Top MDS Coding Misses and What It’s Costing Your Facility

While MDS Coordinators consistently strive for accuracy, complying with the intricate coding instructions and details in the Resident Assessment Instrument User Manual, in addition to state-specific coding instructions is challenging. Unfortunately, MDS coding errors can often result in gaps in care provision and cost providers vital revenue. This week’s blog reviews two of the most common MDS coding errors and how to avoid them….

Diagnoses – There are several diagnosis categories that are listed in section I of the MDS that can impact Medicare or Medicaid reimbursement. One common error is coding diagnosis in this section without sufficient supporting documentation. Diagnoses in Section I must only be coded when active – defined in the RAI as “Physician-documented diagnoses in the last 60 days that have a direct relationship to the resident’s current functional status, cognitive status, mood or behavior, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period.” In addition to this general requirement, diagnoses used in the Patient Driven Payment Model (PDPM) can be especially challenging due to the model logistics. While a diagnosis may be reported, if it isn’t marked in specific areas of the MDS, it may not be impacting vital reimbursement areas.

Consider these examples:

1. Respiratory Failure may be marked at I6400, but an appropriate ICD-10-CM must also be reported at I8000 to receive NTA points.
2. A wound infection may be addressed in Section M or reported at I8000 but must also be marked at I2500 to receive NTA points.
3. Burns may be reported in section M, but an appropriate ICD-10-CM must also be reported at I8000 to receive NTA points.
4. Malnutrition (or risk for) at I5600 can be reported with documentation of Malnutrition as diagnosed from a physician. This item can also be coded if we assess the risk for malnutrition and collaborate with the physician to implement interventions prior to the assessment reference date. It takes coordination with the dietician, MDS, and physician to assess and document risk early in a stay and considered a missed opportunity if the process is not completed prior to the ARD of the PPS 5-day assessment.
5. Diabetic Retinopathy is often included at I2900, Diabetes, but can result in an additional NTA point when the appropriate ICD-10-CM is reported at I8000.
6. Dysphagia codes (for example, R47.02) may be reported, but do not impact the SLP component of the rate. If the dysphagia is related to a Cerebral Vascular condition, the appropriate ICD-10-CM (I69.xxx) must also be reported at I8000 to impact the SLP Component

Parenteral/IV Feedings – IV fluids can potentially be captured when administered during the hospital stay and prior to admission to the SNF. This can significantly increase PDPM reimbursement when all coding requirements are met. First, we must have supporting documentation that the hospital administered IV fluids specifically for a nutrition/hydration need. Next, we must adjust the MDS ARD so that the date(s) of administration fall within our allotted 7-day look-back period. Many MDS nurses miss this coding opportunity or may not consider it at all in situations where a member of dietary is completing Section K. Best practice dictates that we obtain and review the hospital administration records and other documents timely to identify if and when IV fluids were received prior to scheduling the 5-day ARD. When IV fluids are administered, it may be necessary to set the 5-day ARD earlier than expected (e.g., day 1, 2, or 3).

These two examples of top errors noted by Proactive auditors occur frequently, and can cost providers an average of $80/day in the Nursing and NTA portions of  PDPM reimbursement. Other frequently missed opportunities include inadequate assessment of Section GG self-care and mobility items and failure to identify changes in condition that may warrant an Interim Payment Assessment (IPA) when eligible for a higher per diem rate.

It is essential that MDS nurses participate in training early and often to become experts in these areas. ICD-10-CM coding and MDS accuracy are not a part of traditional nursing education and should be areas of supplemental education.

Proactive provides consultation and training solutions that drive MDS accuracy. For new MDS nurses or others needing a basic overview of the RAI process, registration is now open for 3 days of virtual MDS Orientation Training 4/29-5/1/2024. Training includes MDS coding instructions, PDPM management, QMs, ICD-10-CM coding basics, and more. For those looking specifically to advance ICD-10-CM coding proficiency, join Proactive for a virtual ICD-10-CM Coding Refresher for Skilled Nursing Facilities on 05/23/24.