to patients. Includes only
medically necessary therapies furnished after admission to the swing bed. Also
includes only therapies ordered by a physician, based on a therapist’s assessment
and treatment plan that is documented in the patient’s clinical record. The
therapy treatment may occur either inside or outside the facility. Therapies
received in the acute care setting are not included.
Intent:
To record the (A) number of days, and (B) total number of minutes each of the
following therapies was administered to the patient in the last 7 days.
Definition:
a. Speech-Language Pathology and Audiology - Services that are provided by
a licensed speech-language pathologist.
b. Occupational Therapy - Therapy services that are provided or directly
supervised by a licensed occupational therapist. A qualified occupational
therapy assistant may provide therapy but not supervise others (aides or
volunteers) giving therapy. Include services provided by a qualified
occupational therapy assistant who is employed by (or under contract to) the
swing bed only if he or she is under the direction of a licensed occupational
therapist.
c. Physical Therapy - Therapy services that are provided or directly supervised
by a licensed physical therapist. A qualified physical therapy assistant may
provide therapy but not supervise others (aides or volunteers) giving therapy.
Include services provided by a qualified physical therapy assistant who is
employed by (or under contract to) the swing bed only if he or she is under
the direction of a licensed physical therapist.
d. Respiratory Therapy – Therapy services that are provided by a qualified
professional (respiratory therapists, trained nurse). Included treatments are
coughing, deep breathing, heated nebulizers, aerosol treatments, assessing
breath sounds, and mechanical ventilation, etc., which must be provided by a
qualified professional (i.e., trained nurse, respiratory therapist). Does not
include hand held medication dispensers. Count only the time that the
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qualified professional spends with the patient. (See clarification below
defining “trained nurse.”) A trained nurse may perform the assessment and
the treatments when permitted by the state nurse practice act.
Process:
Review the patient’s clinical record and consult with each of the licensed
therapists.
Coding:
Box A: In the first column, enter the number (#) of days therapy was
administered for 15 minutes or more in the last seven calendar days.
Enter “0” if none.
Box B: In the second column, enter the total number (#) of minutes the
particular therapy was provided in the last seven days, even if you
entered “0” in Box A. The time should include only the actual
treatment time (not time waiting or writing reports or performing initial
evaluation). Enter “0” if none.
Clarifications:
October 2003
Coding Minutes of Therapy:
Includes only therapies that were provided once the individual is actually
living/being cared for at the swing bed. Do NOT include therapies that
occurred while the person was an inpatient at a hospital or
recuperative/rehabilitation center or other nursing facility, or a recipient of
home care or community-based services. If a patient returns from a hospital
stay and a readmission assessment is done, count only those therapies that
occurred since readmission to the swing bed.
If a whirlpool treatment is specifically ordered by a physician to be
performed by or under the supervision of a physical therapist, it may be
coded as therapy.
Transdermal Wound Stimulation (TEWS) treatment for wounds can be coded
when complex wound care procedures, requiring the specialized skills of a
licensed therapist, are ordered by a physician. However, routine wound care,
such as applying/changing dressings, should not be coded as therapy, even
when performed by therapists.
Qualified professionals for the delivery of respiratory services include
“trained nurses.” A trained nurse refers to a nurse who received specific
training on the administration of respiratory treatments and procedures. This
training may have been provided at the swing bed, during a previous work
experience or as part of an academic program. Nurses do not necessarily
learn these procedures as part of their formal nurse training programs.
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October 2003
The SB-MDS instructions require reporting the actual minutes of therapy
received by the patient.
•
The patient’s treatment time starts when he/she begins the first treatment
activity or task and ends when he/she finishes with the last apparatus and
the treatment is ended.
•
The time required to adjust equipment or otherwise prepare for the
individualized therapy of a particular patient, is the set-up time and may
be included in the count of minutes of therapy delivered to the patient.
•
The therapist’s time spent on documentation or on initial evaluation may
not be included.
•
Time spent on periodic reevaluations conducted during the course of a
therapy treatment may be included.
•
Services provided at the request of the patient or family that are not
medically necessary (sometimes referred to as a family-funded services)
may not be counted, even when performed by a licensed therapist.
Historically, units of therapy time have been used for billing and have been
derived from the actual therapy minutes. Conversion from units to minutes is
not appropriate and the actual minutes are the only appropriate measures that
can be counted for completion. Please note that therapy logs are not a
requirement, but reflect a standard clinical practice expected of all therapy
professionals. These therapy logs may be used to verify the provision of
therapy services in accordance with the plan of care and to validate
information reported on the SB-MDS assessment.
Swing beds may elect to have licensed professionals perform repetitive
exercises and other maintenance treatments or to supervise aides performing
these maintenance services. In these situations, the services may not be
coded as therapy since the specific interventions would be considered
restorative nursing services when performed by nurses or aides.
A licensed therapist starts work directly with one patient beginning a specific
task. Once the patient can proceed with supervision, the licensed therapist
works directly with a second patient to get him/her started on a different task,
while continuing to supervise the first patient. The treatment ends for each
patient 30 minutes after it begins. For each patient, record 30 minutes
therapy time for each patient. This delivery of therapy is often referred to as
supervisory treatment, dovetailing, or concurrent therapy.
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In some cases, the patient will be able to perform part of the treatment tasks
with supervision, once set up appropriately. Time supervising the patient is a
part of total treatment time. For example, as the last treatment task of the
day, a patient uses an exercise bicycle for 10 minutes. It may take the
therapist 2 minutes to set the patient up on the apparatus. The therapist, or
assistant under the supervision of a PT, may then leave the patient to help
another patient in the same exercise room. However, the therapist still has
eye contact with the patient and is providing supervision, verbal
encouragement and direction to the patient on the bicycle. Therefore, if it
took 2 minutes to set the patient up with the cycling apparatus, the patient
was supervised during two 5-minute cycling periods; one 2-minute rest
between the exercise periods; and took 1 minute to get out of the apparatus,
the total cycling activity is 15 minutes. Include in this example that the
patient did three additional treatment activities totaling 45 minutes before
beginning to cycle. The total time reported on the assessment is 60 minutes.
The key is that the patient was receiving treatment the entire time and had the
physical presence of a therapist in the room, supervising the entire treatment
process.
Two licensed therapists, each from a different discipline, begin treating one
patient at the same time. The treatment ends 30 minutes after it starts. Split
the time between the two disciplines as appropriate. For example, PT = 20
minutes, OT = 10 minutes; or PT = 15 minutes, OT = 15 minutes, etc. In the
first example, where the beneficiary received 20 minutes of PT and only 10
minutes of OT, for each session code 1 day of PT and 20 minutes of PT. Also
code the 10 minutes of OT. In this example, no days may be coded for OT
because the session only lasted 10 minutes.
Group Therapy (for Speech-Language Pathology and Occupational and
Physical Therapies):
October 2003
For groups of four or fewer patients per supervising therapist (or assistant),
each patient is coded as having received the full time in the therapy session.
For example, if a therapist worked with three patients for 45 minutes on
training to return to the community, each patient received 45 minutes of
therapy so long as that does not exceed 25% of his/her therapy time per
therapy discipline, during the 7-day observation period. Remember, code for
the patient’s time, not for the therapist’s time.
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Supervision:
Aides cannot independently provide a skilled service. The services of aides
performing therapy treatments may only be coded when the services are
performed under line of sight supervision by a licensed therapist. This type
of coordination between the licensed therapist and therapy aide under the
direct, personal (e.g., line of sight) supervision of the therapist is considered
individual therapy for counting minutes. When the therapist starts the
session and delegates the performance of the therapy treatment to a therapy
aide, while maintaining direct line of sight supervision, the total number of
minutes of the therapy session may be coded as therapy minutes.
Therapy students are recognized as skilled providers under Medicare A only.
They must be “in line of sight” supervision (Federal Register November 4,
1999).
Maintenance Therapy/Nursing Rehabilitation:
Once the licensed therapist has designed a maintenance program and
discharged the patient from the rehabilitation (i.e., skilled) therapy program,
the services performed by the therapist and the aide should no longer be
reported as skilled therapy. The services of the aide may be reported on the
SB-MDS assessment as restorative nursing at Item 39, provided they meet
the requirements for restorative therapy.
Example
Following a stroke Mrs. F was admitted to the swing bed in stable condition for
rehabilitation therapies. Since admission she has been receiving speech therapy twice
weekly for 30-minute sessions, occupational therapy twice weekly for 30-minute sessions,
and physical therapy twice a day (30 minute sessions) for 5 days and respiratory therapy
for 10 minutes per day on each of the last 7 days. During the last seven days Mrs. F has
participated in all of her scheduled sessions.
Coding
a. Speech-language pathology,
audiology services
b. Occupational therapy
c. Physical therapy
d. Respiratory therapy
e. Psychological therapy
October 2003
A
B
2
2
5
0
0
60
60
300
70
0
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39. Nursing Rehabilitation/Restorative Care
Intent:
(7-day look back)
To determine the extent to which the patient receives nursing rehabilitation or
restorative services from other than specialized therapy staff (e.g., occupational
therapist, physical therapist, etc.). Rehabilitative or restorative care refers to
nursing interventions that promote the patient’s ability to adapt and adjust to
living as independently and safely as is possible. This concept actively focuses
on achieving and maintaining optimal physical, mental, and psychosocial
functioning. Generally, restorative nursing programs are initiated when a patient
is discharged from formalized physical, occupational, or speech rehabilitation
therapy. A patient may also be started on a restorative program when he/she is
admitted to the swing bed with restorative needs, but is not a candidate for
formalized rehabilitation therapy, or when a restorative need arises during the
course of a custodial stay. Restorative nursing does not require a physician’s
order.
Skill practice in such activities as walking and mobility, dressing and grooming,
eating and swallowing, transferring, amputation care, and communication can
improve or maintain function in physical abilities and ADLs and prevent further
impairment.
Definition:
Rehabilitation/Restorative Care - Included are nursing interventions that assist
or promote the patient’s ability to attain his or her maximum functional potential.
This item does not include procedures or techniques carried out by or under the
direction of qualified therapists, as identified in Item 38b. In addition, to be
included in this section, rehabilitation or restorative care must meet all of
the following additional criteria:
•
Measurable objectives and interventions must be documented in the plan of
care and in the clinical record.
•
Evidence of periodic evaluation by a licensed nurse must be present in the
clinical record.
•
Nurse assistants/aides must be trained in the techniques that promote patient
involvement in the activity.
•
These activities are carried out or supervised by members of the nursing staff.
Sometimes, under licensed nurse supervision, other staff and volunteers will
be assigned to work with specific patients.
•
This category does not include groups with more than four patients per
supervising helper or caregiver.
a. Range of Motion (Passive) - The extent to which, or the limits between
which, a part of the body can be moved around a fixed point or joint. A
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program of passive movements to maintain flexibility and useful motion in
the joints of the body. The caregiver moves the body part around a fixed
point or joint through the patient’s available range of motion. The patient
provides no assistance. These exercises must be planned, scheduled and
documented in the clinical record. Helping a patient get dressed does not, in
and of itself, constitute a range of motion exercise session.
b. Range of Motion (Active) - Exercises performed by a patient, with cueing,
supervision, or physical assist by staff, that are planned, scheduled, and
documented in the clinical record. Include active ROM and active assisted
ROM. Any participation by the resident in the ROM activity should be
coded here.
c. Splint or Brace Assistance - Assistance can be of 2 types: 1) where staff
provide verbal and physical guidance and direction that teaches the patient
how to apply, manipulate, and care for a brace or splint, or 2) where staff
have a scheduled program of applying and removing a splint or brace, assess
the patient’s skin and circulation under the device, and reposition the limb in
correct alignment. These sessions are planned, scheduled, and documented
in the clinical record.
TRAINING AND SKILL PRACTICE IN: - Activities including repetition,
physical or verbal cueing, and task segmentation provided by any staff member
or volunteer under the supervision of a licensed nurse.
d. Bed Mobility - Activities used to improve or maintain the patient’s selfperformance in moving to and from a lying position, turning side to side, and
positioning him or herself in bed.
e. Transfer - Activities used to improve or maintain the patient’s selfperformance in moving between surfaces or planes either with or without
assistive devices.
f. Walking - Activities used to improve or maintain the patient’s selfperformance in walking, with or without assistive devices.
g. Dressing or Grooming - Activities used to improve or maintain the patient’s
self-performance in dressing and undressing, bathing and washing, and
performing other personal hygiene tasks.
h. Eating or Swallowing - Activities used to improve or maintain the patient’s
self-performance in feeding one’s self food and fluids, or activities used to
improve or maintain the patient’s ability to ingest nutrition and hydration by
mouth.
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i. Amputation/Prosthesis Care - Activities used to improve or maintain the
patient’s self-performance in putting on and removing a prosthesis, caring for
the prosthesis, and providing appropriate hygiene at the site where the
prosthesis attaches to the body (e.g., leg stump or eye socket). Dentures are
not considered to be prostheses for coding this item.
j. Communication - Activities used to improve or maintain the patient’s selfperformance in using newly acquired functional communication skills or
assisting the patient in using residual communication skills and adaptive
devices.
Process:
Review the clinical record. Consult with staff. Review rehabilitation/restorative
care schedule and implementation record sheet.
Coding:
For the last seven days, enter the number of days on which the technique,
procedure, or activity was practiced for a total of at least 15 minutes during the
24-hour period. The time provided must be coded separately in time blocks of 15
minutes or more. For example, to check Item 39a, 15 or more minutes of PROM
must have been provided during a 24-hour period in the last 7 days. The 15
minutes of time in a day may be totaled across 24 hours (e.g., 10 minutes on the
day shift plus 5 minutes on the evening shift) however; 15-minute time
increments cannot be obtained by combining Items 39a, b and c. Remember
that persons with dementia learn skills best through repetition that occurs
multiple times per day. Review for each activity throughout the 24-hour period.
Enter zero “0” if none.
Clarifications:
If a restorative nursing program is in place when a plan of care is being
revised, it is appropriate to reassess progress, goals and duration/frequency as
part of the care planning process. Good clinical practice would indicate that
the results of this “reassessment” should be documented in the record.
When not contraindicated by state practice act provisions, a progress note
written by the restorative aide and countersigned by a licensed nurse is
sufficient to document the restorative nursing program once the purpose and
objectives of treatment have been established.
Facilities may elect to have licensed professionals perform repetitive
exercises and other maintenance treatments or to supervise aides performing
these maintenance services. In these situations, the services may not be
coded as therapy in Item 38b, since the specific interventions are considered
restorative nursing services when performed by nurses or aides. The
therapist’s time actually providing the maintenance service can be included
when counting restorative nursing minutes. Although therapists may
participate, members of the nursing staff are still responsible for overall
coordination and supervision of restorative nursing programs.
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October 2003
Active or passive movement by a patient that is incidental to dressing,
bathing, etc. does not count as part of a formal restorative care program. For
inclusion in this section, active or passive range of motion must be a
component of an individualized program with measurable objectives and
periodic evaluation delivered by staff specifically trained in the procedures.
The use of Continuous Passive Motion (CPM) devices as
Rehabilitation/Restorative Nursing is coded when the following criteria are
met: 1) ordered by a physician, 2) nursing staff have been trained in
technique (e.g., properly aligning patient’s limb in device, adjusting available
range of motion), and 3) nursing staff monitor the device. Nursing staff
should document the application of the device and the effects on the patient.
Do not include the time the patient is receiving treatment in the device.
Include only the actual time staff required to apply the device and monitor.
Grooming programs, including programs to help patients learn to apply
make-up, may be considered restorative nursing programs when conducted
by a member of the activity staff. These grooming programs would need to
have goals, objectives and documentation of progress included in the clinical
record.
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Examples of Nursing Rehabilitation/Restoration
Mr. V has lost range of motion (ROM) in his right arm, wrist and hand due to a CVA
experienced several years ago. He has moderate to severe loss of cognitive decision-making
skills and memory. To avoid further ROM loss and contractures to his right arm, the
occupational therapist fabricated a right resting hand splint and instructions for its application
and removal. The nursing coordinator developed instructions for providing passive range of
motion exercises to his right arm, wrist and hand 3 times per day. The nursing assistants and
Mr. V’s wife have been instructed on how and when to apply and remove the hand splint and
how to do the passive ROM exercises. The total amount of time involved each day in
removing and applying the hand splint and completing the ROM exercises is 30 minutes. The
nursing assistants report that there is less resistance in Mr. V’s affected extremity when
bathing and dressing him. For both Splint or Brace assistance and Range of Motion (passive),
enter “7” as the number of days these nursing rehabilitative techniques were provided.
