In this Minimum Data Set (MDS) Accuracy Blog, we will highlight Sections and items in the MDS to review key misses that the experts at LW Consulting, Inc. (LWCI) have encountered. At LWCI, we thrive in partnering with clients to complete audits or provide consultative services to support concerns. As the experts at LWCI conduct audits, we identify commonalities with coding. Throughout this blog series we will be sharing information on optimal MDS coding, based on the regulations and our findings.
This blog highlights Section I which relates to the primary diagnosis and other active diagnoses. Items in this MDS section are intended to report co-morbidities related to the resident’s current functional status, cognition level, or mood. Codes documented in Section I relate directly to the patient characteristics and the reason the resident needs skilled care under Medicare Part A. When coding Section I correctly, an auditor should have a definitive picture of the resident’s health and understand why skilled services are necessary to improve the resident’s function and prevent mortality. The care plans should also have a direct correlation to the illnesses or injuries that are highlighted in Section I.
The coding in Section I is considered in the calculation for each of the five components of the Patient-Driven Payment Model, or PDPM. Always check the CMS ICD-10 Diagnosis Codes mapping for updates.
For the PT and OT components, the primary diagnosis coded in item I0020B must map to one of the ten PDPM Clinical Categories. For the SLP Component, the primary diagnosis in item I0020B could map to an Acute Neurologic SLP Clinical Category. The presence of SLP-Related Comorbidities is coded in the MDS items I4300, Aphasia; I4500, CVA, TIA, or Stroke; I4900 Hemiplegia or Hemiparesis; I5500, Traumatic Brain Injury or TBI. For active diagnoses listed in I8000, check if the corresponding ICD-10-CM codes map to comorbidities in the PDPM SLP Component using the CMS mapping tool. The Nursing and NTA categories are predicated upon comorbidities and conditions coded on the MDS and supported by documentation.
What Supports an Active Diagnosis?
There are several items that auditors identify as issues with Section I related to the requirements outlined in the Resident Assessment Instrument (RAI) Manual. The first criteria is that the physician must document and identify the active diagnoses. There is a 60-day lookback period for the diagnoses to be identified and documented by the physician. The next step is to determine whether the diagnosis is active or inactive. A common trend among facilities is coding diagnoses on the MDS that are resolved or list diagnoses from a previous SNF stay that are no longer active for the resident. Inactive diagnoses should not be coded if there is not documentation of an active issue affecting the resident’s function or plan of care in the current seven-day lookback period.
Auditors are trained to scrutinize the documentation to determine if active diagnoses are supported within the medical record. Refer to the list below for documentation auditors review to support a resident’s active diagnosis:
– Hospital records or transfer documents/transfer summaries
– Physician progress notes
– A recent history and physical
– Any discharge summaries
– Nursing assessment documentation
– Care plans
– Medication or treatment records
– Lab work or other diagnostic testing results
– Physician orders
– Other pertinent consults/specialty consults
Frequently, facilities use a diagnosis list to support the diagnoses coded on the MDS. If a diagnosis list is used, only the diagnoses confirmed by the physician or other authorized personnel are permitted to be coded on the MDS. The list, without confirmation by the physician, is insufficient. If the physician signs the diagnosis list, make sure it is also dated within the lookback period.
Common Mistakes in Section I
Section I is a critical piece of the MDS that is directly tied to payment. Accuracy in this section is imperative. Here are some common miscoding examples discovered by auditors at LWCI:
– Primary diagnosis is for a previous skilled nursing facility (SNF) stay
– Active diagnoses are not supported in the documentation and most likely are a resolved issue or from a previous SNF stay.
– Issues with lack of supporting physician documentation with the use of the COVID waiver as there are no hospital records or if there is no evidence the physician treated the resident
– Overuse of malnutrition with no supporting documentation to substantiate the NTA point. Although the dietician documentation may indicate the resident is at risk of malnutrition, the physician has not documented the diagnosis and without the physician documentation, it cannot be counted.
– The physician does not document a diagnosis and only a diagnosis list that is not signed and dated by the physician is used.
– No orders or treatment related to the diagnosis are evident.
– Check boxes on the MDS are checked, but there is no coding of the ICD-10 code in I8000. Respiratory Failure is an example. CMS is very specific about where codes need to be entered in the MDS to qualify for reimbursement.
– Morbid obesity in I8000 must be physician documented and the appropriate ICD-10 code reported may be listed in the NTA PDPM Mapping. Listing E66.9-Morbid obesity, unspecified is not a NTA comorbidity.
The above notations are just some of the most frequent miscoding LWCI has encountered. There are others that have been identified during audits. Facilities are still having issues with Section I regarding the provision of supportive documentation and identifying all of the codes that should be included in the MDS.
How Can LW Consulting, Inc. Help?
LWCI can review an audit sample to identify areas where you may be at risk. Our consultants are well versed in reviewing the data, identifying the trends, and examining the documentation to highlight such risk areas. Our Pre-Bill audit reviews allow for capture of miscoding prior to closing the MDS. Our turn-around time is quick to meet facility needs.
