Much to be done before MDS, RUG 2010 changes

At a glance…

Technology now holds promise for compliance with some of the new CMS interpretive guidance (effective June 12, 2009), for several of the quality of life requirements and ultimately contributes additional means for good care.

Version 2.0 of the Minimum Data Set (MDS), the assessment tool used to determine payment for Medicare Part A, will be obsolete on October 1, 2010; MDS 3.0 will be “in.” The next generation of the Resource Utilization Group (RUG) system that uses the MDS information to categorize residents into payment groups based on acuity also kicks in on that day.

MDS 2.0 to MDS 3.0 and RUG-III to RUG-IV sound like they might be upgrades to existing systems. No problem, you might think-find out what’s changed, incorporate the changes into existing systems and processes, and go from there. But from all indications, that would be a mistake. While the underlying concepts of the MDS and the RUG systems are very familiar, the changes are so extensive that it would be wise to approach them almost as if they were brand new.

How a facility approaches implementation of these important and powerful requirements can be the difference between success down the road and problems with reimbursement, surveys, and quality reporting. Administrative team members who were around when the MDS originally was implemented circa 1990, probably understand in retrospect that a lot was learned about how not to implement change: It wasn’t taken seriously, it wasn’t given priority from an organizational perspective, and the result too often was survey deficiencies, Medicare denials, missed reimbursement opportunities, and poor quality indicator scores. Some of this continues today. Here’s an opportunity to get it right.

It starts with effective leadership. An effective and dynamic leader develops a vision for what must be accomplished and shares that vision in a clear and positive manner that leaves no question about the goal-and the worthiness of the goal-that everyone will work toward together. A great leader entices others to follow. As leaders, administrative team members have the central role in this vision.

Start preparing now

A critical first step is to make a plan for implementation well in advance of the October 2010 start date. Involve the entire facility team, and, as a leader, be the facilitator throughout the process-leave no doubt that this project has the full support of the facility’s administrative team.

Provide formal training. Ensure that all staff members who will participate in the MDS assessment and in SNF PPS receive formal training from recognized experts. As the leader, be sure to remove obstacles that might prevent them from receiving the training and support they will need. Also, ensure they have the most up-to-date MDS 3.0 RAI User’s Manual at all times. Affiliation with the American Association of Nurse Assessment Coordinators (AANAC) can be instrumental in meeting these needs.

Create team specialists. Solicit volunteers among the staff to become the experts on the various items, one person/one item (or section). Each of these specialists would provide additional mentoring and support to other team members with regard to the item specialty and would act as a resource person on that item on a continuing basis.

Find out about your software vendor’s transition plan. Each vendor will develop its own process and timeline for software development and testing. It is critical that your facility be aware of your vendor’s plan well in advance and that a joint plan for integration of the new software into your facility, including plenty of time for staff training, be developed.

Recognize that the MDS is a complex process. When the original MDS was implemented, in many ways, the complexities of the process were not recognized and accounted for at that time, and to this day, the ripple effect of consequences continues in inaccurate assessment data that may be attributed to inadequate training, lack of priority from administrative team members, and a job description for MDS nurses that in many ways cannot be accomplished.

Understand the MDS 3.0 yourself. Make sure you have a clear understanding of the processes of the MDS 3.0-how it works and how it can be used to improve quality of care, quality of life, and outcomes for your residents-how it can be the foundational tool for culture change for your facility. Understanding the MDS 3.0 yourself is important also so you can assist the interdisciplinary team by removing obstacles to success, providing needed resources, and monitoring to identify training needs and to recognize successes.

Administrative team members in many organizations have never really understood their key role in the MDS 2.0 in this context. To this day they may have significant problems with MDS accuracy and effectiveness as a care planning tool, despite the critical role this instrument plays in the survey process, reimbursement, and quality monitoring. Unless you will be completing some portion of the MDS 3.0, that doesn’t mean that you have to know how to fill out every item on the MDS. But it does mean that you must know enough about it to ensure that the team responsible for completion of the form gets it right.

Empower a team to analyze and revise processes. The team should study current MDS- and PPS-related processes in the facility; flowcharting the processes can be very helpful in analyzing what works and what doesn’t work. Brainstorm with them on what will be needed in terms of processes for the team to be able to do its work efficiently and effectively. This team should then flowchart the proposed new processes step by step in order to be able to identify and remove barriers to success and to be able to know when aspects of the proposed processes should be altered.