Mrs. K was admitted to the swing bed 7 days ago following repair of a fractured hip. Physical
therapy was delayed due to complications and a weakened condition. Upon admission, she
had difficulty moving herself in bed and required total assistance for transfers. To prevent
further deterioration and increase her independence, the nursing staff implemented a plan on
the second day following admission to teach her how to move herself in bed and transfer from
bed to chair using a trapeze, the bedrails, and a transfer board. The plan was documented in
Mrs. K’s clinical record and communicated to all staff at the change of shift. The charge
nurse documented in the nurses notes that in the five days Mrs. K has been receiving training
and skill practice for bed mobility and transferring, her endurance and strength are improving,
and she requires only extensive assistance for transferring. Each day the amount of time to
provide this nursing rehabilitation intervention has been decreasing so that for the past five
days, the average time is 45 minutes. Enter “5” as the number of days training and skill
practice for bed mobility and transfer was provided.
Mrs. J had a CVA less than a year ago resulting in left-sided hemiplegia. Mrs. J has a strong
desire to participate in her own care. Although she cannot dress herself independently, she is
capable of participating in this activity of daily living. Mrs. J’s overall care goal is to
maximize her independence in ADL’s. A plan, documented on the medical record, has been
developed to teach Mrs. J how to put on and take off her blouse with no physical assistance
from the staff. All of her blouses have been adapted for front closure with velcro. The
nursing assistants have been instructed in how to verbally guide Mrs. J as she puts on and
takes off her blouse. It takes approximately 20 minutes per day for Mrs. J to complete this
task (dressing and undressing). Enter “7” as the number of days training and skill
practice for dressing and grooming was provided.
(continued on next page)
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Examples of Nursing Rehabilitation/Restoration
(continued)
Using a quad cane and a short leg brace, Mrs. D is receiving training and skill practice in
walking. Together, Mrs. D and the nursing staff have set progressive walking distance
goals. The nursing staff has received instruction on how to provide Mrs. D with the
instruction and guidance she needs to achieve the goals. She has three scheduled times each
day where she learns how to apply her short leg brace followed by walking. Each teaching
and practice episode for brace application and walking, supervised by a nursing assistant,
takes approximately 15 minutes. Enter “7” as the number of days for splint and brace
assistance and training and skill practice in walking were provided.
Experiencing a slow recovery from Guillain Barre syndrome, Mr. B is receiving daily
training and skill practice in swallowing. Along with specially designed cups and
appropriate food consistency, the documented plan of care to improve his ability to swallow
involves proper body positioning, consistent verbal instructions, and jaw control techniques.
Mr. B requires close monitoring when given food and fluids as he is at risk for choking and
aspiration. Therefore, only licensed nurses provide this nursing rehabilitative intervention.
It takes approximately 35 minutes each meal for Mr. B to finish his food and liquids. He
receives supplements via a gastrostomy tube if he does not achieve the prescribed fluid and
caloric intake by mouth. Enter “7” as the number of days training and skill practice in
swallowing was provided.
Mr. W’s cognitive status has been deteriorating progressively over the past several months.
Despite deliberate nursing restoration, attempts to promote his independence in feeding
himself, he will not eat unless he is fed. Because Mr. W did not receive nursing
rehabilitation/restoration for eating in the last 7 days, enter “0” as the number of days
training and skill practice for eating was provided.
Mrs. E has amyotrophic lateral sclerosis. She no longer has the ability to speak or even to
nod her head “yes” and “no”. Her cognitive skills remain intact, she can spell, and she can
move her eyes in all directions. The speech language pathologist taught both Mrs. E and
the nursing staff to use a communication board so that Mrs. E. could communicate with
staff. The communication board has proven very successful and the nursing staff,
volunteers and family members are reminded by a sign over Mrs. E’s bed that they are to
provide her with the board to enable her to communicate with them. This is also
documented in Mrs. E’s medical record. Because the teaching and practice in using the
communication board had been completed two weeks ago and Mrs. E is able to use the
board to communicate successfully, she no longer receives skill and practice training in
communication. Enter “0” as the number of days training and skill practice in
communication was provided.
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40. Physician Visits
(14-day look back)
Intent:
To record the number of days during the last 14-day period a physician has
examined the patient (or since admission/readmission if less than 14 days ago).
Examination can occur in the facility or in the physician’s office. In some cases
the frequency of physician’s visits is indicative of clinical complexity.
Definition:
Physician - Includes MD, DO (osteopath), podiatrist, or dentist who is either the
primary physician or consultant. Also include an authorized physician assistant,
nurse practitioner, or clinical nurse specialist working in collaboration with the
physician. Does not include visits made by Medicine Men nor licensed
psychologists (PhD).
Physician Exam - May be a partial or full exam at the facility or in the
physician’s office. This does not include exams conducted in an emergency
room.
Coding:
Enter the number of days the physician examined the patient. If none, enter “0”.
Clarifications:
If a patient is evaluated by a physician off-site (e.g., while undergoing
dialysis or radiation therapy), it can be coded as a physician visit.
Documentation of the physician’s evaluation should be included in the
clinical record. The physician’s evaluation can include partial or complete
examination of the patient, monitoring the patient for response to the
treatment, or adjusting the treatment as a result of the examination.
Do not count physician visits that occurred during the patient’s acute care
stay.
41. Physician Orders
(14-day look back)
Intent:
To record the number of days during the last 14-day period (or since
admission/readmission if less than 14 days ago) in which a physician has
changed the patient’s orders. In some cases the frequency of physician’s order
changes is indicative of clinical complexity.
Definition:
Physician - Includes MD, DO (osteopath), podiatrist, or dentist who is either the
primary physician or a consultant. Also includes authorized physician assistant,
nurse practitioner, or clinical nurse specialist working in collaboration with the
physician.
Physician Orders - Includes written, telephone, fax, or consultation orders for
new or altered treatment. Does NOT include standard admission orders, return
admission orders, renewal orders, or clarification orders without changes. Orders
written on the day of admission as a result of an unexpected deterioration in
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condition or injury are considered as new or altered treatment orders and should
be counted as a day with order changes.
Coding:
Enter the number of days on which physician orders were changed. Do not
include order renewals without change. If no order changes, enter “0”.
Clarifications:
A sliding scale dosage schedule that is written to cover different dosages
depending on lab values does not count as an order change simply because a
different dose is administered based on the sliding scale guidelines.
Do not count orders prior to the date of admission or reentry. Do not count
return admission orders or renewal orders without changes. Do not count
orders written by a pharmacist. The prohibition against counting standard
admission or readmission orders applies, regardless of whether the orders are
given at one time or are received at different times on the date of admission
or readmission.
A monthly Medicare Certification is a renewal of an existing order and
should not be included when coding this item.
If a patient has multiple physicians; e.g., surgeon, cardiologist, internal
medicine, etc., and they all visit and write orders on the same day, the
SB-MDS must be coded as 1 day during which a physician visited, and 1 day
in which orders were changed.
Orders requesting a consultation by another physician may be counted.
However, the order must be reasonable; e.g., for a new or altered treatment.
An order written on the last day of the SB-MDS observation period for a
consultation planned 3-6 months in the future should be carefully reviewed.
Orders written to increase the patient’s RUG-III classification and swing bed
payment are not acceptable.
When a PRN order was already on file, the potential need for the service had
already been identified. Notification of the physician that the PRN order was
activated does not constitute a new or changed order and may not be counted
when coding this item.
Orders for transfer of care to another physician may not be counted.
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42. Ordered Therapies
(first 14 days)
Skip these items unless this is a Medicare 5-Day assessment or a Medicare
Readmission/Return assessment.
Intent:
To recognize ordered and scheduled therapy services [physical therapy (PT),
occupational therapy (OT) and speech pathology services (SP)] during the early
days of the patient’s stay. Often therapies are not initiated until after the end of
the observation assessment period.
For the Medicare 5-Day or
Readmission/Return assessment, this section provides an overall picture of the
amount of therapy that a patient will likely receive through the fifteenth day from
admission.
Process:
Review the patient’s clinical record to determine if the physician has ordered one
or more of the medically necessary therapies to begin in the first 14 days of stay.
Therapies include PT, OT, and/or SP. If orders exist, consult with the therapist(s)
involved to determine if the initial evaluation is completed and therapy
treatment(s) has (have) been scheduled.
If the patient is scheduled to receive at least one of the therapies, have the
therapist(s) calculate the total number of days through the patient’s fifteenth day
since admission to Medicare Part A when at least one therapy service will be
delivered. Then have the therapist(s) estimate the total PT, OT, and SP treatment
minutes that will be delivered through the fifteenth day of admission.
Coding:
a. Ordered Therapies – Code “1”, Yes, if the physician has ordered any of the
following therapy services to begin in the first 14 days of the stay – physical
therapy, occupational therapy, or speech pathology services. Consult with the
therapist to complete Item 42b and 42c. If the physician has not ordered therapy,
enter “0” in Item 42a and skip to Item 43 (Case Mix Group).
b. Estimate of Number of Days - Enter the number of days at least one therapy
service can be expected to have been delivered through the patient’s fifteenth day
of admission. Count the days of therapy already delivered. Calculate the
expected number of days through day 15. If orders are received for more than
one therapy discipline, enter the number of days at least one therapy service is
performed. For example, if PT is provided on MWF, and OT is provided on
MWF, the SB-MDS should be coded as 3 days, not 6 days.
c. Estimate of Number of Minutes - Enter the estimated total number of
therapy minutes (across all therapies) it is expected the patient will receive
through day 15. Include the number of minutes already provided. Calculate the
expected number of minutes through day 15.
Clarifications:
October 2003
Do not include evaluation minutes in the estimate of number of minutes.
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October 2003
Do not count the evaluation day in the estimate for number of days unless
treatment is rendered.
When the physician orders a limited number of days of therapy, then the
projection is based on the actual number of days of therapy ordered. For
example, if the physician orders therapy for 7 days, the projected number of
days in Item 42b will be 7.
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Example of Ordered Therapies on Medicare 5-Day Assessments
Mr. Z was admitted to the swing bed late Thursday afternoon. The physician’s orders for both
physical therapy and speech language pathology evaluation were obtained on Friday. Both therapy
evaluations were completed on Monday and physical and speech therapy were scheduled to begin on
Tuesday. Physical therapy was scheduled 5 days a week for 60 minutes each day. Speech therapy
was scheduled for 3 days a week for 60 minutes each day. The RN Assessment Coordinator
identified Monday as the end of the observation assessment period for this Medicare 5-day
assessment. Within the 15 days from the patient’s admission date (Thursday), the patient will receive
8 days of physical therapy (480 minutes) and 4 days of speech therapy (240 minutes) for a total of
720 minutes in the fifteen days.
Enter “8” in Item 42b for the number of days that at least one therapy service is expected
to be delivered.
Enter “720” in Item 42c for the estimated total number of minutes that both physical
therapy and speech therapy are expected to be delivered.
Mrs. C was admitted to the facility Tuesday with an evaluation order for all three therapies. The
physical therapist completed the evaluation for physical therapy on Wednesday and scheduled
treatment to begin on Thursday, five days a week for 30 minutes each day. The occupational therapist
completed the evaluation on Friday and scheduled therapy to begin on Monday, 3 days a week for one
hour each day. The speech language pathologist’s evaluation did not recommend speech therapy for
the patient so speech therapy was not scheduled. The RN Assessment Coordinator identified
Monday as the end of the observation assessment period. Within the observation assessment period,
the patient received 3 days of physical therapy for a total of 90 minutes. The patient received one
occupational therapy treatment for a total of 60 minutes. It was expected that Mrs. C would receive 6
more days of physical therapy within the 15 days after the patient’s admission for a total of 180
minutes and 3 more days of occupational therapy within the 15 days after the patient’s admission for
a total of 180 minutes.
Enter “9” in Item 42b for the number of days that at least one therapy service is expected
to be delivered.
Enter “510” in Item 42c for the estimated total number of minutes that both physical
therapy and occupational therapy is expected to be delivered.
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43. Case Mix Group
Intent:
Records the RUG-III Classification calculated from the RAVEN-SB software.
a. Medicare
The software calculated RUG-III Classification for the Medicare program
using the 53 Group Version 5.20. The first three characters entered in the
boxes represent one of the 53 RUG-III groups. The last two numbers are an
indicator of the version of the RUG-III Classification system. Currently, this
version is 07. This 07 comes directly from the software and will appear on
every assessment.
b. State
The software calculated RUG-III Classification for the State case mix field
using the State-specified RUG-III Classification system. For states using the
RUG-III Classification system for case mix reimbursement, this item may be
required. States have the option of using either the 34 or 44 RUG-III
Classification systems, or a different version of the RUG-III Classification
system. The first three characters entered in the boxes represent one of the
RUG-III groups. This could vary from the Medicare case mix field if the
state is using the 34 RUG-III Classification system. The last two numbers
may vary depending on the version of the RUG-III Classification system
specified in the state. Please contact your State representatives for your State
requirements.
44. HIPPS Code
Definition:
Health Insurance Prospective Payment System (HIPPS) Code - 5-character
codes used solely for billing the Medicare Part A stay under the SNF PPS. The
codes reflect the 3-character RUG-III group into which the patient is classified,
and a 2-character assessment indicator. The assessment indicator is calculated
based on the answers to Items 11a-d, Reason for Assessment.
Process:
The RAVEN-SB software program calculates the HIPPS code for you. The
HIPPS codes must appear when billing a Part A SNF-level stay under the SNF
PPS. The computer software program will calculate the appropriate HIPPS code
that will be used in the billing process, except for the 5 special payment codes.
Chapter 5, Section 5.4 contains more detailed information on the HIPPS codes.
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Example of HIPPS Code
A 5-Day Medicare assessment that is classified into the High Rehabilitation RUG-III
classification would be coded as RHB01. The “R” indicates Rehabilitation, the “H”
indicates the High Rehabilitation group, the “B” indicates an ADL score of 8-12, and
the “01” indicates a 5-Day Medicare assessment.
R
H
B
0
1
45. Signature
Intent:
Federal regulations at 42 CFR 483.20 (i) (1) require that a registered nurse must
sign, date, and certify that the assessment is complete.
Coding:
The registered nurse who is certifying the completion of the SB-MDS must sign
and date the assessment. Use the actual date the SB-MDS was completed,
reviewed, and signed, even if it is after the patient’s date of discharge. If, for
some technical reason, such as computer or printer breakdown, the SB-MDS
cannot be signed on the date it is completed, it is appropriate to use the actual
date that it is signed. It is recommended that the nurse document the reason for
the discrepancy in the clinical record. Backdating Item 45 on the printed copy to
the date the handwritten copy was completed and/or signed is not acceptable.
Clarification:
October 2003
The use of a signature stamp is allowed. The facility must have policies in
place to ensure proper use and secured storage of the stamps. The State may
have additional regulations that apply.
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CMS’s SB Version 1.0 Manual
Chapter 4: Submission and Correction of the
Swing Bed Minimum Data Set Assessment
4.1
Legal and Submission Authority
According to Section 4432(a) of the Balanced Budget Act (BBA) of 1997, swing bed hospitals are to
be incorporated into the SNF PPS system effective with cost reporting periods beginning on or after
July 1, 2002. To accomplish this, a unique 2-page SB-MDS assessment has been developed and
must be completed, encoded, and submitted to a national database. Directions for this process are
included in Program Memorandum Transmittal Number A-02-016 dated February 15, 2002. The
SB-MDS must be completed in compliance with the Medicare PPS schedule found in Chapter 2 of
this manual.
Swing bed providers must complete the SB-MDS assessment within 14 days of the Assessment
Reference Date. An SB-MDS is considered complete on the day that the registered nurse (RN)
responsible for coordinating the SB-MDS assessment process signs and dates the assessment. The
SB-MDS records must be submitted electronically to the national database and will be considered
timely if submitted and accepted into the database within 14 days of completion.
The Swing Bed facility is required to submit SB-MDS records for patients in a Medicare Part A
SNF-level stay. The swing bed facility may also choose to submit assessments for other patients,
but only when the SB-MDS assessments are for patients in a Medicare or Medicaid certified swing
bed. Submission of assessments for other patients is a violation of patient privacy rights.
