MDS 3.0 Clinical Issues--tell CMS!!

[edhcinc]

hi.

hopefully, by now everyone is somewhat familiar with the proposed mds 3.0 (current version 1.00.2) and the accompanying rai manual.

attendees at last week's conference also learned the following:

***despite all that has been said and written (see the mds 3.0 rai manual november 2009, page m-4--"the pressure ulcer definitions incorporate those

recommended by the national pressure ulcer advisory panel (npuap)

and are recognizable by providers across settings.),

some "accurately" coded mds 3.0 stage ii and sdti will not match

the npuap and industry-accepted ulcer descriptions.

:hdvwl:

we again heard--"you can use the npuap guidelines in your facility clinical documentation . to code the mds accurately, follow the directions in the rai manual."

• stage ii
  
  

1. current status--npuap definition and on mds 3.0 form--(m00300b) "stage 2: partial thickness loss of dermis presenting as a shallow open ulcer with a red or ("or" should be omitted) pink wound bed, without slough. may also present as an intact or open/ruptured
   serum-filled blister."
   
   
2. new status--last sentence--"may also ...
   serum or blood-filled blister."
   
   

• sdti
  
  

1. current status--npuap definition, and on mds 3.0 rai manual page m-1
   
   6 --"purple or maroon localized area of discolored intact skin or
   blood-filled blister
   due to damage of underlying soft tissue from pressure and/or shear. the area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue."
   further description from npuap:
   
   
   "deep tissue injury may be difficult to detect in individuals with dark skin tones. evolution may include a thin blister over a dark wound bed. the wound may further evolve and become covered by thin eschar. evolution may be rapid exposing additional layers of tissue even with optimal treatment."
   
   
   
   
2. 
   new status--as in current, but remove "or
   blood-filled blister
   ..."
   
   

comments:

• this change, we were told, was made "for payment reasons", and was included in the version 1.002 data specs.
  
  

what could those reasons be?

• what are the clinical issues? why is this important? (sorry if this seems like a "lecture"; just painting a "picture")
  
  
  
  

1. a sdti is not a stage i or a stage ii ulcer. neither a stage i nor a stage ii involve damage to soft tissue. with mds 2.0, some sdti were coded as stage i. with mds 3.0, some sdti could be coded as stage ii.
   
   
2. a serum-filled blister indicates
   injury at the dermis layer
   . a blood-filled blister indicates
   injury of soft-tissue.
   
   
   
   
3. most stage ii ulcers show improvement and may heal within 2 to 4 weeks. most sdti's evolve rapidly and relentlessly reveal a stag ii/iv ulcer, despite optimal treatment--then gradually granulate and epithelialize over a 6 to ?12 month period.
   
   
   
   
4. if not coded at m0300g, we must find an easily understood, accurate, alternative method to code this active and serious medical condition--section i at i8000. per the coding guidelines, two codes are necessary to completely describe a pressure ulcer: a code from subcategory 707.0, pressure ulcer, to identify the site of the pressure ulcer, and a code from new subcategory 707.2. any
   unstageable
   pressure ulcer is coded as 707.25.
   
   
5. if we do not recognize, then code a sdti on the mds, we may "face the wrath" of the ombudsman, surveyors, resident/family, and lawyers when stage ii ulcers "deteriorate"/worsen and become stage iv's
   
   

• what about this scenario...you are giving testimony, when the judge, who has also been a nurse for 40 years, asks you--"as a professional nurse who knows the seriousness of the difference between these ulcer stages, why did you flagrantly disregard clinical standards of practice and deliberately misrepresent the ulcer on this mds?"
  :chair:
  "ummm...the manual told me to do it...um..." "and where is this manual?"
  
  
  
  

***section f--preferences for customary routine and activities interview must be completed

with every assessment.

no reason was given. (although "every assessment" could refer to obra assessments only, we cannot speculate)

if you

• have comments about these or any other mds 3.0 data items, or
  
  
• question the frequency and use of certain mds assessment types, or
  
• are seriously contemplating a "career move" away from mds work, or
  
  
• anticipate specific implementation issues, or
  
  
• need to speak up about other mds 3.0 related issues
  
  

please e-mail your concerns and comments to [email protected]

[lisalake]

Great post! I have already sent my comments to CMS (more than once). After attending the CMS Train-the Trainer conference in Baltimore, I am more convinced that this tool is a real mess if I ever saw one. While CMS and all their "experts" have lauded the fact over & over that 3.0 will solve the SDTI issue, and "back-staging", we still WILL NOT be coding by clinical guidelines! It's an outrage! Can't this not be interpreted as going against our Practice Act?? Willfully and knowingly mis-categorizing/coding a a potentially serious medical condition for payment?? What are these people thinking? They had more than enough time (and then an extra year) to map the tool correctly. That's what you get when trying to combine a tool that is clinically relevant with a payment tool.

And what about the PHQ-9 interview? What if a cognitively intact patient refuses to answer? (as many would, including me) How can you do a staff assessment on these items... for the most part, they ARE NOT observational items, and who are we to code answers here for someone who chooses not to participate? Ex: I come into your facility for a ten day stay after a knee replacement, I'm cognitively intact with no history of depression, and I refuse to answer. Are you then instructed to tell me you'll be conducting this assessment FOR ME?? NO! How does this comport with my rights, and the so-called Culture change" movement? How is it valid to conduct the same assessments over and over for all populations; LTC, short term, MR, and children?? And how valid are the studies, if you keep changing the item-sets?

CMS has only succeeded in creating a more burdensome tool, for the already troubled LTC community, and for LESS reimbursement. After years for work, and countless taxpayer dollars??? Unbelievable.....