MDS 3.0: Processing the flurry of updates

Over the past year the Centers for Medicare & Medicaid Services (CMS) has published survey and certification errata, prospective payment clarifications and RAI User’s Manual updates. It’s sometimes hard to pull it all together to code and bill accurately. Inaccuracies put facilities at risk for default payment and survey deficiencies. Because CMS has reduced the frequency of updates, providers can take a break from interpreting new MDS requirements and can dig deeper into the current regulations. Some of the most impactful regulations relate to interviewing residents, combining different types of assessments, and handling coding errors. Getting it right is crucial to avoid the revenue loss and survey fines that can result from not following MDS protocols.

Resident interviews this year, providers welcomed the reduction of interview frequency for stand-alone unscheduled PPS assessments (Change of Therapy, End of Therapy and Start of Therapy). MDS coders are allowed to carry forward the previous interview data to the current assessment. The April 1, 2012, errata clarified the requirements by stating that providers can use the previous interview if it was conducted and coded on the previous assessment within 14 days of the current assessment as determined by the dates at Z0400 on both assessments. In the March 30 SNF PPS clarification memo, CMS also required that providers not carry the interview data over from a previous assessment if a resident’s interview items—such as cognition, mood or pain—have been observed to have changed during the observation period for the unscheduled PPS assessment. Additionally, interviews may be carried forward if the same staff member signs item Z0400, attesting to having completed and evaluated the resident on both assessments.

Whether facility staff members enter the interview data directly onto the MDS item set or use another charting source, the signature at Z0400 should indicate the date that the interview was conducted. In order to fully utilize this policy, facility leaders may want to evaluate how they capture the interview information so that they ensure proper charting when choosing not to conduct a new interview.

Potential risks of combining assessments

Combining unscheduled with scheduled PPS assessments has been challenging for facility staff. If the assessment reference date (ARD) of a scheduled assessment is set in the appropriate window and the ARD is on or before Day 7 of the COT, the staff has the option of combining the assessments or completing the scheduled assessment alone. CMS explains in the March clarification that “if a COT OMRA has an ARD set for Day 13 and the facility sets the ARD of the 14-day assessment for Day 13, then the facility may choose either to complete only the 14-day assessment or to combine the 14-day assessment and COT OMRA.” To decide whether to combine the assessments or to complete a stand-alone scheduled assessment, facility staff should choose the option that results in the best RUG payment level.

However, completing a stand-alone scheduled assessment can be a non-payment risk if a COT is needed. If a resident is discharged from Medicare before the scheduled assessment is used for payment, the facility cannot receive payment for the days that the COT would have covered. To ensure your MDS scheduling process is flexible and aware of these changing circumstances, it is advisable to have staff trained to open and set ARDs and reason codes every day of the week, including weekends. If both nursing and therapy clinicians are in close daily communication on coverage, therapy minutes and the schedule, the risk of non-payment is significantly reduced.

Clarification on inactivation and corrections

If a facility staff member discovers an error on an ARD or reason for assessment (RFA) after transmission of the record, it will have to be inactivated and replaced with a new record and ARD. If the error was noted while the resident was still on Medicare, it may result in a default payment. If the resident has been discharged from Medicare, it may result in no payment (provider liability). This is because the ARD on the replacement assessment is likely to be late—that is, after the ARD window for the assessment has closed. To minimize these types of errors, providers may want to consider utilizing flexibility in scheduling to provide the opportunity for the team to cross-check accuracy of these items during the encoding period in the seven days following completion of the record, when corrections can still be made without penalty before the record is submitted.

Questions on MDS 3.0

In order to manage some of the most difficult coding items accurately, it’s necessary to look at all the CMS documents and put the instructions together. However, after reading the errata, clarifications or manual, staff may still have questions regarding how to code or schedule an MDS. In these situations, CMS wants providers to contact their state RAI coordinator instead of contacting the central office directly. The hope is that this will yield faster, more consistent responses to questions. Each state has an RAI coordinator, whose contact information is found in Appendix B of the RAI User’s Manual. If the state RAI coordinator is unable to answer a provider’s question, then the RAI coordinator will refer it to the RAI panel, which is a committee composed of state RAI coordinators. After these steps have been taken, the question may go to the CMS central office staff.

For questions regarding Medicare billing or claims processing, CMS instructs providers to contact their fiscal intermediary (FI) or Medicare administrative contractor (MAC) first, because the FI/MAC will be reviewing the claims. During the May Open Door Forum, officials stated, “If the FI or MAC is unsure of the policies or unsure of how to respond to a given question, then that question would then get referred to the [CMS] regional office for that area. Any questions that the regional office might have that they are unaware of in terms of an answer would then get referred to central office.”

Every day, AANAC members grapple with these and other issues in our online community. Our nationally recognized MDS content experts can clarify the regulations and help members understand them. For more information on receiving expert assistance, please visit

Judi Kulus is the vice president of curriculum development for the American Association of Nurse Assessment Coordination (AANAC). She can be reached at

Topics: Articles , Executive Leadership , Regulatory Compliance