Appropriate authority to submit records is denoted in the submission record in the SUB_REQ field.
The SUB_REQ field is explained in more detail later in this chapter.
4.2
Computer Requirements
Hardware - Specifications are available detailing the hardware that is needed at the Swing Bed
facility to support this data submission program. They may be found at http://www.qtso.com/
download/swingbed/readme.txt.
Software - The Swing Bed facility must use software that will allow accurate encoding of the
SB-MDS data and assure that the records pass the standardized edits defined by CMS. The Resident
Assessment and Verification Entry Software for Swing Beds (RAVEN-SB) is available free to the
Swing Bed facility at http://www.cms.hhs.gov/providers/snfpps/raven-sb.asp or
http://www.qtso.com/ravensbdownload.html. It meets all of the CMS standardized
edits and creates the files needed to submit the SB-MDS data to the national database and download
reports.
Commercial software may be purchased that incorporates more features than RAVEN-SB. If the
facility chooses to purchase such a system, it must be certain that it conforms to the data
specifications required by CMS. The vendor can access these specifications at
http://www.cms.hhs.gov/providers/snfpps/swingbed_specs.asp.
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4.3
Submission Rules
Timing Rules - There are currently two timing rules in the SB-MDS data specifications:
1. Completion Timing: Item 45b, Completion Date, can be no more that 14 days later than
Item 10a, Assessment Reference Date. Although the record will be accepted into the
national database, failure to follow this rule will result in a warning message. NOTE:
Discharge and Reentry tracking information must be completed within 7 days of the
event (Items 15 and 16 respectively).
2. Submission Timing: All assessments must be submitted within 14 days of Item 45b,
Completion Date. Although the record will be accepted into the national database,
failure to follow this rule will result in a warning message.
Date Sequencing Rules - There is a logical sequence of dates on the SB-MDS. For example, it
would be illogical for the patient’s birth date to be later than the admission date or for any date on
the SB-MDS to be later than the current date. If there are date inconsistencies within a record when
submitted to the national database, the record will receive a fatal error and will be rejected.
The following table lists each date field from the SB-MDS and the related date fields that must be
either later or the same as that date field.
Date Field (MDS Crosswalk)/Description
Item 3 Birth Date
Item 10a Assessment Reference Date
Item 13 Admission Date
Item 15 Discharge Date
Item 16 Reentry
Item 45b Completion Date
Revised--October 2003
Date Fields that Must Be Later or the Same
10a Assessment Reference Date
12 Prior Acute Care Stay
13 Admission Date
15 Discharge Date
16 Reentry Date
45b Completion Date
Current Date
15 Discharge Date
16 Reentry Date
45b Completion Date
Current Date
10a Assessment Reference Date
15 Discharge Date
16 Reentry Date
45b Completion Date
Current Date
Current Date
Current Date
Current Date
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Item 12, Prior Acute Care Stay captures the admission date of the qualifying 3-day hospital stay that
occurred before admission to the swing bed for Part A SNF-level care. It should always be earlier
than Item 13, Admission Date (to the swing bed), Item 10a, Assessment Reference Date, Item 45b,
Completion Date and the current date.
Another fatal date edit requires that Item 3, Birth Date, be no more than 140 years prior to the
current date.
4.4
Submission File Structure
Each submission file consists of a Header Record, one or more Body Records and a Trailer
Record. The RAVEN-SB software will create the files, including header and trailer records needed
to submit the SB-MDS data to the national database. Commercial software vendors can access
record specifications at http://www.cms.hhs.gov/providers/snfpps/swingbed_specs.asp.
The Header Record contains basic identifying information for the swing bed hospital submitting
SB-MDS data, the contact persons, and telephone numbers to use in the event that the file is in error.
Each Body Record contains information for a single SB-MDS assessment. These assessments
include original SB-MDS forms, corrected SB-MDS forms, and discharge and reentry information.
The Trailer Record indicates the end of the submission file and includes a count of the total records
in the file including the header and trailer records.
Each Body Record will contain a SUB_REQ field. This field indicates whether the submission of
the record is authorized. There is CMS authority to submit an assessment if the patient is in a
Medicare or Medicaid certified swing bed. If the assessment submitted is AUTHORIZED, the
SUB_REQ should be “1”.
A SUB_REQ code of “0” identifies an assessment with no authority for submission. If the patient is
not in a Medicare or Medicaid certified swing bed, the record must not be submitted. If a swing bed
provider inadvertently transmits an SB-MDS with a SUB_REQ of 0, it will be rejected.
4.5
Prospective Payment System (PPS) Requirements
Every Medicare assessment that is submitted to the national database must include a RUG-III case
mix code and a Health Insurance Prospective Payment System (HIPPS) Code.
RUG-III Code - The first three characters are the RUG-III group code and the last two characters
are a valid RUG-III version code. The RAVEN-SB software determines the correct code for you
and inserts the code on each patient’s SB-MDS record.
Revised--October 2003
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HIPPS Code - The first three characters are the RUG-III group code and the last two characters are
a valid assessment indicator. The RAVEN-SB software determines the correct code for you and
inserts the code on each patient’s SB-MDS record.
When a Medicare SB-MDS assessment record is received by the national database, both the RUG-III
case mix code and HIPPS Code are recalculated and verified. Once the patient’s SB-MDS record
has been accepted into the national database, clinical staff should give the HIPPS code to the billing
office. The HIPPS code must appear on the claim, and the claim cannot be filed until the patient’s
SB-MDS record has been accepted into the national database.
It is important to remember that the record will be accepted into the database even if the calculated
RUG-III code or HIPPS code differ from the submitted values. The error will be flagged on the final
validation report by issuing a warning message and listing the correct RUG-III or HIPPS code.
When such discrepancies occur, the RUG-III and/or HIPPS code reported on the validation report
should always be used for billing.
4.6
Definitions for Correction Procedures
There are several definitions relevant to correction procedures:
Test Batch - The national database system allows a swing bed hospital to submit test SB-MDS
batches. This allows the hospital to test the submission process and to verify that it is
submitting valid data. A Test/Production field in the header record identifies that the data to
follow is for test purposes only and should be edited but not accepted into the database.
Production Batch - A Test/Production field in the header record identifies that the data to
follow is production data and should be edited and accepted into the database.
Unauthorized Record - The hospital has no “submission authority” to submit the record to
CMS.
Submission Authority - The hospital has authority to submit SB-MDS assessments to CMS
for patients in a Medicare or Medicaid certified swing bed. States may also establish
additional submission requirements. Submission authority and the SUB_REQ have been
discussed earlier in this chapter.
Key Fields - Key fields are used by the national database to uniquely identify an assessment.
The following table lists the key fields in an assessment record.
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CMS’s SB Version 1.0 Manual
Key Field Name (MDS 2.0 Crosswalk)
FAC_ID
Item 1a (AA1a)
Item 1c (AA1c)
Item 2 (AA2)
Item 3 (AA3)
Item 7a (AA5a)
Item 10a (A3a)
Item 11a (AA8b)
Item 11b (AA8b)
Item 15 (R4)
Item 16 (A4a)
Description
Unique Hospital ID code
Patient First Name
Patient Last Name
Gender
Birth Date
Social Security Number
Assessment Reference Date
Primary Reason for Assessment
PPS Scheduled Assessment
Discharge Date
Reentry Date
Non-Key Fields – Includes all SB-MDS fields, except SUB_REQ and the key fields, which
are listed above.
Active Record – An SB-MDS record that has been submitted and accepted into the national
database.
Original Record – The initial version of an active record. An original record must have a
unique combination of key fields. For an assessment to be coded as an original record the
correction counter field Item 10b must be 00.
Correction Record - A new version of the assessment submitted to correct an existing active
record. A correction record must have the same key fields as the active record in error. Code
the correction record in Item 10b with a value one greater than Item 10b on the record being
corrected. If you were correcting an original record, the counter in Item 10b on the correction
record would be 01. You can correct any record in error, including active correction records.
If you were correcting an already existing correction record with an Item 10b value of 01, then
Item 10b on the new correction record would be 02.
Inactivation Record - A special SB-MDS record containing the key fields needed to identify
and inactivate an active record in the national database. An inactivation record must have key
fields exactly matching the active record.
Correction Counter - Item 10b, Original or Correction, on the SB-MDS is used to identify
the version of a record. Entering 00 in this field indicates an original record. A correction
record will always have an entry greater than zero. Item 10b must be incremented to 01 (zero,
one) for the first corrected version accepted in the national database, to 02 (zero, two) for the
second corrected version accepted in the national database, etc.
Revised--October 2003
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4.7
Timing and Types of Corrections
After an assessment has been completed and submitted to the national database, no further changes
should be made to the assessment record. Corrections are allowed if an assessment, data entry or
software error has been made. Corrections must be completed within 14 days of detecting the error
or errors, and then submitted within 14 days of completion of the correction.
There are different correction procedures for different types of errors.
I.
Records in Error Not Accepted Into the National Database:
This includes records that have been submitted and rejected, production records that were
inadvertently submitted as test records, or records that have not been submitted at all. Since none of
these records have been accepted into the national database, corrections can be made, and these
records can simply be submitted without any special procedures.
II. Records in Error Accepted Into the National Database:
This includes test records submitted and accepted as production, unauthorized records submitted
with incorrect submission authority, records with errors in key fields (see Page 4-5 for more
information on key fields), and records with errors in non-key field items. Each requires special
correction procedures.
A. Test batch is inadvertently submitted as a production batch.
These assessments must be deleted from the national database. When such a deletion is necessary,
the swing bed facility must submit a written deletion request to the support office for the national
database.
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CMS’s SB Version 1.0 Manual
The following is an example of the deletion request worksheet:
Example Swing Bed Test File Deletion Request Worksheet
1. Complete a copy of this form for each Test File to be deleted.
2. Submit to:
Iowa Foundation For Medical Care, QTSO Support
6000 Westown Parkway Suite 350E
West Des Moines, IA 50266-7771
(This information must not be sent via e-mail due to confidentiality of the information)
SB Facility information
Name
ID (FAC_ID)
Requester information
Name
Title
Phone #
Submission information
Date and time
Batch #
Reason For Deletion Request
This test file was inadvertently submitted as a production file. Please delete all of
the assessments from the national database.
Assessment Coordinator Name
Assessment Coordinator Signature
Date
B. Unauthorized record is accepted.
Only assessments for Medicare or Medicaid certified swing beds are authorized for submission to the
national database. These assessment(s) must be deleted from the database. When such a deletion is
necessary, the swing bed facility must submit a written deletion request to the support office for the
national database.
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The following is an example of the unauthorized record deletion request worksheet:
Example SB-MDS Unauthorized Record Deletion Request Worksheet
Instructions:
1. Complete a copy of this form for each unauthorized record to be deleted.
2. Submit to:
Iowa Foundation For Medical Care, QTSO Support
6000 Westown Parkway Suite 350E
West Des Moines, IA 50266-7771
(This information must not be sent via e-mail due to confidentiality of the information)
Facility information
Name
ID (FAC_ID)
Requester information
Name
Title
Phone #
Resident information
First Name
Last Name
SSN
Birth date
Gender
Record information
Item 11a
Item 11b
Event Date1
Submission information
Date and time
Batch #
Assessment Internal ID
Reason for Deletion Request
This record was inadvertently submitted indicating it had submission authority,
when it did not have authority. Please delete this record from the national database.
Assessment Coordinator Name
Assessment Coordinator Signature
Date
1
Event Date:
SB-MDS Item 10a, reference date, for an assessment record.
SB-MDS Item 15, discharge date, for a discharge record.
SB-MDS Item 16, reentry date, for a reentry record.
Revised--October 2003
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CMS’s SB Version 1.0 Manual
C. Authorized record is accepted with incorrect key fields.
An authorized record with incorrect key fields identifies the wrong swing bed facility, patient, type
of assessment, or event date, such as birth date, discharge date, reentry date or ARD. If an
authorized record is accepted into the national database with incorrect key fields, the record must be
inactivated and, if appropriate, a new original record with all information correct (both key and nonkey fields) must be submitted. To inactivate a record, the authorized facility staff member must
inactivate the record according to the SB-MDS software procedure, which moves the erroneous
record from the active part of the database to a history file maintained as an audit trail of corrections.
Once the erroneous assessment has been inactivated, a replacement assessment may be submitted as
an original record with Item 10b entered as 00.
The key fields of the inactivation must match all the key fields of the existing active record. If all
key fields do not match the active record existing in the database (i.e., the record with the error), the
inactivation record will be rejected. Once the record is properly inactivated, if appropriate, complete
a replacement assessment. For submission purposes, both the inactivation record and the
replacement assessment record may be included in the same submission batch.
For example, if an assessment was submitted with an incorrect patient birth date (Item 3), an
inactivation record would be submitted and a replacement assessment with the correct birth date
would also be submitted. The replacement assessment would be an original record with Item 10b
equal to 00. It is important to submit inactivation records when mistakes are identified, since the
system will not recognize assessments with different information in the key fields as belonging to
the same patient.
D. Authorized record is accepted with incorrect non-key fields.
If an active authorized assessment is determined to have errors only in non-key fields, a correction
record must be submitted. The non-key errors should be corrected in a copy of the assessment. The
correction field Item 10b should be increased by 1, from 00 to 01 etc. The correction record must
be submitted to CMS.
When a correction record is accepted, the existing active record is moved to an inactive history file
as an audit trail and the new corrected record will be placed in the active database. Standard system
reports and procedures are limited to active records.
A correction record will be rejected if the national database does not already contain an existing
active version of the record with exactly the same key fields, and the correction field Item 10b
having a value exactly one greater than the Item 10b value in the existing version of the record.
Revised--October 2003
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CMS’s SB Version 1.0 Manual
Correction Policy Examples
Your swing bed hospital just submitted the first production batch of assessments after successfully
testing the submission process. After reviewing the validation reports, you realize that the test
indicator had not been switched to production. To correct this, change the Test/Production indicator
and resubmit the batch. Do not increment Item 10b (Original and Correction field). You are
resubmitting the Original Record and it should still be coded 00.
Today is July 3, 2002 and you have just submitted an SB-MDS batch and received the validation
report. After reviewing the report you notice the assessment submitted for Mr. J has been rejected.
The birth date submitted was invalid because it is after the current date. After a review of the
assessment, you see that rather than 10 07 1922, his birth date was entered as 10 07 2002. You
should reopen the assessment, correct the birth date, and submit the assessment. Do not increment
Item 10b (Original and Correction field). You are resubmitting the Original Record and it should
still be coded 00.
Your swing bed hospital is anxious to test the submission process. You enter several fictitious
assessments into the software using silly names and made-up data. You submit the batch but forget
to set the Test/Production indicator to test. The validation report shows that the data has been
accepted into the database. You must submit a written Test File Deletion Request to the Support
office for the national database. The request should include the swing bed hospital name, the name,
title and phone number of the person making the request, the Hospital ID (FAC_ID), the submission
data and time, and the submission batch ID number. (A sample request form is included on Page
4-7.)
When entering the 30-Day assessment for Mr. G, you notice that his social security number is
incorrect in the system. Both the 5-Day and the 14-Day assessment have been submitted with this
incorrect number. Item 7a (Social Security Number) is a key field. To correct this error, you would
need to submit an Inactivation Record for both the 5-Day and 14-Day assessments. Then create
new original records for both assessments with the correct social security numbers. Submit the new
original for the 5-Day and 14-Day assessments with Item 10b (Original and Correction field)
coded 00. Also, submit the 30-Day assessment with the correct social security number. Both the
inactivation records and the replacement assessment records may be included in the same
submission batch.
When reviewing a 5-Day assessment on Mrs. Y, you realize that Item 38aa (Chemotherapy) had
been incorrectly marked and Item 38ab (Dialysis) should have been marked but was not. This error
is in a non-key field and can be corrected with a correction record. Using RAVEN-SB software,
make a correction copy of the assessment. Revise Items 38aa and 38ab with the correct answers.
Increment Item 10b (Original and Correction field). Since the 5-Day was an original record coded
00, you would now code it 01. Submit the corrected assessment.
