Improving MDS Accuracy

Vol. 11 •Issue 15 • Page 42-43
Improving MDS Accuracy

The potential impact of one error is greater than you may think. Use these strategies to increase your MDS accuracy.

By Cheryl Field, MSN, RN, CRRN

The Minimum Data Set (MDS) has received much attention and resources, yet despite staff training and education, the Center for Medicare and Medicaid Services (CMS) predicts that the data in state databases are only 80 percent accurate.1

A recent study of 25,000 MDS assessments found that 68 percent contained at least one data integrity error.2 In other words, the responses coded were not clinically or logically consistent in relationship to one another (i.e., patients dependent in all areas of physical mobility should not be wandering). The study also found that assessments with errors had an average of 2.7 errors each.2

There are more than 500 questions on the MDS. So what is the potential consequence of just one error? The answer may surprise you.

MDS Coding Issues

The MDS is part of the Resident Assessment Instrument, a process by which facilities assess and reassess residents for triggers, or additional risk factors. The reassessment process is called working the RAP (Resident Assessment Protocol), which helps the clinician make care plan decisions. Thus, the MDS assessment serves as the framework around which a resident’s care plan is built.

Under the prospective payment system, this same assessment tool became a reimbursement tool for Medicare. Facilities now send their MDS electronically to their states, which monitor quality indicators (QIs) regularly. Fiscal intermediaries and the Office of the Inspector General are paying close attention to MDS data and drawing conclusions about facilities’ coding practices and billing patterns.

As illustrated in the following examples, just one mistake could impact a facility on many levels.

• Miscoding one item in section G. Section G measures activities of daily living (ADL) ability. Resource Utilization Groups (RUG) are differentiated based on an ADL index, a score calculated by adding the scores from bed mobility, transfers, feeding and toileting. This index plays a pivotal role in determining the daily rate the facility will receive for this resident’s care.

A patient admitted with osteomyolitis on I.V. antibiotics with no need for rehabilitation services will fall into the SE (Extensive Service) category if his ADL index is greater than 7. If the ADL index is less than 7 the resident will fall into the SS (Special Care) category. The actual dollar amount between these two categories is facility-specific, but estimated to be $45 per day.

If this patient needed limited assistance during the day and extensive assistance during late evening hours, the correct bed mobility code would be “3–extensive assistance,” because the MDS manual instructs to code for the greatest amount of dependence measured. If the clinician correctly coded transfers, feeding and toileting as “2–limited assistance,” and in error coded bed mobility as “2–limited assistance” instead of “3,” the RUG category would completely change, resulting in a loss of reimbursement. The facility would provide the more extensive care and continue the I.V. antibiotic course, but at a rate lower than the reimbursement it fairly deserved.

• Miscoding one item in section B. Most residents with short-term memory impairment do not have totally intact decision-making skills, because many daily decisions require a person to draw upon recent information or experience to make rational choices. The consequences of not understanding this relationship impact care planning: The resident with early cognitive impairment does not receive adequate care, and the facility misses opportunities to prevent further decline.

Wrongly assessing these items affects the QIs when residents who are high risk for functional decline due to cognitive impairment are inaccurately classified as low risk. When the assessment team fails to note the relationship between short-term memory and decision-making, the team may not classify the resident into an appropriate Cognitively Impaired RUG group and will lose fair reimbursement.

• Omitting one item in section P. Section P on the MDS measures procedures performed within specific look-back timeframes. The look-back timeframe for I.V. fluids is seven days, and for I.V. medications 14 days. This may not seem significant. However, a patient who received I.V. hydration in an acute care hospital eight days ago could be easily miscoded as having received I.V. hydration as an honest error, made by staff who mix I.V. medications with I.V. fluids. Avoiding this error requires careful scrutiny of hospital records and staff understanding the question. This error might raise a fiscal intermediary’s red flag if the diagnostic codes on the UB 92 do not predict the use of I.V. fluids in the typical treatment protocols.

• Issues with diagnostic coding. Subacute units often see many elders with recent diagnoses of dehydration upon admission, which will appear on the Medicare 5-day Assessment. States do not look at this as a sentinel event. However, subsequent required Medicare assessments are not granted this same waiver. Failure to remove “dehydration” from your diagnosis list when the condition has been treated and resolved could result in sending a false positive sentinel event to the state.

Sometimes all it takes is one record to send a warning signal to the state, prompting action.

Barriers to Accuracy

Given the high error rate and potential consequences, MDS accuracy must be a top priority for long-term care facilities in 2001. Ensuring clinical, regulatory and financial success requires excellence in the Resident Assessment Instrument process. Achieving MDS accuracy requires facility administrators to understand the scope of the challenge and provide the right support and tools.

There are several barriers to accurate coding. Some staff simply don’t receive the necessary training to understand the full intent of each question–not a comforting scenario when your fiscal intermediary denies payment. Another barrier to accurate coding is the fast turnover of nursing staff, resulting in demands for continuous education on MDS process, and creating the need to monitor performance. Additionally, agency staff may not know the patient as well as “regular” staff, and must rely on written flow sheets and narrative notes to complete the MDS. If your current documentation system does not have consistent codes for measurement or “speak the same language” as the MDS, your MDS will not be accurate.

Accuracy Strategies

The first step to achieving accurate MDS data is to commit to the goal. Devote resources to training staff, establish internal and external auditing systems, and monitor outcomes.

Achieving accurate MDS assessments may be one of the greatest challenges facing long-term care, and it may certainly be the most important goal to achieve in overall facility operations. Without dedication, a facility leaves itself vulnerable to many levels of regulatory review, regardless of the outstanding job it may be doing in providing care. n


1. Fitzler S, Hake C, Moore T, Schoeneman K. MDS Data Trends. Lecture given at American Health Care Association, 51st Annual Convention, Orlando, FL, October 11-13, 2000.

2. LTCQ Inc. Q-Metrics provider service database. Available at

Cheryl Field is director of clinical and reimbursement services for LTCQ Inc., Bedford, MA. She can be reached at (781) 275-4567, or via e-mail at [email protected].

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