Put together a team to analyze the facility’s staffing patterns and job designs. Too often, job descriptions evolve into task lists that have little relationship to their purpose. This may be a good time to restructure or redesign jobs to meet the needs of the facility and residents.

Experiment with the interviews yourself. Go out there and sit down with a resident and complete the scripted interviews that are an integral part of the MDS 3.0. Get comfortable with the process. Don’t forget to take your cues from the MDS 3.0 RAI User’s Manual. It will provide you and your team with the script to use, but also with some tips on how to help residents stay focused and to narrow their answers.

Also, it would be wise to time the interviews, so you can begin to have an idea of how long they are going to take. This will really help when your staff needs support and guidance about these interviews. And this doesn’t have to wait until the 3.0 is implemented. These scripted interviews can be very valuable right now-not for use with the MDS 2.0-but as an assessment tool for care planning purposes outside of the MDS process.

Incorporate staff practice time into the facility transition plan. With phasing-in of the scripted interviews long before MDS 3.0 implementation and providing ample time for staff to practice completing the new form, October 1, 2010, will not have to be a frantic time.

Conduct a thorough financial impact analysis. The indications are that RUG-IV, including redistribution of various skilled nursing services and changes in some of the MDS assessment requirements, may result in less income from rehabilitation therapy and extensive nursing services for many facilities. Providers should begin assessing the financial impact to their facilities as soon as possible in order to have a clear picture for budgeting purposes.

Identify missed reimbursement opportunities and potential new revenue streams. For many providers, Medicare Part A has become so familiar over the years that they have long foregone systematic reevaluation of utilization in the facility. Some common missed opportunities include:

  • Use of “what if?” scenarios to select the MDS Assessment Reference Date (ARD) that results in capturing the care and services that best reflect the true intensity of care needed and received by the resident.

  • Avoiding default days through implementation of backup systems to ensure that ARDs are set before the ARD window closes. If an assessment falls through the cracks and the ARD isn’t set, once the ARD window mandated by the regulations closes, the ARD cannot be set within that window. Worst-case scenario: The missed assessment isn’t discovered until after the resident is discharged from Part A and, in most cases, the days can’t be billed at all.

  • Part A coverage for skilled restorative nursing. Although the provision for Part A coverage for stand-alone restorative nursing has been in the code of federal regulations for decades, most providers don’t seem to know about it, even though beneficiaries are entitled to it when it is a part of active treatment as opposed to maintenance and when all other coverage criteria are met.

  • Accurately capturing depression in the Clinically Complex category for MDS 2.0. With MDS 3.0, this will also be a factor in the Special Care categories.

  • Systematic monitoring in-house residents for 30 days after discharge from Part A. They may be picked up on Part A again without a new hospital qualifying stay for a condition treated during the qualifying hospital stay or for a condition which arose while on Part A following the hospital stay.

Develop a quality improvement plan for MDS 3.0 and RUG-IV activities. Include practice in auditing the accuracy of the MDS 3.0 and related documentation, and implement routine monitoring of accuracy as part of the facility’s Quality Assessment and Assurance activities.

Be prepared for resistance-but be undaunted by it. Resistance to change is inevitable. Prepare for it. Learn from it. Harness the energy and use it toward change.

Be a cheerleader for this change

Change is very difficult, even at best. Be a leader in this transition-be an example for others to follow.

You can do this by presenting this MDS upgrade as a very positive change for residents. The interview process gets to the core of what the resident wants and what is important to him or her-it is the basis for resident-directed care and for culture change.

And you can also do this by presenting this change as a positive one for the facility. The improvements in quality of care and quality of life that can result from fully implementing the MDS 3.0 approach will shine through at survey time and in staff and resident satisfaction.

Rena R. Shephard, MHA, RN, RAC-MT, C-NE, is Executive Editor of the American Association of Nurse Assessment Coordinators (AANAC). She can be reached at (858) 592-6799, or for more information, visit

To send your comments to the editor, please e-mail

Long-Term Living 2010 January;59(1):34-37

Topics: Articles , MDS/RAI