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CMS’s SB Version 1.0 Manual
SB-MDS Correction Policy Flowchart
Enter and submit assessment
Not submitted
or rejected
by database
Accepte
by natl
N
Correct clinical record
appropriate
Correct/submit
CORRECTION_NU
unchanged
Ye
Accepted
test
submitted
as production
Accepted
no
Tes
submitted as
duction
Ye
Submit test file deletion request to
N
Doe
assessment
errors
N
Take no further
Ye
Accepted:
unauthorized
asmt
submitted
Accepted
nonfield
Unauthorize
assessment
Ye
Submit unauthorized record deletion request to IFMC
N
Correct clin. record
appropriate
N
Key field
Submit correction record with increment in
Ye
Accepted
key field
Submit
N
Replacement
needed
Take no further
Ye
Submit replacement original record with
Correct clinical record
appropriate
Revised--October 2003
Page 4-11
CMS’s SB Version 1.0 Manual
Chapter 5: Medicare Skilled Nursing Facility
Prospective Payment System (SNF PPS)
5.1
SNF PPS Coverage Guidelines
Under SNF PPS, beneficiaries must continue to meet the established eligibility requirements for a
Part A SNF-level stay; i.e., the beneficiary must have received acute care as a hospital inpatient for a
medically necessary stay of at least 3 consecutive calendar days. In addition, the beneficiary must
have started receiving extended care swing bed services within 30 days after discharge as an acute
care patient from the swing bed facility or other hospital, unless the exception in §3131.3b of the
Medicare Intermediary Manual (MIM) applies. To be covered, the extended care services must be
needed for a condition which was treated during the beneficiary’s qualifying hospital stay or for a
condition which arose while receiving extended care services for a condition for which the
beneficiary was previously treated during the acute care stay.
Swing bed providers will assess the clinical condition of beneficiaries by completing the SB-MDS
assessment for each Medicare beneficiary receiving Part A SNF-level care. The SB-MDS
assessment data is used to calculate the RUG-III Classification necessary for payment. The SBMDS contains extensive information on the patient’s nursing needs, ADL impairments, cognitive
status, behavioral problems, and medical diagnoses. This information is used to define RUG-III
groups that form a hierarchy from the greatest to the least resources used. Patients with more
specialized nursing requirements, licensed therapies, greater ADL dependency or other conditions
will be assigned to higher groups in the RUG-III hierarchy. Providing care to these patients is more
costly and is reimbursed on a higher level. The table below shows the applicable assessment days
and grace days for each PPS assessment, as well as the applicable payment days.
Medicare Assessment Schedule for Swing Bed Hospitals
Medicare
SB-MDS
Assessment
Type
5-Day
14-Day
30-Day
60-Day
90-Day
Reason for
Assessment
(SB-MDS Item
11b code)
1
7
2
3
4
Assessment
Reference Date *
(based on start of
Part A stay)
Assessment Number of Days Applicable
Reference
Authorized for
Medicare
Date
Coverage and
Payment
Grace Days
Payment
Days
1-5**
11-14
21-29
50-59
80-89
6-8**
15-19
30-34
60-64
90-94
14
16
30
30
10
1-14
15-30
31-60
61-90
91-100
*The assessment reference date is the last date of the observation period for the clinical assessment. The timeliness
requirements are calculated using the first day of the Medicare Part A-covered stay as “day 1”.
**If a beneficiary expires or transfers to another facility before the 5-Day assessment has been completed, the facility
will still need to prepare an SB-MDS as completely as possible for the RUG-III classification and Medicare payment
purposes. Otherwise the days will be paid at the default rate. The assessment reference date must also be adjusted to no
later than the date of discharge.
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5.2
Payment Provisions Under SNF PPS
Federal Rate
Swing bed services reimbursed under the SNF PPS will be paid at the full Federal rate. The Federal
payment rates were developed by CMS using allowable costs from hospital-based and freestanding
Part A SNF-level cost reports from reporting periods beginning in fiscal year 1995. The data used in
developing the Federal rates also incorporated an estimate of the amount payable under Part B for
covered SNF-level services furnished during fiscal year 1995 to individuals who were patients of the
facility and receiving Part A covered services.
In accordance with the formula prescribed in the BBA, the Federal rates were set at a level equal to
the weighted mean of freestanding costs plus 50 percent of the difference between the freestanding
mean and the mean of all SNF costs (hospital-based and freestanding) combined. In addition, the
portion of the Federal rate attributable to wage-related costs is adjusted by an appropriate wage
index. Payment rates are computed and applied separately for facilities located in urban and rural
areas. All swing bed hospitals are classified as rural providers, and will be paid at the rural rate for
their geographic locations.
The Federal rate incorporates adjustments to account for facility case mix from the RUG-III patient
classification system used under the national PPS. RUG-III is a 53-group patient classification
system that provides the basis for the case-mix payment indices (or relative payment weights) used
to standardize the Federal rates and subsequently to establish case mix adjustments to the rates for
patients with different service use. Information from the SB-MDS is used to classify patients into
one of 53 RUG-III groups. Like other providers subject to the SNF PPS, swing bed providers must
complete these assessments according to an assessment schedule specifically designed for Medicare
payment.
When assessments are performed late (i.e., the ARD is a later date than the allowed ARD window),
the swing bed facility will be paid at a default rate equal to the payment made for the lowest RUG III
group. The default rate will be in effect from the first day of the coverage period to the ARD of the
late assessment.
When assessments are performed early (i.e., the ARD is an earlier date than the allowed ARD
window), the swing bed facility will be paid at the default rate for the number of days the assessment
was out of compliance. For example, a Medicare-required 14-Day assessment with an ARD of day
10 (1 day early) would be paid at the default rate for the first day of the payment period that begins
on day 15.
Under the SNF PPS, covered swing bed services will include Part A SNF-level services for which
benefits are provided under Part A (the hospital insurance program). In addition, the SNF PPS rate
includes all items and services for which, prior to July 1, 1998, payment had been made under Part B
(the supplementary medical insurance program) but furnished to SNF patients during a Part A
covered stay.
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Services that are not reimbursed through the SNF PPS per diem rate include physician services,
physician assistant services, nurse practitioner and clinical nurse specialist services, certified
midwife services, qualified psychologist services, certified registered nurse anesthetist services and
anesthesiologist assistant services. Services of nurses and physician assistants are not separately
billable when they are employees of the swing bed facility.
5.3
Resource Utilization Groups Version III
Beginning on the first day of each provider’s next fiscal year on or after July 2002, swing bed
programs are required to conduct assessments that are used to determine reimbursement for their
Medicare patients. The SB-MDS assessment contains items that reflect the acuity level of the
patient, including diagnoses, treatments, and an evaluation of the patient’s functional status. Patient
acuity information is used to calculate a RUG-III classification for each patient. The RUG-III
system predicts levels of resources that are required to care for a mixture of different patient needs.
The RUG-III patient classification system measures both nursing and therapy staff resource use.
The RUG-III Classification system has eight major patient classification groups, Rehabilitation Plus
Extensive Services, Rehabilitation, Extensive Services, Special Care, Clinically Complex, Impaired
Cognition, Behavior Problems, and Reduced Physical Functions. The eight groups are further
divided by the intensity of the patient’s activities of daily living (ADL) needs.
•
In the Extensive Services category, an extensive services count is completed to determine if the
assessment also classifies in other categories such as Special Care, Clinically Complex, and
Impaired Cognition.
•
In the Clinically Complex category, assessments are differentiated by the absence or presence of
depression.
•
In the Impaired Cognition, Behavior Problems and Reduced Physical Functioning categories,
two or more nursing rehabilitation services are recognized.
One very important calculation in the classification process is the scoring of Activities of Daily
Living (ADL). An ADL Score is calculated for all assessment classifications and is one of the
determining factors regarding placement in all RUG-III categories. The ADL Score calculation
includes Item 23a (Bed Mobility), Item 23b (Transfer), Item 23d (Toilet Use), and a calculation
using Items 23c (Eating) and 29 (Nutritional Approaches), and 30 (Parenteral/Enteral Intake). The
ADL Scores range between 4 and 18. An ADL Score of 4 represents the most independent patient
while a score of 18 represents the most dependent patient.
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EIGHT MAJOR RUG-III CLASSIFICATION GROUPS
MAJOR RUG-III GROUP
CHARACTERISTICS ASSOCIATED
WITH MAJOR RUG-III GROUP
Rehabilitation Plus Extensive Services
Patients receiving physical, speech or
occupational therapy AND receiving IV
feeding or medication, suctioning,
tracheostomy care, or ventilator/respirator.
Rehabilitation
Patients receiving physical, speech or
occupational therapy.
Extensive Services
Patients receiving complex clinical care or
with complex clinical needs such as IV feeding
or medications, suctioning, tracheostomy care,
ventilator/respirator and comorbidities that
make the patient eligible for other RUG
categories.
Special Care
Patients with complex clinical care or with
serious medical conditions such as multiple
sclerosis, quadriplegia, cerebral palsy,
respiratory therapy, ulcers, stage III or IV
pressure ulcers, radiation, surgical wounds or
open lesions, tube feeding and aphasia, fever
with dehydration, pneumonia, vomiting,
weight loss or tube feeding.
Clinically Complex
Patients receiving complex clinical care or
with conditions requiring skilled nursing
management and interventions for conditions
and treatments such as burns, coma,
septicemia, pneumonia, foot wounds, foot
infections, diabetes mellitus and injections
with physician order changes, internal
bleeding, dehydration, tube feeding, oxygen,
transfusions, hemiplegia, chemotherapy,
dialysis, and physician visits/order changes.
Impaired Cognition
Patients having cognitive impairment in
decision making, recall and short-term
memory. (Score on SB-MDS cognitive
performance scale >=3).
Behavior Problems
Patients displaying behavior such as
wandering, verbally or physically abusive or
socially inappropriate, or who experience
hallucinations or delusions.
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Reduced Physical Functions
5.4
Patients whose needs are primarily for
activities of daily living and general
supervision.
Relationship Between the SB-MDS and the Claim
The SNF PPS establishes a schedule of Medicare assessments. Each required Medicare assessment
is used to support Medicare PPS reimbursement for a predetermined maximum number of Medicare
Part A days. To verify that the Medicare bill accurately reflects the assessment information, three
data items derived from the SB-MDS assessment must be included on the Medicare claim:
1.
Assessment Reference Date (ARD)
The ARD must be reported on the Medicare claim. If a SB-MDS assessment was not
completed, the ARD is not used and the claim must be billed at the default rate. CMS has
developed mechanisms to link the assessment and billing records.
2.
The RUG-III Group
The RUG-III group is calculated from the SB-MDS assessment data. The software used to
encode and transmit the SB-MDS assessment data calculates the RUG-III group. CMS edits
and validates the RUG-III code of transmitted SB-MDS assessments. Facilities cannot submit
Medicare Part A claims until the assessment has been accepted into the CMS database, and
they must use the RUG-III code as validated by CMS when bills are filed. The following
abbreviated RUG-III codes are used in the billing process:
RUX, RUL, RVX, RVL, RHX, RHL, RMX, RML, RLX
RUA, RUB, RUC, RVA, RVB, RVC, RHA, RHB, RHC, RMA, RMB, RMC, RLA, RLB
SE1, SE2, SE3
SSA, SSB, SSC
CA1, CA2, CB1, CB2, CC1, CC2
IA1, IA2, IB1, IB2
BA1, BA2, BB1, BB2
PA1, PA2, PB1, PB2, PC1, PC2, PD1, PD2, PE1, PE2
AAA (the default code)
3.
Health Insurance PPS (HIPPS) Codes
Each Medicare PPS assessment is used to support Medicare Part A payment for a maximum
number of days. The HIPPS modifier code must be entered on each claim, and must
accurately reflect which assessment is being used to bill the RUG-III group for Medicare
reimbursement.
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The CMS HIPPS modifier codes contain a 3-position code to represent the RUG-III of the
SNF patient, plus a 2-position assessment indicator to indicate which assessment was
completed. Together they make up the 5-position HIPPS modifier code for the purpose of
billing Part A covered days to the Fiscal Intermediary.
HIPPS modifier codes have been established for each type of assessment used to support
Medicare payment. For example, the Medicare reason for assessment on a Medicare 5-Day
assessment is “1”, and the HIPPS modifier code is “01”. The chart shown below lists the
HIPPS codes used by swing beds.
HIPPS MODIFIERS/ASSESSMENT TYPE INDICATORS
Basic Assessments:
• 01 5-Day Medicare-required assessment
• 02 30-Day Medicare-required assessment
• 03 60-Day Medicare-required assessment
• 04 90-Day Medicare-required assessment
• 05 Readmission/Return Medicare-required assessment
• 07 14-Day Medicare-required assessment
• 08 Off-cycle other Medicare-required assessment (OMRA)
• 30 Off-cycle swing bed change in clinical status (outside assessment window)
Replacement Assessments - OMRAs:
• 18 OMRA replacing 5-Day Medicare-required assessment or 5-Day Readmission/Return
Assessment
• 28 OMRA replacing 30-Day Medicare-required assessment
• 38 OMRA replacing 60-Day Medicare-required assessment
• 48 OMRA replacing 90-Day Medicare-required assessment
• 78 OMRA replacing 14-Day Medicare-required assessment
Replacement Assessments -Change in Clinical Status:
• 32 Swing bed change in clinical status replaces 30-Day Medicare-required assessment
• 33 Swing bed change in clinical status replaces 60-Day Medicare-required assessment
• 34 Swing bed change in clinical status replaces 90-Day Medicare-required assessment
• 35 Swing bed change in clinical status replaces a Readmission/Return Medicare-required
assessment
• 37 Swing bed change in clinical status replaces 14-Day Medicare-required assessment
NOTE: A code for a Change in Clinical Status replacing the initial 5-Day Medicare-required
assessment is not provided. If the change in clinical status occurs after the initial 5-Day assessment
has been completed (i.e., between days 1-8), and before the assessment window for the 14-Day
assessment, it will be considered an off-cycle change in clinical status and the HIPPS code will be
coded as 30.
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HIPPS MODIFIERS/ASSESSMENT TYPE INDICATORS
(continued)
Special Payment Situations - New Assessment Indicator Codes Effective July 1, 2002:
In some situations, beneficiaries may change payer source after admission to the swing bed, but fail
to notify the provider in a timely manner; e.g., disenrollment from an HMO, disenrollment from a
hospice, change in Medicare payer status from secondary to primary, etc. In those situations, the
provider may not have completed the SB-MDS assessments needed for Medicare billing. New
assessment indicator codes have been established for these special payment situations. Claims
processing instructions are being developed and will be issued separately.
Since these codes are used to indicate unusual situations, they must be assigned manually.
•
•
•
•
•
19
29
39
49
79
Special payment situation 5-Day assessment
Special payment situation 30-Day assessment
Special payment situation 60-Day assessment
Special payment situation 90-Day assessment
Special payment situation 14-Day assessment
Default Code - No Assessment Completed:
• 00 Default code (No assessment completed)
5.5
RUG-III 53 Group Model Calculation Worksheet for Swing Beds
This RUG-III Version 5.20 calculation worksheet is a step-by-step walk through to manually
determine the appropriate RUG-III classification based on the data from an SB-MDS assessment.
The worksheet takes the grouper logic and puts it into words. We have carefully reviewed the
worksheet to insure that it represents the standard logic.
This worksheet is for the 53-group RUG-III Version 5.20 model. In the 53-group model, there are
23 different Rehabilitation Plus Extensive Services and Rehabilitation groups representing 10
different levels of rehabilitation services. In the 53-group model, the patients in the Rehabilitation
Plus Extensive Services groups have the highest level of combined nursing and rehabilitation need,
while patients in the Rehabilitation groups have the next highest level of need. Therefore, the 53group model has the Rehabilitation Plus Extensive services groups first, followed by the
Rehabilitation groups, the Extensive Services groups, the Special Care groups, the Clinically
Complex groups, the Impaired Cognition groups, the Behavior Problems groups, and finally the
Reduced Physical Function groups.
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There are two basic approaches to RUG-III classification: (1) hierarchical classification and (2)
index maximizing classification. The present worksheet is focused on the hierarchical approach but
can be adapted to the index maximizing approach.
Hierarchical Classification - The present worksheet employs the hierarchical classification method.
Hierarchical classification is used in some payment systems, in staffing analysis, and in many
research projects. In the hierarchical approach, you start at the top and work down through the
RUG-III model, and the classification is the first group for which the patient qualifies. In other
words, start with the Rehabilitation Plus Extensive Services groups at the top of the RUG-III model.
