Minimum Data Set Remains the Driver for Clinical Assessment, Regulatory Compliance, Quality Assurance, and Reimbursement in Nursing Homes

The Minimum Data Set (MDS) is a standardized assessment tool that is nationally mandated to be completed in all Medicare or Medicaid certified nursing homes. It is used to assess each resident’s functional capabilities and health needs, and forms the foundation of a comprehensive assessment process.  Since its inception in 1991, the MDS assessment has evolved from an eight-page, four-column form designed to improve the quality of assessment and care planning processes in nursing homes to a multifaceted set of item sets numbering up to 53 pages in some cases.

The MDS impacts each of the following key clinical and operational areas in nursing homes:


Clinical Assessment and Care Planning:

The MDS is a core set of screening, clinical, and functional status elements. As an integral part of the Resident Assessment Instrument (RAI), the MDS is used to identify resident care problems that are then addressed in an individualized care plan. The person-centered care plan aims to. assist each resident to attain or maintain the highest practicable physical, mental, and psychosocial well-being. The MDS also assists the nursing home Interdisciplinary Team (IDT) with evaluating progress toward goal achievement and/or necessary revisions of the resident’s care plan as the resident’s status changes. Skillsets including clinical competence, interviewing techniques, critical thinking, and clinical assessment expertise are essential for all members of the IDT to ensure accurate assessments and the effective development of a relevant and individualized care plan for each resident.


Regulatory and Survey Outcomes

During FY2015 CMS implemented the MDS 3.0 focused survey process, and while these focused surveys have since been discontinued, compliance with the regulatory requirements for timely and accurate completion of OBRA MDS assessments and individualized care plans continue to be a focus of survey teams during the nursing home annual health inspection surveys. 

Using the results of the focused surveys, including reviewing trends and common types of coding errors cited for MDS accuracy during the focused survey period, can assist nursing homes in identifying areas of potential opportunity for ongoing monitoring and training. Key areas identified for follow up corrective action included the following:

  • Antipsychotics:
    • Coding inconsistent for residents with and w/o antipsychotics
    • Incorrect number of days administered
  • Restraints: Residents w/restraints not coded as having a restraint
  • Falls: Residents not coded on the MDS to reflect a fall when a fall had occurred
  • Urinary Tract Infections (UTI): Incorrect coding based on UTI criteria in RAI MDS User Manual
  • Continence/Catheters:
    • MDS Coding inconsistent with residents with and w/o a catheter
    • Residents coded on the MDS as having a catheter with no supporting diagnosis
    • MDS coding inconsistent with residents’ actual state of continence
  • Pressure Ulcers:
    • MDS coding inconsistent with residents with and w/o pressure ulcers
    • Pressure Ulcers not coded on the MDS at the correct stages
    • Identified as healed and not accurately coded on the MDS when not healed
    • Incorrect number of pressure ulcers coded on the MDS
  • MDS Quarterly, Comprehensive (annual), and Significant Change in Status Assessment (SCSA):
    • Not completed timely or not completed at all 

Quality Measures and Public Reporting of Data

Several programs use MDS data to calculate quality measures for nursing homes, including the following:

  • MDS Quality Measures (QMs) available from CASPER (QIES Portal)
  • Skilled Nursing Facility Quality Reporting Program (SNF QRP)
  • CMS Care Compare / Five-Star Rating

CMS uses quality measures in its quality improvement, public reporting, and pay-for-reporting programs. The purpose of these MDS-based quality measures is to provide data to the nursing home to help in their quality improvement efforts and to provide the public with information about the care provided in nursing homes. This information helps to facilitate discussions with nursing home staff related to the quality of care and assists consumers in the selection of a quality nursing facility for themselves or their loved ones.

