Long-Term Care Success Depends on Knowledgeable MDS Coordinator
BY JOAN WAGNER, MSN, CRNP
Providing care to residents in nursing facilities is complex and challenging work. With the latest regulatory changes, a long-term care facility’s success is greatly dependent on a knowledgeable Minimum Data Set (MDS) coordinator. This position requires a strong background in coding and reimbursement issues and would be well suited for a health information management (HIM) professional.
Emphasis has been placed on looking at residents holistically, utilizing the comprehensive Resident Assessment Instrument (RAI) mandated by the nursing home reform law of OBRA ’87. This RAI process utilizes clinical competence, observational skills and assessment expertise from an interdisciplinary team of care providers and has done much to improve the quality of care and life for residents. Care planning is now individualized to each resident’s strengths and needs utilizing the resources and disciplines necessary to ensure that residents achieve the highest level of functioning possible.
MDS and RUGS
A major component of the RAI is the MDS, a core set of screening, clinical and functional status elements, that forms the foundation of the comprehensive assessment for all residents of long-term care facilities certified to participate in Medicare or Medicaid. While staff working in nursing facilities have been completing the MDS since 1990, this assessment tool has taken on additional importance under the prospective payment system (PPS).
The PPS provides a mechanism for facilities to be reimbursed in a manner that reflects the kinds of residents (i.e., case mix) and types of services provided in a facility. Under PPS, facilities are paid a fixed daily rate based on the acuity of each individual resident. Coding information from the MDS is utilized to classify the resident into one of 44 different Resource Utilization Groups (RUGS III). Specific criteria are utilized for classifying each resident into a RUG III category. Each RUG has a different and distinct payment rate that has been adjusted for the intensity of resource use (for example, hours of nursing or therapy time needed per day) and/or other relevant factors (for example, requirement for a ventilator, etc.).
The amount of time and resources required to care for the resident who requires aggressive rehabilitation therapy, for example, may differ significantly from the time and resources required for a resident whose major need relates to total dependence on tube feeding to achieve required nutritional balance. The amount Medicare pays a facility will be different for the care of these two residents.
Staff Understanding Necessary
It is of critical importance that staff understand the new function that the MDS plays in the operational and financial success of the facility. Because the MDS is now also the source of data for Medicare PPS/ RUGS III payment, accurate coding is essential if facilities are to be paid appropriately for the services they provide. Important to accurate coding is a clear picture of the functional level of the resident.
Physical functioning and structural problems that affect the residents’ activities of daily living (ADL) are addressed in Section G of the MDS. Based on what is coded in the MDS, residents are assigned an ADL Index Score. The ADL Index Score is a major factor in determining to which PPS/RUG III category the resident is assigned. Inaccurate coding in this area can result in assignment to a lower payment category that does not appropriately reflect the resident’s acuity of care.
Skilled MDS Coordinator Essential
Making sure that the individual responsible for coordinating the MDS/PPS process is competent in performing the job is now of critical importance. The success, both operationally and financially, of units providing Medicare Part A service depends upon a knowledgeable and skilled MDS coordinator.
The responsibilities of this individual are monumental. Not only has the MDS taken on new financial importance in the nursing facility, but the frequency of completing the MDS assessment has also increased. For Medicare Skilled residents, a 5-day, 14-day, 30-day, 60-day and 90-day assessment is required for each resident.
The MDS coordinator’s responsibilities include:
* Organizing and coordinating the case-mix management process. (This includes pre-admission screening of residents and the scheduling and tracking of the multiple assessments required.)
* Coordinating the RAI process. Inter-disciplinary team members receive, for each resident, direction from the coordinator regarding:
1) Individualized Assessment Reference Dates (a carefully planned and specific span of observation days for each assessment);
2) The date each assessment is expected to be completed; and
3) The need for collaboration among interdisciplinary team members to ensure accurate coding.
* Monitoring for continued skilled care eligibility. When the resident’s status changes to the extent that he/she no longer meets the criteria of one of the RUG III categories deemed Medicare Skilled, the coordinator will need to activate plans for discharge from this level of care.
* Auditing of clinical records.
* Reporting inaccurate coding to specific team members so that corrective action can be taken.
* Assuring that ongoing documentation supports MDS coding and the RUG III category to which the resident has been assigned.
* Educating the team. When inaccuracies in coding or documentation occur, the coordinator must educate those having difficulties with the process. Assuring competency of all staff involved in the RAI process is a major responsibility of the MDS coordinator. The PPS is still evolving and regulatory changes and/or clarifications are likely. The coordinator must stay abreast of all new developments and directives related to PPS and share this information with team members.
* Acting as a resource. The coordinator is responsible for sharing information related to Medicare coverage issues with physicians, utilization review, social service, rehabilitation and hospital/nursing facility staff.
* Submitting electronic MDS data. Regu-lations related to a specific process and time frames related to electronic submission have been established and must be coordinated to avoid compliance and payment penalties.
* Interfacing with the billing department. Billing information must accurately reflect the resident’s RUG III category and appropriate services for the specific billing period. The MDS coordinator plays an integral role in this process.
Nursing facility administrators need to give thought to the many and complex responsibilities of the MDS coordinator. They need to screen carefully to be sure that the person they are hiring or already have in place demonstrates competency skills related to this multi-faceted and important position.
Likewise, HIM professionals interested in the role of MDS coordinator need to look for programs that go beyond basic information about PPS and focus on the practical clinical application of the processes required for the position. Programs that test or evaluate the individual’s understanding of PPS and skills to do the job are absolutely necessary.
In fact, certification as an MDS/PPS coordinator may well become the desired norm of the future for health care professionals assuming this role. Certification guarantees that core competencies for the job have been met and MDS/PPS coordinators and their employers can move ahead with greater confidence toward success under PPS.
Goal of PPS
The PPS presents new and exciting challenges for health care providers. It is a system designed to structure more equitable payment for Medicare skilled services and promote a high quality of care. More focused attention to the time, resources and factors relevant to the care of residents in our long-term care facilities has finally come into being–and with it the recognition that there are differences among residents and what is required to care for them.
The goal of PPS is to ensure that payment levels are adequate to support both quality and access to care. Achievement of this goal will depend in large part on a strong MDS coordinator who has the leadership skills necessary to move the team toward successful outcomes for the facility and the residents. *
Joan Wagner is senior manager of The Whitman Group, a national geriatric consulting firm.