Then you work your way down through the groups in hierarchical order: Rehabilitation Plus
Extensive Services, Rehabilitation, Extensive Services, Special Care, Clinically Complex, Impaired
Cognition, Behavior Problems, and Reduced Physical Functions. When you find the first of the 53
individual RUG-III groups for which the patient qualifies, assign that group as the RUG-III
classification and you are finished.
If the patient qualifies in the Extensive Services group and also in a Special Care group, always
choose the Extensive Services classification, since it is higher in the hierarchy. Likewise, if the
patient qualifies for Special Care and Clinically Complex, always choose Special Care. In
hierarchical classification, always pick the group nearest the top of the model.
Index Maximizing Classification - Index maximizing classification is used in Medicare PPS and
most Medicaid payment systems. There is a designated Case Mix Index (CMI) for each RUG-III
category. The first step in index maximizing is to determine all of the RUG-III groups for which the
patient qualifies. Then from the qualifying groups you choose the RUG-III group that has the
highest case mix index. The index maximizing method uses the case mix indices effective with
RUG-III changes on January 1, 2006.
While the present worksheet illustrates the hierarchical classification method, it can be adapted for
index maximizing. To index maximize, you would evaluate all classification groups rather than
assigning the patient to the first qualifying group. In the index maximizing approach, you again start
at the beginning of the worksheet. You then work down through all of the 53 RUG-III classification
groups, ignoring instructions to skip groups and noting each group for which the patient qualifies.
When you finish, record the CMI for each of these groups. Select the group with the highest CMI.
This group is the index-maximized classification for the patient.
If the patient qualifies in an Extensive Services group and a Special Care group, choose the RUG-III
classification with the higher CMI. Likewise, if the patient qualifies for Special Care and Clinically
Complex, again choose the RUG-III classification with the higher CMI. Always select the
classification with the highest CMI.
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CALCULATION OF TOTAL “ADL” SCORE
RUG-III, 53 GROUP HIERARCHICAL CLASSIFICATION
The ADL score is used in all determinations of a patient’s placement in a RUG-III category.
It is a very important component of the classification process.
f STEP # 1
To calculate the ADL score use the following chart for Item 23a (Bed Mobility), Item 23b
(Transfer), and Item 23d (Toilet Use). Enter the ADL scores to the right.
Column A =
-, 0 or 1
2
3, 4, or 8
3, 4, or 8
and
and
and
and
Column B =
(any number)
(any number)
-, 0, 1 or 2
3 or 8
ADL score =
= 1
= 3
= 4
= 5
SCORE
23a = _____
23b = _____
23d = _____
f STEP # 2
If Item 29a (Parenteral/IV) is checked, the eating ADL score is 3. If Item 29b (Feeding
Tube) is checked and EITHER (1) Item 30a is 51 % or more calories OR (2) Item 30a is
26% to 50% calories and Item 30b is 501cc or more per day fluid enteral intake, then the
eating ADL score is 3. Enter the ADL eating score (23c) below and total the ADL score.
If not, go to Step #3.
f STEP # 3
If neither Item 29a nor Item 29b (with appropriate intake) are checked, evaluate the chart
below for Item 23cA (Eating Self-performance). Enter the score to the right and total the
ADL score. This is the RUG-III TOTAL ADL SCORE. (The total ADL score range
possibilities are 4 through 18.)
EATING
Column A (23c) =
ADL score =
SCORE
-, 0 or 1
= 1
23c = _____
2
= 2
3, 4, or 8
= 3
TOTAL RUG-III ADL SCORE ________
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CATEGORY I: REHABILITATION PLUS
EXTENSIVE SERVICES
RUG-III, 53 GROUP HIERARCHICAL CLASSIFICATION
You start the classification process beginning at the Rehabilitation Plus Extensive Services
level. In order for a patient to qualify for this category, he/she must meet 3 requirements,
which are 1) have an ADL score of 7 or more, 2) meet one of the criteria for Extensive
Services category, and 3) meet the criteria for one of the Rehabilitation categories.
f STEP # 1
Determine the patient’s ADL score. If the patient’s ADL score is 7 or higher go to step 2.
If the ADL score is less than 7, skip to Category II now.
f STEP # 2
Is the patient coded for receiving one or more of the following extensive services?
Item 29a
Item 38ac
Item 38af
Item 38ag
Item 38ai
Parenteral / IV
IV Medication
Suctioning
Tracheostomy care
Ventilator or respirator
If the patient does not receive one of the above, skip to Category II now.
f STEP # 3
Determine if the patient’s rehabilitation therapy services satisfy the criteria for one of the
RUG-III Rehabilitation groups. If the patient does not meet all of the criteria for one
Rehabilitation group (e.g., Ultra High Intensity), then move to the next group (e.g.,
Very High Intensity).
A.
Ultra High Intensity Criteria
In the last 7 days (Item 38b [a, b, c]):
720 minutes or more (total) of therapy per week AND
At least two disciplines, 1 for at least 5 days, AND
2nd for at least 3 days
RUG-III ADL Score
16 - 18
7 - 15
October 2003
RUG-III Class
RUX
RUL
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B.
Very High Intensity Criteria
In the last 7 days (Item 38b [a, b, c,]):
500 minutes or more (total) of therapy per week AND
At least 1 discipline for at least 5 days
RUG-III ADL Score
16 - 18
7 - 15
C.
High Intensity Criteria (either (1) or (2) below may qualify)
(1)
In the last 7 days (Item 38b [a, b, c]):
325 minutes or more (total) of therapy per week AND
At least 1 discipline for at least 5 days
(2)
If this is a Medicare 5-day or a Medicare Readmission/Return
Assessment, then the following apply (Item 42a, Item 42b, Item 42c and
Item 38b [a, b, c]):
Ordered Therapies, Item 42a is checked AND
In the last 7 days:
Received 65 or more minutes, Item 38b [a, b, c] AND
In the first 15 days from admission:
520 or more minutes expected, Item 42c AND
rehabilitation services expected on 8 or more days, Item 42b.
RUG-III ADL Score
13 - 18
7 - 12
D.
RUG-III Class
RHX
RHL
Medium Intensity Criteria (either (1) or (2) below may qualify)
(1)
In the last 7 days: (Item 38b [a, b, c])
150 minutes or more (total) of therapy per week AND
At least 5 days of any combination of the 3 disciplines
(2)
E.
RUG-III Class
RVX
RVL
If this is a Medicare 5-day or a Medicare Readmission/Return
Assessment, then the following apply: (Item 42a, Item 42b, Item 42c):
Ordered Therapies, Item 42a is checked AND
In the first 15 days from admission:
240 or more minutes are expected, Item 42c AND
rehabilitation services expected on 8 or more days, Item 42b.
RUG-III ADL Score
RUG-III Class
15 - 18
RMX
7 - 14
RML
Low Intensity Criteria (either (1) or (2) below may qualify):
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(1)
In the last 7 days (Item 38b [a, b, c] and Item 39):
45 minutes or more (total) of therapy per week AND
At least 3 days of any combination of the 3 disciplines AND
2 or more nursing rehabilitation services* received for
at least 15 minutes each with each administered for 6 or more
days.
(2)
If this is a Medicare 5-day or a Medicare Readmission/Return
Assessment, then the following apply (Item 39 and Item 42a, Item 42b,
Item 42c):
Ordered therapies Item 42a is checked AND
In the first 15 days from admission:
75 or more minutes are expected, Item 42c AND
rehabilitation services expected on 5 or more days, Item 42b AND
2 or more nursing rehabilitation services* received for at
least 15 minutes each with each administered for 2 or more days,
Item 39.
*Nursing Rehabilitation Services
Items 24a,b**
Any scheduled toileting program and/or
bladder retraining program
Items 39a,b**
Passive and/or active ROM
Item 39c
Splint or brace assistance
Items 39d,f**
Bed mobility and/or walking training
Item 39e
Transfer training
Item 39g
Dressing or grooming training
Item 39h
Eating or swallowing training
Item 39i
Amputation/Prosthesis care
Item 39j
Communication training
**Count as one service even if both provided
RUG-III ADL Score
7 - 18
RUG-III Class
RLX
RUG-III CLASSIFICATION ________
If the patient does not classify in the Rehabilitation Plus Extensive Services
Category, proceed to Category II.
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CATEGORY II: REHABILITATION
RUG-III, 53 GROUP HIERARCHICAL CLASSIFICATION
Rehabilitation therapy is any combination of the disciplines of physical, occupational, and
speech therapy. This information is found in Item 38b. Nursing rehabilitation is also
considered for the low intensity classification level. It consists of providing active or passive
range of motion, splint/brace assistance, training in transfer, training in dressing/grooming,
training in eating/swallowing, training in bed mobility or walking, training in
communication, amputation/prosthesis care, any scheduled toileting program, and bladder
retraining program. This information is found in Item 39 and Items 24a, b of the SB-MDS.
f STEP # 1
Determine if the patient’s rehabilitation therapy services satisfy the criteria for one of the
RUG-III Rehabilitation groups. If the patient does not meet all of the criteria for one
Rehabilitation group (e.g., Ultra High Intensity), then move to the next group (e.g.,
Very High Intensity).
A.
Ultra High Intensity Criteria
In the last 7 days (Item 38b [a, b, c]):
720 minutes or more (total) of therapy per week AND
At least two disciplines, 1 for at least 5 days, AND
2nd for at least 3 days
RUG-III ADL Score
16 - 18
9 - 15
4- 8
B.
RUG-III Class
RUC
RUB
RUA
Very High Intensity Criteria
In the last 7 days (Item 38b [a, b, c,]):
500 minutes or more (total) of therapy per week AND
At least 1 discipline for at least 5 days
RUG-III ADL Score
16 - 18
9 - 15
4- 8
October 2003
RUG-III Class
RVC
RVB
RVA
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CMS’s SB Version 1.0 Manual
C.
High Intensity Criteria (either (1) or (2) below may qualify)
(1)
In the last 7 days (Item 38b [a, b, c]):
325 minutes or more (total) of therapy per week AND
At least 1 discipline for at least 5 days
(2)
If this is a Medicare 5-day or a Medicare Readmission/Return
Assessment, then the following apply (Item 42a, Item 42b, Item 42c and
Item 38b [a, b, c]):
Ordered Therapies, Item 42a is checked AND
In the last 7 days:
Received 65 or more minutes, Item 38b [a, b, c] AND
In the first 15 days from admission:
520 or more minutes expected, Item 42c AND
rehabilitation services expected on 8 or more days, Item 42b.
RUG-III ADL Score
13 - 18
8 - 12
4- 7
D.
RUG-III Class
RHC
RHB
RHA
Medium Intensity Criteria (either (1) or (2) below may qualify)
(1)
In the last 7 days: (Item 38b [a, b, c])
150 minutes or more (total) of therapy per week AND
At least 5 days of any combination of the 3 disciplines
(2)
If this is a Medicare 5-day or a Medicare Readmission/Return
Assessment, then the following apply: (Item 42a, Item 42b, Item 42c):
Ordered Therapies, Item 42a is checked AND
In the first 15 days from admission:
240 or more minutes are expected, Item 42c AND
rehabilitation services expected on 8 or more days, Item 42b.
RUG-III ADL Score
15 - 18
8 - 14
4- 7
October 2003
RUG-III Class
RMC
RMB
RMA
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E.
Low Intensity Criteria (either (1) or (2) below may qualify):
(1)
In the last 7 days (Item 38b [a, b, c] and Item 39):
45 minutes or more (total) of therapy per week AND
At least 3 days of any combination of the 3 disciplines AND
2 or more nursing rehabilitation services* received for
at least 15 minutes each with each administered for 6 or more
days.
(2)
If this is a Medicare 5-day or a Medicare Readmission/Return
Assessment, then the following apply (Item 39 and Item 42a, Item 42b,
Item 42c):
Ordered therapies Item 42a is checked AND
In the first 15 days from admission:
75 or more minutes are expected, Item 42c AND
rehabilitation services expected on 5 or more days, Item 42b AND
2 or more nursing rehabilitation services* received for at
least 15 minutes each with each administered for 2 or more days,
Item 39.
*Nursing Rehabilitation Services
Items 24a,b**
Any scheduled toileting program and/or
bladder retraining program
Items 39a,b**
Passive and/or active ROM
Item 39c
Splint or brace assistance
Items 39d,f**
Bed mobility and/or walking training
Item 39e
Transfer training
Item 39g
Dressing or grooming training
Item 39h
Eating or swallowing training
Item 39i
Amputation/Prosthesis care
Item 39j
Communication training
**Count as one service even if both provided
RUG-III ADL Score
14 - 18
4 - 13
RUG-III Class
RLB
RLA
RUG-III CLASSIFICATION ________
If the patient does not classify in the Rehabilitation Category, proceed to Category III.
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CATEGORY III: EXTENSIVE SERVICES
RUG-III, 53 GROUP HIERARCHICAL CLASSIFICATION
The classification groups in this hierarchy are based on various services provided. Use the
following instructions to begin the calculation:
f STEP # 1
Is the patient coded for receiving one or more of the following extensive services?
Item 29a
Item 38ac
Item 38af
Item 38ag
Item 38ai
Parenteral / IV
IV Medication
Suctioning
Tracheostomy care
Ventilator or respirator
If the patient does not receive one of the above, skip to Category IV now.
f STEP # 2
If at least one of the above treatments is coded and the patient has a total RUG-III ADL score
of 7 or more, he/she classifies as Extensive Services. Move to Step #3. If the patient's ADL
score is 6 or less, he/she classifies as Special Care (SSA). Skip to Category IV, Step #5
now and record the classification as SSA.
f STEP # 3
The patient classifies in the Extensive Services category. To complete the scoring, however,
an extensive count will need to be determined. If Item 29a, Parenteral/IV is checked, add 1
to the extensive count below. If Item 38ac, IV Medication is checked, add 1 to the
extensive count below. To complete the extensive count, determine if the patient also meets
the criteria for Special Care, Clinically Complex, and Impaired Cognition. The final split
into either SE1, SE2, or SE3 will be completed after these criteria have been scored. Go to
Category IV, Step #1 now.
Item 29a
Item 38ac
Parenteral / IV
IV Medication
Extensive Count ________
(Enter this count in Step #4 on Page 5-24.)
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CATEGORY IV: SPECIAL CARE
RUG-III, 53 GROUP HIERARCHICAL CLASSIFICATION
The classification groups in this hierarchy are based on certain patient conditions or services.
Use the following instructions:
f STEP # 1
Determine if the patient is coded for one of the following conditions or services:
Item 25c
Cerebral palsy, with ADL sum >=10
Item 25e
Multiple sclerosis, with ADL sum >=10
Item 25f
Quadriplegia, with ADL sum >=10
Item 27c
Fever and one of the following;
Item 26a
Pneumonia
Item 27a
Dehydration
Item 27f
Vomiting
Item 28
Weight loss
Item 29b
Tube feeding*
Item 29b, Item 25b Tube feeding* and aphasia
Items 31a,b,c,d
Ulcers 2+ sites over all stages with 2 or more skin
treatments**
Item 32
Any stage 3 or 4 pressure ulcer with 2 or more skin
treatments**
Items 33b,c
Surgical wounds or open lesions with 1 or more skin
treatments***
Item 38ae
Radiation treatment
Item 38bdA
Respiratory therapy =7 days
*Tube feeding classification requirements:
(1)
Item 30a is 51% or more calories OR
(2)
Item 30a is 26% to 50% calories and Item 30b is 501 cc or more per day
fluid enteral intake in the last 7 days.
**Skin treatments:
Items 34a, b#
Pressure relieving chair and/or bed
Item 34c
Turning/repositioning
Item 34d
Nutrition or hydration intervention
Item 34e
Ulcer care
Item 34g
Application of dressings (not to feet)
Item 34h
Application of ointments (not to feet)
#
Count as one treatment even if both provided
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***Skin Treatments
Item 34f
Item 34g
Item 34h
Surgical wound care
Application of dressing (not to feet)
Application of ointments (not to feet)
If the patient does not have one of the above conditions, skip to Category V now.
f STEP # 2
If at least one of the special care conditions above is met:
a.
If the patient previously qualified for Extensive Services, proceed to Extensive
Count Determination. Go to Step #3. OR
b.
If the RUG-III ADL score is 7 or more, the patient classifies as Special Care.
Go to Step #4. OR
c.
