Q & A

Q: A resident is alert and verbally responsive, able to understand and make her needs known in her native language, but can’t understand English. This creates a communication barrier between the staff and the resident.

How should items C4, making self understood, and C6, ability to understand others, be coded? I have been coding them 0, understands others and is understood by others, because she can communicate well even though it is limited to her own language, but this is now being questioned.

A: The MDS is a very functional assessment. Although the resident can speak and understand in her native language, functionally she has a communication deficit in your facility. She has problems making her needs known, having social conversations, etc., and has problems understanding others in your facility. The MDS coding for communication has to take these deficits into consideration. You must care plan to assist this resident to get her needs met and to address the communication deficit related to language.

Q: Can the look-back periods of the 5-day and 14-day assessments overlap? That would mean that some of the minutes captured on the 5-day will also be captured on the 14-day. Is that okay?

A: It is perfectly acceptable to overlap. With a 7-day look-back period, the observation period for the 14-day can start as early as day 5 (if the ARD is set on day 11) or it can end on day 19 (if the ARD is on day 19) if you need to use grace days.

Q: If a Medicare Part A admission now needs a sitter because of wandering, is that the facility’s responsibility under consolidated billing or can we bill the family?

A: The rate the facility receives from Medicare Part A is all-inclusive—meds, room and board, treatments, therapy, etc.—except for a small number of items that are excluded as listed in the consolidated billing transmittals (see https://www.cms.hhs.gov/SNFConsolidatedBilling/01_Overview.asp for details). Since sitters have never been part of the Medicare Part A benefit, it is not part of the all inclusive payment received by SNFs, and therefore the facility is not responsible to pay for it. Give the resident’s family a Notice of Excluded Medicare Benefits(NEMB), (see https://www.cms.hhs.gov/BNI/13_FFS%20NEMB%20SNF.asp#TopOfPage) so they are aware that the cost of the sitters will not be covered by Medicare.

Q: Is a repaired hip fracture counted as a hip fracture in section I?

A: If the hip fracture continues to affect the resident’s current ADL or functional status, treatments, monitoring, etc., then it would be coded in I1m. See page 3-128 of the RAI User’s Manual. When it affects the current status and is coded in I1m, care related to it would be expected to be found somewhere on the care plan. If it has no effect on the resident currently, then it would not be coded in I1m.

As far as coding for Part A reimbursement is concerned, the fracture itself would not be coded on the bill or by rehab in the SNF—that diagnosis code is reserved for the hospital care that directly treated the fracture. The SNF would code aftercare.

With thanks to Diane Carter, RN, MSN, CS, President and CEO of the American Association of Nurse Assessment Coordinators (AANAC), and Rena R. Shephard, MHA, RN, RAC-MT, C-NE, AANAC Chair, and President of RRS Healthcare Consulting Services, San Diego.



The American Association of Nurse Assessment Coordinators is a nonprofit association of your peers, including all members of the interdisciplinary team dedicated to networking, education, and advocacy on behalf of all clinicians involved in the RAI/MDS process. From our online discussion group each week, we select the best questions and answers our members have raised. The questions and answers are reviewed by a national advisory board of experts in this field and are subsequently published in NAC News, AANAC’s weekly online newsletter. In addition to our weekly questions and answers, the newsletter contains a variety of timely and accurate information on the RAI/MDS process. AANAC also offers certification and other educational information services for clinicians committed to accurate and timely completion of the MDS. For further information on AANAC, call (800) 768-1880 or visit https://www.aanac.org.

Long-Term Living 2008 August;57(8):38

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