After months of deliberation and confusion surrounding coding for activities of daily living (ADLs), CMS posted clarifying instructions in the RAI User’s Manual, version 1.11,1 which became effective October 1, 2013. While the instructions are clear, the results may be different from what coders might have previously expected. Most notable is the emphasis on coders’ following the “Rule of 3” in sequential steps as opposed to strictly using the ADL algorithm (p. G-7).
In the October update, the “Rule of 3” (p. G-6) states: “Use the first instruction encountered that meets the coding scenario (e.g., if #1 applies, stop and code that level).” For example, when a resident requires multiple episodes of Supervision (e.g., three times), and only one or two episodes of Limited assistance, Extensive assistance or Total assistance, but not three times at any one of these levels, the code would be Supervision. Coders are not allowed to combine episodes of higher levels of assistance when the definition for the first Rule of 3 is met at lower levels of coding.Because of this clarification, coders who exclusively rely on the algorithm to code the MDS might not arrive at the correct score. It is best to think of the algorithm as a tool that “augments” the ADL scoring instructions and is useful in some but not all coding situations (p. G-4). The algorithm is most helpful in cases where the ADL activity occurred at least three times, but not three times at any one level.
The updated RAI User’s Manual outlines the following sequential steps in the Rule of 3 (p. G-6).
ADL Scoring Step 1: “When an activity occurs three or more times at any one level, code that level.”
For example, a resident was Supervision on five occasions, Limited assistance on two occasions and Extensive assistance on two occasions. The correct score is Supervision because the first Rule of 3 was met at Supervision. Note that because the first step applies, we do not combine the episodes of Limited and Extensive assistance.
ADL Scoring Step 2: “When an activity occurs three or more times at multiple levels, code the most dependent level that occurred three or more times.”
For example, a resident was Supervision on six occasions, Limited assistance on five occasions, Extensive assistance on two occasions and Total assistance on one occasion. The correct score is Limited assistance since that was the most dependent level at which the activity occurred at least three times. Note that in this example, there are three episodes of Limited assist and fewer than three episodes of either of the two higher levels of dependency. This step does allow the combining of Extensive and Total assistance.
ADL Scoring Step 3: When an activity occurs three or more times and at multiple levels, but not three times at any one level, apply the following:
a. Convert episodes of full staff performance to weight-bearing assistance when applying the third Rule of 3, as long as the full staff performance episodes did not occur every time the ADL was performed in the 7-day look-back period.
b. When there is a combination of full staff performance and weight-bearing assistance that total three or more times—code Extensive assistance(3).
c. When there is a combination of full staff performance/weight-bearing assistance, and/or non-weight-bearing assistance that total three or more times—code Limited assistance(2).
For example, a resident was Extensive assistance on two occasions and Total assistance on two occasions. Since none of the coding levels occurred at least three times, apply step 3, part b, by combining the episodes of Extensive and Total assistance. The correct code is Extensive assistance.
Finally, the Rule of 3 instructions say, “If none of the above are met, code Supervision.” For example, the resident was Independent throughout the look-back period but on two occasions required limited assistance. Using the Self-Performance Algorithm is useful in this situation; coders will arrive at the very bottom of the tool, which indicates that when none of the boxes in the algorithm applies, code Supervision.
If coders have not been following the instructions outlined above, then facility staff might see a downgrade in a resident’s Resource Utilization Group (RUG) levels and therefore potentially facility payments. While at many facilities, staff capture ADLs by charting once per shift, it is a best practice to chart every episode of care provided to the resident. This will decrease the likelihood of reimbursement changes as a result of this clarification.
Ensuring that ADL scoring is accurate is the concern of every facility manager and MDS coder. Precision in coding ADLs is critical for obtaining the proper payment for the care provided. It is also essential for capturing the appropriate data for Quality Measures and Five-Star ratings. Most importantly, ADL scoring accuracy is vital to ensuring that the care plan is fashioned according to the resident’s goals in order to achieve his or her highest practicable level of physical well-being. To avoid inaccurate coding of ADLs, review these instructions with your facility teams and work to shore up weaknesses in your charting systems. This will be time well spent.
Judi Kulus, NHA, RN, MAT, RAC-MT, C-NE, is Vice President of Curriculum Development for the American Association of Nurse Assessment Coordination (AANAC). To contact her, email her at firstname.lastname@example.org.
1. Centers for Medicare & Medicaid Services. Long-Term Care Facility Resident Assessment Instrument User’s Manual (version 3.0, October 2013). Baltimore: Author. Available: www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual.html.