If the RUG-III ADL score is 6 or less, the patient classifies as Clinically
Complex. Skip to Category V, Step #4.
f STEP # 3 (Extensive Count Determination)
If the patient previously met the criteria for the Extensive Services category and the
evaluation of the Special Care category is done only to determine if the patient is an SE1,
SE2, or SE3, enter 1 for the extensive count below and skip to Category V, Step #1.
Extensive Count ________
(Enter this count in Step #4 on Page 5-24.)
f STEP # 4
If at least one of the special care conditions above is coded and the RUG-III ADL score is 7
or more, the patient classifies in the Special Care category. Select the Special Care
classification below based on the ADL score and record this classification in Step #5:
RUG-III ADL Score
17 - 18
15 - 16
7 - 14
RUG-III Class
SSC
SSB
SSA
f STEP #5
Record the appropriate Special Care classification:
RUG-III CLASSIFICATION ________
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CATEGORY V: CLINICALLY COMPLEX
RUG-III, 53 GROUP HIERARCHICAL CLASSIFICATION
The classification groups in this category are based on certain patient conditions. Use the
following instructions:
f STEP # 1
Determine if the patient is coded for one of the following conditions or services:
Item 17
Coma (Item 17 =1) and not awake (Items 36a,b,c = 0)
and completely ADL-dependent (Item 23aA, Item
23bA, Item 23cA, Item 23dA= 4 or 8)
Item 25a, Item 37, Item 41 Diabetes mellitus and injection 7 days and Physician
order changes >= 2 days
Item 25d
Hemiplegia with ADL sum >=10
Item 26a
Pneumonia
Item 26b
Septicemia
Item 27a
Dehydration
Item 27e
Internal bleeding
Item 29b
Tube feeding*
Item 33a
Burns
Items 35a,b,c
Infection of foot (Item 35a or Item 35b) with treatment
in Item 35c
Item 38aa
Chemotherapy
Item 38ab
Dialysis
Item 38ad
Oxygen therapy
Item 38ah
Transfusions
Item 40, Item 41
Number of Days in last 14, Physician Visit/order
changes:
Visits >= 1 day and changes >= 4 days OR
Visits >= 2 days and changes >= 2 days
*Tube feeding classification requirements
(1) Item 30a is 51% or more calories OR
(2) Item 30a is 26% to 50% calories and Item 30b is 501 cc or more per day fluid enteral intake
in the last 7 days.
If the patient does not have one of the above conditions, skip to Category VI now.
f STEP # 2
If at least one of the clinically complex conditions above is met:
a.
Extensive Count Determination. Go to Step #3 OR
b.
Clinically Complex classification. The patient classifies as Clinically
Complex. Go to Step #4.
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CMS’s SB Version 1.0 Manual
f STEP # 3 (Extensive Count Determination)
If the patient previously met the criteria for the Extensive Services category, and the
evaluation of the Clinically Complex category is done only to determine if the patient is an
SE1, SE2, or SE3, enter 1 for the extensive count below and skip to Category VI Step #1.
Extensive Count ________
(Enter this count in Step #4 on Page 5-24.)
f STEP # 4
Evaluate for Depression. Signs and symptoms of a depressed or sad mood are used as a third
level split for the Clinically Complex category. Patients with a depressed or sad mood are
identified by the presence of a combination of symptoms, as follows:
Count the number of indicators of depression. The patient is considered depressed if he/she
has at least 3 of the following:
(Indicator exhibited in last 30 days and coded “1” or “2”)
Item 21a
Item 21b
Item 21c
Item 21d
Item 21e
Item 21f
Item 21g
Item 21h
Item 21i
Item 21j
Item 21k
Item 21l
Item 21m
Item 21n
Item 21o
Item 21p
Negative statements
Repetitive questions
Repetitive verbalization
Persistent anger with self and others
Self deprecation
Expressions of what appear to be unrealistic fears
Recurrent statements that something terrible is going
to happen
Repetitive health complaints
Repetitive anxious complaints/concerns
(Non-health related)
Unpleasant mood in morning
Insomnia/changes in usual sleep pattern
Sad, pained, worried facial expression
Crying, tearfulness
Repetitive physical movements
Withdrawal from activities of interest
Reduced social interaction
Does the patient have 3 or more indicators of depression? YES_____ NO_____
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f STEP # 5
Assign the Clinically Complex category based on both the ADL score and the presence or
absence of depression.
RUG-III ADL Score
17 - 18
17 - 18
12 - 16
12 - 16
4 - 11
4 - 11
Depressed
YES
NO
YES
NO
YES
NO
RUG-III Class
CC2
CC1
CB2
CB1
CA2
CA1
RUG-III CLASSIFICATION ________
October 2003
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CATEGORY VI: IMPAIRED COGNITION
RUG-III, 53 GROUP HIERARCHICAL CLASSIFICATION
f STEP # 1
Determine if the patient is cognitively impaired according to the RUG-III Cognitive
Performance Scale (CPS). The patient is cognitively impaired if one of the three following
conditions exists:
(1)
(2)
(3)
Item 17
Coma (Item 17 = 1) and not awake (Item 36a, b, c = 0) and
completely ADL dependent (Item 23aA, Item 23bA, Item
23cA, Item 23dA = 4 or 8)
Item 19
Severely impaired cognitive skills (Item 19 = 3)
Item 18, Item 19, Item 20
These three Items (18, 19, and 20) are all assessed with none
being blank or unknown (value N/A or “-“)
AND
Two or more of the following impairment indicators are present
Item 18 = 1
Short-term memory problem
Item 19 > 0
Cognitive skills problem
Item 20 > 0
Problem being understood
AND
One or more of the following severe impairment indicators are
present:
Item 19 >= 2
Severe cognitive skills problem
Item 20 >= 2
Severe problem being understood
If the patient does not meet the criteria for cognitively impaired:
a.
and the evaluation is being done to determine if the patient is in SE1, SE2, or
SE3, skip to Step #4 on Page 5-24 “Category III: Extensive Services
(cont.).” OR
b.
Skip to Category VII now.
f STEP # 2
If the patient meets the criteria for cognitive impairment:
a.
Extensive Count Determination. Go to Step #3. OR
b.
Impaired Cognition classification. The patient may classify as Impaired
Cognition. Go to Step #4.
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f STEP # 3 (Extensive Count Determination)
If the patient previously met the criteria for the Extensive Services category, and the
evaluation of the Impaired Cognition category is done to determine if the patient is in SE1,
SE2, or SE3, enter 1 for the extensive count below and skip to Step #4 on Page 5-24,
“Category III: Extensive Services (cont.)”.
Extensive Count ________
f STEP # 4
(Enter this count in Step #4 on Page 5-24.)
The patient’s total RUG-III ADL score must be 10 or less to be classified in the RUG-III
Impaired Cognition category. If the ADL score is greater than 10, skip to Category VIII
now. If the ADL score is 10 or less and one of the impaired cognition conditions above
is present, then the patient classifies as Impaired Cognition. Proceed with Step #5.
f STEP # 5
Determine Nursing Rehabilitation Count
Count the number of the following services provided for 15 or more minutes a day for 6 or
more of the last 7 days:
Enter the nursing rehabilitation count to the right.
Items 24a,b*
Any scheduled toileting program and/or
bladder retraining program
Items 39a,b*
Passive and/or active ROM
Item 39c
Splint or brace assistance
Item 39d,f*
Bed mobility and/or walking training
Item 39e
Transfer training
Item 39g
Dressing or grooming training
Item 39h
Eating or swallowing training
Item 39i
Amputation/Prosthesis care
Item 39j
Communication training
*Count as one service even if both provided
Nursing Rehabilitation Count ________
f STEP # 6
Select the final RUG-III classification by using the total RUG-III ADL score and the Nursing
Rehabilitation Count.
RUG-III ADL Score
6 - 10
6 - 10
4- 5
4- 5
Nursing Rehabilitation
2 or more
0 or 1
2 or more
0 or 1
RUG-III Class
IB2
IB1
IA2
IA1
RUG-III CLASSIFICATION ________
October 2003
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CATEGORY III: EXTENSIVE SERVICES (cont.)
RUG-III, 53 GROUP HIERARCHICAL CLASSIFICATION
If the patient previously met the criteria for the Extensive Services category with an ADL
score of 7 or more, complete the Extensive Services classification here.
f STEP # 4 (Extensive Count Determination)
Complete the scoring of the Extensive Services by summing the extensive count items:
Page 5-16
Page 5-18
Page 5-20
Page 5-23
Extensive Count - Extensive Services
Extensive Count - Special Care
Extensive Count - Clinically Complex
Extensive Count - Impaired Cognition
Total Extensive Count
Select the final Extensive Service classification using the Total Extensive Count.
Extensive Count
4 or 5
2 or 3
0 or 1
RUG-III Class
SE3
SE2
SE1
RUG-III CLASSIFICATION ________
October 2003
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CATEGORY VII: BEHAVIOR PROBLEMS
RUG-III, 53 GROUP HIERARCHICAL CLASSIFICATION
f STEP # 1
The patient's total RUG-III ADL score must be 10 or less. If the score is greater than 10,
skip to Category VIII now.
f STEP # 2
One of the following must be met:
Item 22a
Wandering (2 or 3)
Item 22b
Verbal abuse (2 or 3)
Item 22c
Physical abuse (2 or 3)
Item 22d
Inappropriate behavior (2 or 3)
Item 22e
Resisted care (2 or 3)
Item 27b
Delusions
Item 27d
Hallucinations
If the patient does not meet one of the above, skip to Category VIII now.
f STEP # 3
Determine Nursing Rehabilitation
Count the number of the following services provided for 15 or more minutes a day for 6 or
more of the last 7 days:
Enter the nursing rehabilitation count to the right.
Items 24a,b*
Any scheduled toileting program and/or
bladder retraining program
Items 39a,b*
Passive and/or active ROM
Item 39c
Splint or brace assistance
Item 39d,f*
Bed mobility and/or walking training
Item 39e
Transfer training
Item 39g
Dressing or grooming training
Item 39h
Eating or swallowing training
Item 39i
Amputation/Prosthesis care
Item 39j
Communication training
*Count as one service even if both provided.
Nursing Rehabilitation Count ________
October 2003
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f STEP # 4
Select the final RUG-III classification by using the total RUG-III ADL score and the Nursing
Rehabilitation Count.
RUG-III ADL Score
6 - 10
6 - 10
4- 5
4- 5
Nursing Rehabilitation
2 or more
0 or 1
2 or more
0 or 1
RUG-III Class
BB2
BB1
BA2
BA1
RUG-III CLASSIFICATION ________
October 2003
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CATEGORY VIII: REDUCED PHYSICAL FUNCTION
RUG-III, 53 GROUP HIERARCHICAL CLASSIFICATION
f STEP # 1
Patients who do not meet the conditions of any of the previous categories, including those
who would meet the criteria for the Impaired Cognition or Behavior Problems categories but
have a RUG-III ADL score greater than 10, are placed in this category.
f STEP # 2
Determine Nursing Rehabilitation
Count the number of the following services provided for 15 or more minutes a day for 6 or
more of the last 7 days:
Enter the nursing rehabilitation count to the right.
Items 24a,b*
Any scheduled toileting program and/or
bladder retraining program
Items 39a,b*
Passive and/or active ROM
Item 39c
Splint or brace assistance
Items 39d,f*
Bed mobility and/or walking training
Item 39e
Transfer training
Item 39g
Dressing or grooming training
Item 39h
Eating or swallowing training
Item 39i
Amputation/Prosthesis care
Item 39j
Communication training
*Count as one service even if both provided
Nursing Rehabilitation Count ________
f STEP # 3
Select the RUG-III classification by using the RUG-III ADL score and the Nursing
Rehabilitation Count.
RUG-III ADL Score
16 - 18
16 - 18
11 - 15
11 - 15
9 - 10
9 - 10
6- 8
6- 8
4- 5
4- 5
Nursing Rehabilitation
2 or more
0 or 1
2 or more
0 or 1
2 or more
0 or 1
2 or more
0 or 1
2 or more
0 or 1
RUG-III Class
PE2
PE1
PD2
PD1
PC2
PC1
PB2
PB1
PA2
PA1
RUG-III CLASSIFICATION ________
October 2003
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APPENDIX A
GLOSSARY AND
COMMON ACRONYMS
October 2003
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CMS’s SB Version 1.0 Manual
Glossary
Activities of
Daily Living
ADL
The time period during which the assessment coordinator starts
the assessment until it is signed as complete.
Assessment
Period
Assessment
Reference Date
Activities of daily living are those needed for self-care: bathing,
dressing, mobility, toileting, eating, and transferring. The lateloss ADLs (eating, toileting, bed mobility, and transferring) are
used in classifying a patient into a RUG-III group.
ARD
The last day of the observation period for the SB-MDS
assessment. All SB-MDS items refer back in time from this
common endpoint. May also be referred to as the “Target Date”
in CMS system-generated reports. The SB-MDS field name is
10a.
Assessment
Window
The period of time defined by Medicare regulations that specify
when the Assessment Reference Date must be set. For example,
the assessment window for a Medicare 5-Day assessment is
between days 1-8, including grace days.
Browser
A program, such as Internet Explorer or Netscape, that allows
access to the internet or a private intranet site. A browser with
128-bit encryption is necessary to access the CMS intranet for
data submission or report retrieval.
Case Mix Index
CMI
A payment system that measures the intensity of care and
services required for each patient, and translates these measures
into the amount of reimbursement given to the facility for care of
a patient. Payment is linked to the intensity of resource use.
Case Mix
Reimbursement
System
Centers for
Medicare and
Medicaid
Services
October 2003
Weight or numeric score assigned to each RUG-III group that
reflects the relative resources predicted to provide care to a
patient. The higher the case mix weight, the greater the resource
requirements for the patient.
CMS
Formerly known as HCFA, the Federal agency that administers
the Medicare, Medicaid, and Child Health Insurance Programs.
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Clinical Change
Assessment
CCA
An assessment required when there is a decline or improvement
in a patient’s status that a) will not normally resolve itself
without intervention by staff or by implementing standard
disease-related clinical interventions, b) impacts more than one
area of the patient’s health status, and c) requires
interdisciplinary review and/or revision of the plan of care.
Code of Federal
Regulations
CFR
A codification of the general and permanent rules published in
the Federal Register by the Executive departments and
agencies of the Federal Government. The CFR is divided into
50 titles that represent broad areas subject to Federal regulation.
Each title is divided into chapters that usually bear the name of
the issuing agency. Each chapter is further subdivided into
parts covering specific regulatory areas. Large parts may be
subdivided into subparts. All parts are organized in sections,
and most citations to the CFR will be provided at the section
level.
Cognitive
Performance
Scale
CPS
The measure of cognitive status used in the RUG-III
Classification system.
Discharge
For the purposes of the SB-MDS, a discharge is reported when
a patient leaves the facility for more than 24 hours for other
than a temporary home visit or therapeutic leave, or is admitted
to the hospital.
Dually Certified
Facilities
Nursing facilities that participate in both the Medicare and
Medicaid programs.
Facility ID
Fatal File
October 2003
FACID
The facility identification number is assigned to each nursing
facility by the State agency. The FACID must be placed in the
header record in each SB-MDS file, and in the individual
SB-MDS and tracking form records. This normally is
completed as a function within the facility’s SB-MDS data
entry software.
An SB-MDS file that has an error in the format and causes the
entire file to be rejected. The individual records are not
validated or stored in the database. The facility must contact its
software support to resolve the problem with the submission
file.
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Fatal Record
An SB-MDS record that has an error severe enough to result in
record rejection. A fatal record is not saved in the CMS
database. The facility must correct the error that caused the
rejection and resubmit a corrected original record.
Federal Register
The official daily publication for rules, proposed rules and
notices of Federal agencies and organizations, as well as
Executive Orders and other Presidential Documents. It is a
publication of the National Archives and Records
Administration, and is available by subscription and on-line.
The web site is http://www.gpoaccess.gov/fr/index.html.
Final Validation
Reports
Fiscal
Intermediary
FVR
A report generated after the successful submission of SB-MDS
assessment data. This report lists all of the patients for whom
assessments have been submitted in a particular submission
batch, and displays all errors and/or warnings that occurred
during the validation process. A FVR with a submission type
of “production” is a facility’s documentation for successful file
submission. An individual record listed on the FVR marked as
“accepted” is documentation for successful record submission.
FI
An organization designated by CMS to process Medicare
claims for payment that are submitted by a swing bed facility.
