MDS coding question

[Humblednurse]

Hi I've recently started a job as an MDS coordinator.  Can MDS coordinators complete code and sign other departments such as social service wound care and Activities  sections and CAA's? I would really like some feedback please 🙏 . Thank you.

[NRSKarenRN, BSN, RN]

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 Can MDS coordinators complete code and sign other departments such as social service wound care and Activities  sections and CAA's?

YES, YES, YES  in most states ---see info below.

 

Who Can Do MDS Assessments?

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The RAI (Resident Assessment Instrument) consists of the MDS (Minimum Data Set) and the CAA (Care Area Assessment). Members of the IDT (Interdisciplinary Team) are usually assigned to answer certain sections of the MDS and the CAA portions, depending on the facility's policy and procedure and depending on the job descriptions. These IDT members who know how to answer (or code) the MDS can input data in the MDS.Social Service Designee, Dietary Supervisor/Designee, Therapists, Activity Directors or Assistants, CNAs, DON, Administrator, LVNs and RNs. These IDT members may fill in the CAA as well. Therapists (PT/OT/ST) who are not in-house usually do not sign the MDS but provide answers to sections pertaining therapy treatments. The Business Office and/or Admission Department input resident demographics into the facility's software that sometimes automatically transfers into the MDS program. An RN must then sign the MDS as complete when all the sections are completed.

 

2023 Codify by AAPC

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Context: The RAI Manual does not specify which staff members or departments are responsible for completing specific sections of the MDS. In Chapter 1 - 7, the RAI Manual states: "The RAI process has multiple regulatory requirements.
Federal regulations at 42 CFR 483.20(b)(1)(xviii), (g), and (h) require that: (2) a registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals and nursing homes are left to determine (1) who should participate in the assessment process.”
Ideally, an interdisciplinary team (IDT) is involved in assessing and care planning for each individual, a collaboration that may or may not be reflected in your facility's determination of who completes which section of the MDS.

Beware: The MDS software that your facility uses may affect who is able to complete a particular section. For this reason, some MDS coordinators or NACs may have sole access to the software and therefore find that they have to interview their colleagues for the information necessary to complete a section.

Additionally, your state may have specific requirements for who should complete particular sections of the MDS, especially for Section S, if your state requires that section.
Remember: The MDS coordinator or NAC is usually the person who ultimately signs off on the accuracy and completion of the MDS, as well as taking on the responsibility of submitting it.

https://www.aapc.com/codes/scc_articles/article_pdf/74/mds-best-practices-mds-section-assignment-who-does-what-160018

Full info in October 2023: MDS 3.0 RAI User's Manua