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 we will be sharing information on optimal MDS coding, based on the regulations and our findings.
In continuing our discussion with the Minimum Data Set (MDS) Accuracy Blog, we are going to highlight Section C which includes the Brief Interview for Mental Status (BIMS). LWCI consultants complete a variety of audits. Some of the most frequent miscoding is seen within Section C of the MDS.
Importance of a Timely Interview
The BIMS score is derived from Section C, items C0200-C0500 of the MDS. According to the regulations outlined in the Resident Assessment Instrument (RAI) manual, the BIMS should be completed within the assessment reference period. The scores are entered into the MDS in Section C. The person entering the scores should sign the MDS in item Z0400. The RAI Manual recommends that the interview be administered on the Assessment Reference Date (ARD) or one day prior. A very common miscoding error is when the signature in MDS Section Z0400 is dated after the ARD. If Section Z0400 is signed late, which would be after the ARD, and the documentation does not provide verification of when the actual interview took place, the scoring for cognition is impacted. A change in the scoring of cognition can ultimately affect the speech-language pathology (SLP) HIPPS component. It is important to note that Medicare Administrative Contractors (MACS) expect to see item Z0400 signed on the day the interview is completed. Another key factor and potential miss occur when an Interim Performance Assessment (IPA) is completed. The BIMS needs to be performed and coded accurately if an IPA is completed.
When the BIMS is not completed in a timely manner and the medical record does not provide any evidence of a timely interview, the resident must be scored as cognitively intact regardless of the resident’s cognitive status. The score of 15, which is used to indicate that the resident is cognitively intact, will have an impact on the SLP case-mix group. If the resident actually has a cognitive impairment, the late date will nullify proper assignment to the SLP case-mix group and negatively affect reimbursement.
Score Accurately to Avoid Mishaps
Mishaps occur when items are not scored correctly. Let’s review a few more examples. If the resident does not answer a question, code it as incorrect. If the resident refuses to answer or gives non-sensical answers to four or more questions, code the interview as incomplete and the Staff Assessment would be the next appropriate step. Code 99 if the interview is not able to be completed. Do not score as a 0 if the interview is not completed. Entering 00 is a legitimate value for item C0500 and indicates that the interview was completed and supports the resident has cognitive deficits. Miscoding of C0500 can be costly.
The information in the table below can be found on page 151 of the Resident Assessment Instrument (RAI) Manual. https://downloads.cms.gov/files/mds-3.0-rai-manual-v1.17.1_october_2019.pdf
Who Is Completing the Interview?
An effort should be made to conduct the interview for every resident. Depending upon who is administering the interview and when the interview is completed could impact the ability to draw a clear picture of the resident’s actual cognitive status. Consider the timing of the BIMS interview based on the residents’ deficits. For example, a resident with dementia who demonstrates the “Sundowner’s” condition may be appropriate to interview later in the day so that the interviewer can fully capture the resident’s deficits versus administering the interview in the morning when it might be more convenient for the interviewer. The Social Service representative typically completes the BIMS. Another consideration may be to have the Speech Language Pathologist (SLP) conduct the interview. A SLP may identify more cognitive impairments based on the SLP’s knowledge, educational background, skill set and discernment while asking the questions. Whoever administers the interview must receive training in the BIMS interview process and follow the RAI-specific requirements for the interview. Knowing how long to wait for a response, how not to prompt a resident, and knowing the time and place to administer the exam can impact the score.
Staff Assessment Guidance
When would it be appropriate to administer the staff assessment instead of the interview? The resident interview should be administered unless the resident is coded as rarely/never understood in item B0700 of the MDS. If the resident is rarely or never understood, it is still the interviewer’s choice as to whether the interview should be conducted, or the Staff Assessment for Mental Status (items C0700-C1000) be completed. The interview should be attempted timely and then if the interview is not successful, the staff assessment is the next appropriate response.
CMS has also allowed the completion of the staff assessment if the resident is unexpectedly discharged prior to completing the BIMS, for example, the resident is discharged to the hospital. Do not dash the MDS but ensure the staff assessment is completed. The facility cannot choose to do the staff assessment for a resident who classifies as a resident who should have been interviewed but the interview was missed and there was no unplanned discharge.
What if Neither is Completed?
The Centers for Medicare & Medicaid Services (CMS) PDPM Frequently Asked Questions (FAQ) number 5.4 explains how the patient is classified under the Patient-Driven Payment Model (PDPM) when neither the BIMS nor the staff assessment is completed to determine the cognitive level. If neither are completed, then a resident will be classified under PDPM as if the patient were “cognitively intact.” Therefore, even if the patient has a cognitive impairment, but neither the BIMS nor the staff Assessment was done, the cognitive impairment is not considered a part of the patient’s PDPM classification. It is allowable to complete an IPA to reclassify the resident should a situation such as this arise.
To summarize the focus areas related to scoring the MDS Section C:
– Section Z needs to be signed promptly (the date the section is completed)
– The BIMS interview needs to be completed appropriately and prior to the ARD
– Missed interviews consider the resident as “cognitively intact” regardless of actual status
– Miscoding of a cognitive impairment will impact the SLP case-mix group and negatively affect reimbursement.
Do you know if your team is having difficultly completing timely interviews or coding the MDS correctly? LW Consulting, Inc. can provide training, education, or conduct a sampling of audits to paint a clearer picture for you.