F-Tag
Numerical designations for criteria reviewed during the facility
survey.
Grace Days
Additional days that may be added to the assessment window
for Medicare assessments without incurring financial penalty.
These may be used in situations such as an absence/illness of
the RN assessor, reassignment of the assessor to other duties for
a short period of time, or an unusually large number of
assessments due at approximately the same time. Grace days
may also be used to more fully capture therapy minutes or other
treatments.
Header
The first record in an SB-MDS file submitted to the CMS Data
Collection System. This record contains facility and software
vendor information for the subsequent records within the file.
Health Care
Finance
Administration
October 2003
HCFA
Former name for CMS, (see CMS).
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Health Insurance
Portability and
Accountability
Act of 1996
HIPAA
Federal law that gives the Department of Health and Human
Services (DHHS) the authority to mandate regulations that
govern privacy, security, and electronic transactions standards
for health care information.
Health Insurance
Prospective
Payment System
HIPPS
Billing codes used when submitting claims to the FI for
Medicare payment.
Hierarchy
The ordering of groups within the RUG-III Classification
system. A hierarchy begins with groups with the highest
resource use and descends to those groups with the lowest
resource use. The RUG-III Classification system has 8
hierarchical groups: Rehabilitation Plus Extensive Services,
Rehabilitation, Extensive Services, Special Care, Clinically
Complex, Impaired Cognition, Behavior Problems, and
Reduced Physical Functions.
Inactivation
A type of correction allowed under the SB-MDS Correction
Policy. When an invalid record has been accepted into the
database, a correction record is submitted with inactivation
selected as the type of correction.
Index
Maximizing
The process of RUG-III Classification where the RUG-III
category with the highest case mix index (CMI) is selected
from all of the possible groups in which a patient’s assessment
is classified.
Initial Feedback
Report
Internal
Assessment ID
October 2003
IFR
The first report generated by the CMS Data Collection System
after an SB-MDS data file is electronically submitted. This
report validates the file structure, provides the submission batch
ID, and indicates whether the file has been accepted or rejected.
If the file has been accepted, each record will go through the
edit process and be reported on the final validation report. If
the file is rejected, there will be no final validation report.
A sequential numeric identifier assigned to each record
submitted to the CMS Data Collection System.
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Invalid Record
As defined by the SB-MDS Correction Policy, a record that
was accepted into the CMS Data Collection System that should
not have been submitted. Invalid records are defined as: a test
record submitted as production, a record for an event that did
not occur, a record with the wrong patient identified, or the
wrong reason for assessment, or submission of an inappropriate
non-required record.
Login ID
A State-assigned facility identifier required to access the CMS
Data Collection System. This may or may not be the same as
the Facility ID.
Look Back
Period
A period of time in the past 7, 14, or 30 days from the
Assessment Reference Date that is used when completing
certain sections of the SB-MDS.
Medicaid
A Federal and State program subject to the provisions of
Title XIX of the Social Security Act that pays for specific kinds
of medical care and treatment for low-income families.
Medicare
A health insurance program administered by CMS under
provisions of Title XVIII of the Social Security Act for people
aged 65 and over, for those who have permanent kidney failure,
and for certain people with disabilities.
Medicare Part A: The part of Medicare that covers inpatient
hospital services and services furnished by other institutional
health care providers, such as nursing facilities, swing bed
programs, home health agencies, and hospices.
Medicare Part B: The part of Medicare that covers services of
doctors, suppliers of medical items and services, and various
types of outpatient services.
Medicare Data
Communications
Network
Minimum Data
Set
October 2003
MDCN
A secure dial-up connection through the AT&T Global
Network that is used to transmit SB-MDS data to the national
repository. A user ID and password is issued and maintained
by the MDCN Help Desk for each person who requires access
to the CMS SB-MDS intranet through this network.
MDS
A core set of screening, clinical, and functional status elements,
including common definitions and coding categories that forms
the foundation of the comprehensive assessment for all
residents of long-term care facilities certified to participate in
Medicare and Medicaid.
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Nursing Facility
NF
A facility which primarily provides to residents skilled nursing
care and related services for the rehabilitation of injured,
disabled, or sick persons, or on a regular basis, health related
care services above the level of custodial care to other than
mentally retarded individuals.
The time period, ending with the Assessment Reference Date,
which is used by all staff for gathering information for an
SB-MDS assessment.
Observation
Period
Omnibus Budget
Reconciliation
Act of 1987
OBRA ‘87
Law that enacted reforms in nursing facility care and provides
the statutory authority for the MDS. The goal is to ensure that
residents of nursing facilities receive quality care that will help
them to attain or maintain the highest practicable, physical,
mental, and psychosocial well-being.
Other Medicare
Required
Assessment
OMRA
An assessment required when a Medicare Part A patient that
was in a RUG-III Rehabilitation Plus Extensive Services or
Rehabilitation Classification, continues to require skilled care
after all therapy is discontinued. This assessment is to be done
8-10 days after the cessation of therapies in order to re-calculate
the RUG Classification from a therapy RUG to a non-therapy
group.
Other State
Required
Assessment
OSRA
A specific assessment required by a state in addition to
assessments required by OBRA regulation or for Medicare.
These assessments are defined by State regulations and are
usually used for State Medicaid reimbursement systems.
Peer Review
Organization
PRO
See QIO – Quality Improvement Organization
Post Acute Care
PAC
Refers to patients who are admitted to a facility following an
acute care hospitalization. Their stay is usually of short
duration, about 30 days or less.
Program
Memorandums
Official agency transmittals used for communicating reminder
items, request for action or information of a one time only, nonrecurring nature. Program Memos can be found at the following
web site:
http://www.cms.hhs.gov/manuals/memos/comm_
date_dsc.asp
October 2003
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Transmittal pages summarize the instructions to providers,
emphasizing what has been changed, added or clarified. They
provide background information that would be useful in
implementing the instructions. Program Transmittals can be
found at the following web site:
Program
Transmittals
http://www.cms.hhs.gov/manuals/transmittals/
comm_date_dsc.asp
Prospective
Payment System
PPS
A payment system, developed for Medicare skilled nursing
facilities and swing bed hospitals, that pays facilities an allinclusive rate for all Medicare Part A beneficiary services.
Payment is determined by a case mix classification system that
categorizes patients by the type and intensity of resources used.
Those assessments required by Medicare Prospective Payment
Regulations for patients in a Medicare Part A stay. Each
Medicare assessment is classified into a RUG-III group based
on the clinical resource needs as recorded on the SB-MDS
assessment and is used to determine the Medicare
reimbursement rate. PPS assessments are: 5-Day, 14-Day,
30-Day, 60-Day, 90-Day, OMRA and Return/Readmission.
PPS
Assessments
Quality
Improvement and
Evaluation
System
QIES
The umbrella system that encompasses the MDS and SB-MDS
system as well as other systems for survey and certification, and
home health providers.
Quality
Improvement
Organization
QIO
A program administered by CMS that is designed to monitor
and improve utilization and quality of care for Medicare
beneficiaries. The program consists of a national network of 53
QIOs (formerly known as Peer Review Organizations or PRO)
responsible for each U.S. territory and the District of Columbia.
Their mission is to ensure the quality, effectiveness, efficiency,
and economy of healthcare services provided to Medicare
beneficiaries.
Record Type
A code submitted in the SB-MDS and tracking records used to
identify certain combinations of reasons for assessment.
Reentry
When a patient returns to a facility following a temporary
discharge (return anticipated).
October 2003
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Registered Nurse
Assessment
Coordinator
RNAC
An individual, licensed as a registered nurse by the State Board
of Nursing and employed by a nursing facility, who is
responsible for coordinating and certifying completion of the
resident assessment.
Resident
Assessment
Validation and
ENtry System for
Swing-Beds
RAVEN-SB
Data entry software supplied by CMS for swing-bed hospitals
used to enter SB-MDS assessment data.
The measure of the number of minutes of care used to develop
the classification system. Direct and indirect time is obtained
from RNs, LPNs, nursing assistants, physical, occupational and
speech therapists, social workers, and activity staff. An index
score is created based on the amount of staff time, weighted by
staff salary and benefits.
Resource Use
Resource
Utilization
Group,
Version III
RUG-III
SB-MDS
Completion Date
Skilled Nursing
Facility
Submission
Requirement
October 2003
A category-based classification system in which nursing facility
residents and swing bed patients classify into one of 53 or 44
or 34 RUG-III groups. Patients in each group utilize similar
quantities and patterns of resource. Assignment of a resident to
a RUG-III group is based on certain item responses on the SBMDS. Medicare uses the 53-group classification.
The date at which the RN assessment coordinator indicates that
all portions of the SB-MDS have been completed. For SB-MDS,
this is the date at Item 45b.
SNF
A facility which primarily provides to residents skilled nursing
care and related services for the rehabilitation of injured,
disabled, or sick persons, or on a regular basis, health related
care services above the level of custodial care to other than
mentally retarded individuals.
SUB_REQ
A field in the SB-MDS electronic record that identifies the
authority for data collection. CMS has authority to collect
assessments for all patients (regardless of their payer source)
who reside in Medicare- and/or Medicaid- certified units.
States may or may not have regulatory authority to collect
assessments for patients in non-certified units.
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Swing-Bed MDS
System Of
Records
SB-MDS
MDS assessments completed by swing-bed hospitals for
Medicare Prospective Payment.
SOR
Standards for collection and processing of personal information
as defined by the Privacy Act of 1974.
Target Date
A term used in CMS system-generated reports. This date is the
Assessment Reference Date for an assessment, date of
discharge for a discharge, and date of reentry for a reentry.
Transfer
When a patient leaves a swing bed, either temporarily or
permanently, and goes to another health care setting.
Validation
Report
See FVR or Final Validation Report.
October 2003
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Common Acronyms
ADLs
AHEs
ARD
BBA-97
BBRA
BEA
BIPA
BLS
CBSA
CAH
CCA
CFR
CLIA
CMS
COTA
CPI
CPI-U
CPT
CR
CWF
DME
DMERC
DOS
ECI
ESRD
FI
FMR
FR
FY
GME
HCFA
HCFA Pub. 10
HCFA Pub. 12
HCFA Pub. 7
HCFA Pub.13-3
HCPCS
HIPPS
ICD-9-CM
October 2003
Activities of Daily Living
Average Hourly Earnings
Assessment Reference Date
Balanced Budget Act of 1997
Medicare, Medicaid and SCHIP Balanced Budget
Refinement Act of 1999
(U.S) Bureau of Economic Analysis
Medicare, Medicaid, and SCHIP Benefits Improvement
and Protection Act (BIPA) of 2000
(U.S.) Bureau of Labor Statistics
Core-Based Statistical Area
Critical Access Hospital
Clinical Change Assessment
Code of Federal Regulations
Clinical Laboratory Improvements Amendments (1998)
Centers for Medicare and Medicaid Services
Certified Occupational Therapist Assistant
Consumer Price Index
Consumer Price Index for All Urban Consumers
(Physicians) Current Procedural Terminology
Change Request
Common Working File
Durable Medical Equipment
Durable Medical Equipment Regional Carrier
Dates of Service
Employment Cost Index
End Stage Renal Disease
Fiscal Intermediary
Focused Medial Review
Final Rule
Fiscal Year
Graduate Medical Education
Health Care Financing Administration
Hospital Manual
Skilled Nursing Facility Manual
State Operations Manual
Medicare Intermediary Manual, Claims Process, Part 3
Healthcare Common Procedure Coding System
Health Insurance Prospective Payment System (Rate
Codes)
International Classification of Diseases, Ninth Edition,
Clinical Modification Revision
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IFC
IOM
LOA
MDS
MEDPAR
MIM
MPAF
MRI
MSA
NCS
NDM
NECMA
NSC
OBRA ‘87
OMB
OMRA
OT
PCE
PIM
PM
POS
PPI
PPS
PRM
PT
PTA
Pub. 100-1
Pub. 100-2
Pub. 100-4
Pub. 100-7
Pub. 100-8
Pub. 100-12
QIO
RAI
RUG
SB-MDS
SB-PPS
SNF
SNF PPS
SLP (or ST)
STM
October 2003
Interim Final Rule with Comment
Internet-Only Manual
Leave of Absence
Minimum Data Set
Medicare Provider Analysis and Review (File)
Medicare Intermediary Manual
Medicare Prospective Payment System Assessment
Form
Magnetic Resonance Imaging
Metropolitan Statistical Area
National Supplier Clearinghouse
National Data Mover
New England Country Metropolitan Area
National Supplier Clearinghouse
Omnibus Budget Reconciliation Act of 1987
Office of Management and Budget
Other Medicare Required Assessment
Occupational Therapy/Therapist
Personal Care Expenditures
Program Integrity Manual
Program Memorandum
Point of Service
Producer Price Index
Prospective Payment System
Provider Reimbursement Manual
Physical Therapy/Therapist
Physical Therapist Assistant
Medicare General Information, Eligibility, and
Entitlement IOM
Medicare Benefit IOM
Medicare Claims Processing IOM
Medicare State Operations IOM
Medicare Program Integrity IOM
State Medicaid IOM
Quality Improvement Organization
Resident Assessment Instrument
Resource Utilization Group
Swing Bed Minimum Data Set
Swing Bed Prospective Payment System
Skilled Nursing Facility
Skilled Nursing Facility Prospective Payment System
Speech Language Pathology Services
Staff Time Measure
Page A-12
CMS’s SB Version 1.0 Manual
APPENDIX B
CONTACT INFORMATION
October 2003
Page B-1
CMS’s SB Version 1.0 Manual
1. The following Centers for Medicare and Medicaid Services (CMS) website should be
monitored for swing bed updates.
www.cms.gov/providers/snfpps/snfpps_swingbed.asp
2. Iowa Foundation for Medical Care (IFMC) is the contractor responsible for SB-MDS
data submission.
Help Desk:
1-800-339-9313
Email Address: [email protected]
3.
For SB-MDS Prospective Payment System questions or billing questions, contact your
Fiscal Intermediary.
4.
For questions on completion of MDS items, contact your State RAI Coordinator. Refer
to Pages B-3 thru B-5.
October 2003
Page B-2
CMS’s SB Version 1.0 Manual
STATE RAI COORDINATORS
MDS RAI
Coordinator
STATE
PHONE #
E-mail Address
AK
Diana Parks
907-334-2491
[email protected]
AL
Danna Daughtry
334-206-7929
[email protected]
AR
Sue Gaines
Twyla Moore, RN
501-682-8853
501-661-2201
[email protected]
[email protected]
AZ
Sylvia Balistreri
602-364-3878
[email protected]
CA
Virginia E. Aquino, RN
916-552-8961
[email protected]
CO
Betty Keen, RN
303-692-2894
[email protected]
CT
Lori Griffin
Alternate: Angela White
860-509-7400
[email protected]
[email protected]
DC
Mary Sklenar
202-442-4759
[email protected]
DE
Kim Paugh
302-424-6377
[email protected]
FL
Claire Hoagland
727-552-1133 x179
[email protected]
GA
JoAnne Hanson
404-657-5854
[email protected]
HI
Janice Nakama, RN
Alternate: Sharon
Matsubara
808-692-7420
[email protected]
[email protected]
IA
Karen Zaabel
515-242-5991
[email protected]
ID
Kathleen Mace
208-334-6626
[email protected]
IL
Rhonda Imhoff, RN
217-785-5132
[email protected]
IN
Kimberly Honeycutt, RN
317-233-4719
[email protected]
KS
Lynn Searles
Vera Van Bruggen, RN
785-291-3352
785-296-1246
[email protected]
[email protected]
KY
Ruth Rogers
502-564-2800 x4052
[email protected]
LA
Evelyn Enclarde
225-342-4855
[email protected]
October 2003
Page B-3
CMS’s SB Version 1.0 Manual
MDS RAI
Coordinator
STATE
PHONE #
E-mail Address
MA
Paul Di Natale
617-753-8222
[email protected]
MD
Lynn Condon
410-402-8102
[email protected]
ME
Louis T. Dorogi
Carole Kus, RN
207-624-5443
207-287-3933
[email protected]
[email protected]
MI
Mary Hess
989-732-8837
[email protected]
MN
Susan Pedro
651-215-8749
[email protected]
MO
Mike DeClue, RN
573-751-6308
[email protected]
MS
Lynn Cox
601-576-7316
[email protected]
MT
Kathleen Moran
406-444-3459
Kmoran@ mt.gov
NC
Cindy Deporter
919-733-7461
[email protected]
ND
Patricia Rotenberger
701-328-2364
[email protected]
NE
Dan Taylor
402-471-0535
[email protected]
NH
Susan Grimes
603-271-3024
[email protected]
NJ
Beth Bell, RN
609-633-8981
[email protected]
NM
Sandra Cole
Connie Armijo
505-476-9037
505-476-9056
[email protected]
[email protected]
NV
Juanita Ball, RN
775-687-4475 x235
[email protected]
NY
Kristin Armstrong-Ross
518-478-1124
[email protected]
OH
Patsy Strouse
614-955-0744
[email protected]
OK
Sharon Warlick
405-271-5278
[email protected]
OR
Mary B. Borts
503-691-6587
[email protected]
PA
Susan Williamson
Chris Kelly
717-787-1816
[email protected]
[email protected]
PR
Lourdes Cruz
787-782-0553 x2252
[email protected]
RI
Madeline Vincent, RN
401-277-2566
[email protected]
SC
Sara S. Granger
803-545-4205
[email protected]
SD
Peggy Williams
605-773-3356
[email protected]
TN
Leatrice Coffin
615-741-8002
[email protected]
TX
Angela Chisholm, RN
512-438-2003
[email protected]
October 2003
Page B-4
CMS’s SB Version 1.0 Manual
MDS RAI
Coordinator
STATE
PHONE #
E-mail Address
UT
Carolyn Reese, RN
801-538-6599
[email protected]
VA
Judy Wilhide
804-367-2103
[email protected]
VT
Laine Lucenti
802-241-2345
[email protected]
WA
Marjorie Ray
360-725-2487
[email protected]
WI
Billie March
608-266-7188
[email protected]
WV
Emily Keefer
Beverly Hissom
304-558-1712
304-558-4145
[email protected]
[email protected]
WY
Linda Brown
307-777-7123
[email protected]
NOTE: Not included in this manual is a list of the State MDS Automation Coordinators and
the State Medicaid MDS Coordinators. These lists will be posted on the CMS web site at:
http://www.cms.hhs.gov/medicaid/mds20.