The MDS QMs are divided into short-stay and long-stay measures as follows:

Short Stay QMs:

  • Percent of Residents Who Newly Received an Antipsychotic Medication
  • Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury
  • Percent of Residents Who Made Improvements in Function
  • Percent of Residents Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine
  • Percent of Residents Who Were Assessed and Appropriately Given the Pneumococcal Vaccine

Long Stay QMs:

  • Percent of Residents Who Received an Antipsychotic Medication
  • Percent of Residents Experiencing One or More Falls with Major Injury
  • Percent of High-Risk Residents with Pressure Ulcers
  • Percent of Residents with a Urinary Tract Infection
  • Percent of Residents who Have or Had a Catheter Inserted and Left in Their Bladder
  • Percent of Residents Whose Ability to Move Independently Worsened
  • Percent of Residents Whose Need for Help with Activities of Daily Living Has Increased
  • Percent of Residents Who Were Physically Restrained
  • Percent of Low-Risk Residents Who Lose Control of Their Bowels or Bladder
  • Percent of Residents Who Lose Too Much Weight
  • Percent of Residents Who Have Symptoms of Depression
  • Percent of Residents Who Used Antianxiety or Hypnotic Medication
  • Percent of Residents Assessed and Appropriately Given the Seasonal Influenza Vaccine
  • Percent of Residents Assessed and Appropriately Given the Pneumococcal Vaccine

The MDS is the source document for each of the above QMs. The calculation is derived directly from the MDS; therefore, coding accuracy is essential to achieving accurate QM data.


Federal Medicare and State Medicaid Reimbursement

Under the Medicare program, MDS assessment data is used to calculate the resident’s Patient Driven Payment Model (PDPM) classification necessary for payment. The MDS contains extensive information on the resident’s nursing and therapy needs, ADL status, cognitive status, behavioral problems, and medical diagnoses.

Key MDS items that impact reimbursement under PDPM include the following:

  • Section C – BIMS/Cognitive status
  • Section D – PHQ9/Depression
  • Section GG – Functional Assessment
  • Section I – Active Diagnoses
  • Section J – Major Surgery
  • Section K – Swallowing Disorder and Mechanically Altered Diet
  • Section M – Skin Conditions
  • Section O – Special Treatments, Procedures, and Programs

Additionally, more than half of the state’s Medicaid programs utilize an MDS-based case mix payment methodology for reimbursement. While these programs and the specific calculation methodology can vary, the accuracy of the MDS items is a key driver for appropriate Medicaid reimbursement.

Advancing your facility’s MDS accuracy:

  • Develop a process for MDS self-auditing and engage a third-party reviewer to provide periodic audits of the MDS and supportive documentation to support quality of care and appropriate and accurate reimbursement.
    • Proactive Medical Review has clinical consultants with expertise in medical review and accuracy audits and is available to partner with your team to assist with the development of systems to improve or maintain MDS accuracy.
  • Train the Interdisciplinary team.The importance of education for the entire team involved in the MDS process cannot be overstated.  All team members should be aware of how the completion of their assigned MDS sections impacts each of the areas discussed.  Implementing competency-based training and skill testing with a focus on the accuracy of assessment, resident interviews, and timely completion of supportive documentation is key.
    • Proactive Medical Review has several educational offerings available for the team related to key MDS sections and their impact. Also available are toolkits to assist with focused competency skills for key areas such as section GG, Functional Abilities and Goals.
  • Value in MDS Certification: According to the AAPACN website a recent study determined that Skilled Nursing Facilities (SNFs) employing at least one staff member with an AAPACN certification see higher five-star ratings from the Centers for Medicare & Medicaid Services (CMS) than those without certification.
    • Proactive Medical Review’s team includes a Master Trainer for the RAC- CT and RAC- CTA Resident Assessment Certification (MDS) programs with multiple training opportunities offered throughout the year.
  • Keep abreast of changes. The MDS continues to evolve with the release of the draft Item Set v1.18. With these changes should come a renewed focus on the accuracy of the assessment as it impacts each of the key areas discussed.
    • Join the Proactive Medical Review mailing list to receive up-to-date, relevant content and stay informed about upcoming educational offerings related to the MDS, clinical reimbursement and standards of care for LTC providers.
What our clients say about us…

We have been working with Proactive Medical Review for several years and have always found the team to be courteous and professional; above all, they are all very knowledgeable. When we were having challenges recruiting an MDS Nurse, Proactive was there for us and completely kept our MDS requirements current and organized. Proactive provides frequent educational opportunities on a wide range of topics which helps our facility remain in compliance and supports our mission to provide excellent care.

Bert Papineau, HFA

Administrator, The Good Samaritan Home, Inc.

Proactive Medical Review and Consulting has been a great resource to our team. Their passion and professionalism show in everything they do. From reimbursement processes to regulatory compliance, PMR keeps us on the leading edge of our industry. We are happy to have them in our corner.

Brody O’Niones