October 2003
Page B-5
CMS’s SB Version 1.0 Manual
APPENDIX C
CPS SCORING RULES
October 2003
Page C-1
CMS’s SB Version 1.0 Manual
CPS SCORING RULES
All Residents
Impairment Count
(Number of the following):
- Decision Making: Not Independent=1-2
- Understood: Not Independent=1-3
- Short-Term Memory: Not OK=1
No (0)
Coma?
Yes (1)
Severe Impairment Count
(Number of the following):
- Decision Making: Mod. Impaired=2
- Understood: Sometimes/Never=2-3
0
Impairment
Count?
Severely Impaired (3)
DecisionMaking
Not
Severely
Impaired
(0-2)
No
(0-3)
2 or 3
Total
Dependent
Eating?
Yes
(4)
1
0
Severe
Impairment
Count
2
1
(0)
Average
Intact
mini mental
24.9
score in
field trial where 30 is
best and 0 is worst
(1)
Boarderline
Intact
(2)
Mild
Impairment
(3)
Moderate
Impairment
(4)
Mod. Severe
Impairment
(5)
Severe
Impairment
(6)
Very Severe
Impairment
21.9
19.2
15.4
6.9
5.1
0.4
Reference: Morris, JN, Fries, BF, et al MDS Performance Scale. J. Gerontology 1994; 49, m174-m182
The CPS scale is used in the RUG-III Classification system to measure a patient’s cognitive
performance. The RUG-III Classification system uses the CPS scale to identify patients who
demonstrate moderate to severe cognitive impairment as a basis for classification in the Impaired
Cognition RUG-III groups.
October 2003
Page C-2
CMS’s SB Version 1.0 Manual
Index for the Swing Bed Manual
Acronyms.......................................................................................................................Appendix A
Active Record .............................................................................................................................. 4-5
Activities of Daily Living:
Calculation of Total ADL Score for RUG-III Classification ............................................. 5-9
Self-Performance .............................................................................................................. 3-31
Scoring ADL Self-Performance........................................................................................ 3-43
Support Provided .............................................................................................................. 3-44
Admission Date.......................................................................................................................... 3-16
Admission/Discharge Status Codes ........................................................................................... 3-17
Admitted From........................................................................................................................... 3-19
Appliances and Programs:
Scheduled Toileting Program ........................................................................................... 3-49
Bladder Retraining Program ............................................................................................. 3-49
Assessment:
Information ......................................................................................................................... 1-5
Participation in.................................................................................................................... 1-5
Reference Date.................................................................................................................. 3-10
Readmission/ Return........................................................................................................... 2-3
Schedule.............................................................................................................................. 2-5
Timing................................................................................................................................. 2-2
Type .................................................................................................................................... 2-2
Background Information.............................................................................................................. 1-1
Behavioral Symptoms................................................................................................................ 3-28
Birth Date..................................................................................................................................... 3-6
Case Mix Group......................................................................................................................... 3-87
Clinical Change in Status Assessment:
Definition ............................................................................................................................ 2-3
Guidelines for Determination ............................................................................................. 2-4
Timing................................................................................................................................. 2-3
Coding Conventions SB-MDS..................................................................................................... 3-5
Cognitive Performance Scale......................................................................................... Appendix C
Cognitive Skills.......................................................................................................................... 3-22
Comatose.................................................................................................................................... 3-20
Communication:
Direct Care Staff ................................................................................................................. 1-8
Family ................................................................................................................................. 1-8
Licensed Professionals........................................................................................................ 1-8
Physician ............................................................................................................................. 1-8
Patient ................................................................................................................................. 1-7
October 2003
Index Page 1
CMS’s SB Version 1.0 Manual
Computer Requirements .............................................................................................................. 4-1
Coordinator, RN........................................................................................................................... 1-1
Copy, Paper................................................................................................................................ 1-10
Correction Counter .................................................................................................................... 3-13
Correction Record........................................................................................................................ 4-5
Corrections of the SB-MDS......................................................................................................... 4-4
Correction Policy Flowchart............................................................................................. 4-11
Default Rate ................................................................................................................................. 2-7
Discharge Date........................................................................................................................... 3-19
Discharge Status ........................................................................................................................ 3-19
Discharge Tracking Information.................................................................................................. 2-8
Discharged-Return Anticipated ........................................................................................ 2-10
Discharged-Return Not Anticipated ................................................................................. 2-10
SB-MDS Discharge and Reentry Flowchart..................................................................... 2-12
Diseases:
Aphasia ............................................................................................................................. 3-51
Cerebral Palsy ................................................................................................................... 3-51
Diabetes Mellitus .............................................................................................................. 3-51
Hemiplegia/hemiparesis.................................................................................................... 3-51
Multiple Sclerosis ............................................................................................................. 3-51
Quadriplegia...................................................................................................................... 3-51
Documentation Requirements...................................................................................................... 1-9
Electronic Signature................................................................................................................... 1-10
Enteral Intake ............................................................................................................................. 3-56
Facility Provider Numbers........................................................................................................... 3-9
Factors Impacting the Assessment Schedule:
Combining Assessments ..................................................................................................... 2-6
Default Rate ........................................................................................................................ 2-7
Early Assessment ................................................................................................................ 2-6
Late or Missed Assessment................................................................................................. 2-6
Midnight Rule ..................................................................................................................... 2-7
Non-Compliance with the Assessment Schedule ............................................................... 2-7
Patient Expires or Transfers................................................................................................ 2-6
Physician Hold .................................................................................................................... 2-6
Family, Communication as SB-MDS source............................................................................... 1-8
Federal Requirements .................................................................................................................. 1-1
Foot Care Problems.................................................................................................................... 3-66
Form, Mandated......................................................................................................................... 1-11
October 2003
Index Page 2
CMS’s SB Version 1.0 Manual
Gender.......................................................................................................................................... 3-6
Glossary .........................................................................................................................Appendix A
Grace Days................................................................................................................................... 2-1
Group Therapy ........................................................................................................................... 3-74
Help Desk....................................................................................................................... Appendix B
Hierarchical Classification........................................................................................................... 5-8
HIPPS Codes.............................................................................................................................. 3-87
HIPPS Modifiers/Assessment Type Indicators................................................................... 5-6
Inactivation Record...................................................................................................................... 4-5
Index Maximizing Classification................................................................................................. 5-8
Indicators of Depression ............................................................................................................ 3-24
Infections:
Pneumonia......................................................................................................................... 3-53
Septicemia......................................................................................................................... 3-53
Injections.................................................................................................................................... 3-68
Key Fields .................................................................................................................................... 4-4
Legal and Submission Authority ................................................................................................. 4-1
Lesions ....................................................................................................................................... 3-64
Licensed Professionals, as SB-MDS source ................................................................................ 1-8
Maintenance of Records ............................................................................................................ 1-10
Making Self Understood ............................................................................................................ 3-24
Mandated Assessment Form ...................................................................................................... 1-11
Marital Status............................................................................................................................... 3-6
Medicaid Number ........................................................................................................................ 3-9
Medicare Number ........................................................................................................................ 3-8
Midnight Rule .............................................................................................................................. 2-7
Minimum Data Set-Swing Bed:
Familiarizing Self with SB-MDS ....................................................................................... 3-3
Form.................................................................................................................................. 1-11
How to Use Item-by-Item Guide ........................................................................................ 3-3
Non-Key Fields............................................................................................................................ 4-5
Nursing Rehabilitation/Restorative Care ................................................................................... 3-76
Nutritional Approaches:
Feeding Tube .................................................................................................................... 3-56
Parenteral/IV..................................................................................................................... 3-55
October 2003
Index Page 3
CMS’s SB Version 1.0 Manual
Observation of Patient as SB-MDS Source ................................................................................. 1-7
Occupational Therapy................................................................................................................ 3-71
OMRA Assessment...................................................................................................................... 2-3
Ordered Therapies...................................................................................................................... 3-84
Original Record............................................................................................................................ 4-5
Patient/Resident, Name................................................................................................................ 3-6
Parenteral/Enteral Intake............................................................................................................ 3-56
Payment Provisions SNF PPS...................................................................................................... 5-2
Physical Therapy........................................................................................................................ 3-71
Physician:
Orders................................................................................................................................ 3-82
Participation in SB-MDS .................................................................................................... 1-8
Visits ................................................................................................................................. 3-82
PPS Scheduled Assessments........................................................................................................ 2-2
Pressure Ulcers .......................................................................................................................... 3-61
Prior Acute Care Stay ................................................................................................................ 3-16
Privacy ......................................................................................................................................... 1-2
Contractual Agreements ..................................................................................................... 1-2
Privacy Act Statement ........................................................................................................ 1-4
Problem Conditions:
Dehydrated........................................................................................................................ 3-53
Delusions .......................................................................................................................... 3-54
Fever ................................................................................................................................. 3-54
Hallucinations ................................................................................................................... 3-54
Internal Bleeding............................................................................................................... 3-54
Vomiting ........................................................................................................................... 3-54
Production Batch.......................................................................................................................... 4-4
Race/Ethnicity.............................................................................................................................. 3-7
Readmission Assessment ............................................................................................................. 2-3
Reasons for Assessment............................................................................................................. 3-12
Assessment Codes Used for the Medicare Prospective Payment System ........................ 3-13
Assessment Needed for Other Reasons ............................................................................ 3-16
Clinical Change Assessment............................................................................................. 3-15
OMRA Assessment........................................................................................................... 3-15
Primary Reasons for Assessment...................................................................................... 3-12
State-Required Assessment............................................................................................... 3-16
Record:
Active Record ..................................................................................................................... 4-5
Correction Record............................................................................................................... 4-5
Inactivation Record............................................................................................................. 4-5
Maintenance of SB-MDS in Record ................................................................................. 1-10
Original Record................................................................................................................... 4-5
October 2003
Index Page 4
CMS’s SB Version 1.0 Manual
Production Batch................................................................................................................. 4-4
Record as Source of Information ........................................................................................ 1-9
Test Batch ........................................................................................................................... 4-4
Unauthorized Record .......................................................................................................... 4-4
Reentry Date .............................................................................................................................. 3-20
Reentry, Tracking Information .................................................................................................... 2-8
Regulatory Authority ................................................................................................................... 1-1
Rehabilitation/Restorative Nursing............................................................................................ 3-76
Reproduction of SB-MDS.......................................................................................................... 1-10
Respiratory Therapy .................................................................................................................. 3-71
Resource Utilization Groups (RUG-III) ...................................................................................... 5-3
Hierarchical Classification.................................................................................................. 5-8
Index Maximizing Classification........................................................................................ 5-8
Medical/Nursing:
Behavior Problems....................................................................................................... 5-25
Clinically Complex ...................................................................................................... 5-19
Extensive Services ....................................................................................................... 5-16
Impaired Cognition ...................................................................................................... 5-22
Reduced Physical Function.......................................................................................... 5-27
Special Care ................................................................................................................. 5-17
Rehabilitation:
High Intensity Criteria ................................................................................................. 5-14
Low Intensity Criteria.................................................................................................. 5-15
Medium Intensity Criteria............................................................................................ 5-14
Ultra High Intensity Criteria ........................................................................................ 5-13
Very High Intensity Criteria ........................................................................................ 5-13
Rehabilitation Plus Extensive Services............................................................................. 5-11
Return/Readmission Assessment ................................................................................................. 2-3
RN Coordinator............................................................................................................................ 1-1
RUG-III Calculation Worksheet .................................................................................................. 5-7
SB-MDS:
Coding Conventions ........................................................................................................... 3-5
Forms ................................................................................................................................ 1-11
Item-by-Item Guide ............................................................................................................ 3-1
Short-Term Memory .................................................................................................................. 3-21
Signatures:
Person Completing Assessment........................................................................................ 3-88
Skin:
Problems ........................................................................................................................... 3-64
Treatments......................................................................................................................... 3-65
SNF PPS:
Coverage Guidelines........................................................................................................... 5-1
Medicare Assessment Schedule.......................................................................................... 5-1
Payment Provisions............................................................................................................. 5-2
Social Security Number ............................................................................................................... 3-8
October 2003
Index Page 5
CMS’s SB Version 1.0 Manual
Sources of Information, Completion of SB-MDS ....................................................................... 1-5
Speech Language Pathology and Audiology ............................................................................. 3-71
State RAI Coordinators.................................................................................................. Appendix B
Submission Authority .................................................................................................................. 4-1
Submission of SB-MDS Data ...................................................................................................... 4-1
Submission File Structure ............................................................................................................ 4-3
Body Record ....................................................................................................................... 4-3
Header Record .................................................................................................................... 4-3
SUB_REQ........................................................................................................................... 4-3
Trailer Record ..................................................................................................................... 4-3
Submission Rules:
Date Sequencing Rules ....................................................................................................... 4-2
Timing Rules....................................................................................................................... 4-2
Test Batch .................................................................................................................................... 4-4
Test File Deletion Request Worksheet ........................................................................................ 4-7
Therapies, Ordered..................................................................................................................... 3-84
Time Awake............................................................................................................................... 3-67
Timing and Types of Corrections:
Records in Error Accepted Into the National Database...................................................... 4-6
Records in Error Not Accepted Into the National Database............................................... 4-6
Toileting Programs .................................................................................................................... 3-49
Treatments, Special Procedures and Programs:
Chemotherapy ................................................................................................................... 3-69
Dialysis ............................................................................................................................. 3-69
IV Medications ................................................................................................................. 3-70
Oxygen Therapy................................................................................................................ 3-70
Radiation ........................................................................................................................... 3-70
Suctioning ......................................................................................................................... 3-70
Tracheostomy Care ........................................................................................................... 3-70
Transfusions...................................................................................................................... 3-70
Ventilator or Respirator .................................................................................................... 3-70
Ulcers:
Cause................................................................................................................................. 3-59
Unauthorized Record ................................................................................................................... 4-4
Unauthorized Record Deletion Request Worksheet ........................................................... 4-8
Understood, Making Self ........................................................................................................... 3-24
Weight Loss ............................................................................................................................... 3-54
Zip Code....................................................................................................................................... 3-7
October 2003
Index Page 6
| File Type | application/pdf |
| File Title | LONG TERM CARE FACILITY |
| Author | Administrator |
| File Modified | 2005-11-23 |
| File Created | 2005-11-23 |