The Federal Government’s Campaign to Improve MDS Accuracy

The Federal Government's Campaign to Improve MDS Accuracy
Editor's Note: In June, Health and Human Services Secretary Tommy Thompson announced the name change of the Health Care Financing Administration (HCFA) to the Centers for Medicare & Medicaid Services (CMS). Although some of the events/actions discussed in the following interview occurred or began when the agency was still known as HCFA, the acronym CMS is used throughout the interview for the sake of clarity.
Whether or not the Prospective Payment System (PPS) is "fatally flawed," as suggested by recent reports from the Medicare Payment Advisory Commission (MedPAC) and the Department of Health and Human Services Office of Inspector General (OIG), one thing is certain: The Centers for Medicare & Medicaid Services (CMS, formerly HCFA) is trying to do the best it can with the tools it's got. CMS is focusing this year on accuracy of the Minimum Data Set (MDS), the central document for clinical assessment and, under PPS, reimbursement. Ample evidence of facility confusion has surfaced over the years, most particularly in the recent OIG study disclosing a mishmash of PPS upcoding and downcoding without apparent reason. Through a variety of initiatives, CMS is attempting to get and keep facilities on track. Recently, Cindy Hake, a CMS senior policy analyst and a frequent presenter at the American Association of Nurse Assessment Coordinators (AANAC) national meetings, described these initiatives in some detail in an interview with Nursing Homes/Long Term Care Management Editor Richard L. Peck.
Peck: At a recent AANAC meeting you reported that some MDS accuracy improvement initiatives CMS undertook in May 2000 achieved a 70% reduction in MDS errors. How was this achieved?

Hake: First of all, I just want to say that CMS has recognized the importance of accurate MDS information since the inception of the MDS. Our accuracy improvement and promotion efforts are ongoing, and not just as a response to recent reports. The specific initiatives this year, though, do attempt to focus on the concerns raised by them.

The 70% error reduction refers to a reduction in the total volume of errors that are detectable off-site and the elimination of invalid values from the MDS database. This is the result of a system enhancement CMS implemented in May 2000 as part of MDS correction policy. This enhancement involves stricter enforcement of CMS edits, causing rejection of records that contain even one invalid value-for example, a code of 5 at an MDS item for which the valid response codes are 1, 2, 3 or 4. The MDS system rejects the record and sends back information about the error so that the facility can locate it, correct it and retransmit the record. Prior to this system enhancement, approximately 70% of the MDS records submitted to the database had at least one error of this type. Keep in mind that there are more than 500 items in an MDS assessment, and an "error" could have been something as simple as a transcription or data entry error. The important point is that this system enhancement improved the accuracy of information in the MDS database by effectively eliminating invalid data values. Some commercial software vendors have successfully integrated CMS's edits into their software packages. Such programs are helpful to facilities, in that they alert staff to invalid values, provide an opportunity to correct the errors prior to transmission and reduce the likelihood of record rejection.

In response to requests from the industry for an easy and automated mechanism to correct errors that are within the range of valid response codes-for example, a code of 2 should have been a 3 but both are valid responses-a second system enhancement was developed and implemented. This mechanism enables facilities to electronically correct (or modify) records. Facility staff might discover such an error in a variety of ways, such as their own internal editing and auditing processes, review of "warning" information in the facility feedback reports generated by the MDS system, or by having it called to their attention in the course of a survey or external audit process. Each individual who completes or corrects a portion of the MDS record must sign and attest to the accuracy of the portion(s) they completed. Modifications to MDS data should only be made when the resident's clinical record clearly substantiates the accuracy of the corrected information.

Peck: What about cases, though, in which there is simple confusion-for example, providers have raised concerns about interpretations of Section G1 (Activities of Daily Living), Section E (Mood and Behavior), Section N (Skin Condition) and Item B2a (Short-term Memory)-and this confusion is apparently getting them into trouble?

Hake: In the short term we are trying to address this by publishing MDS Q & A documents. We published our last set of 49 commonly asked questions this March and, hopefully, will have an even larger set available by the time this interview is published. These are available at the CMS Web site at and at the Web sites of many of the major professional organizations in the field. For providers' convenience, we've made the Q and As available at the electronic interface the facility has with the state.

We also plan to have a draft of a revised RAI User's Manual for Version 2.0 by the end of this year, which will incorporate the Q's and A's as of that date.

Peck: Regarding the RAI User's Manual, anecdotally there is evidence that a number of facilities are trying to function without it, for a variety of reasons. Is that your impression, and if so, what should facilities do about it?

Hake: We don't believe that's the case in all facilities. However, we were told by the industry during a debriefing last year at an AANAC meeting that staff in some facilities are either not paying attention to the manual or they simply don't have one. We would certainly urge facilities that don't have a manual to purchase a copy from their professional associations or to download it free of charge from the CMS Web site, although that would be a major printing job. Familiarity with the item-coding instructions in the User's Manual is still the best place to start in order to achieve MDS coding accuracy.

Peck: You've also pointed to your "Train the Trainer" program as a source of possible help in this area.

Hake: We convene annual national training conferences for our state and regional RAI and MDS automation coordinators who, in turn, function as a resource to nursing homes, MDS software vendors and professional associations by providing ongoing technical assistance and answering questions concerning MDS completion and transmission. A list of state RAI coordinators and state MDS coordinators, with their names, phone numbers and e-mail addresses, is published on the CMS Web site at

Peck: How important is it for a facility to have a full-time specialist, such as a nurse assessment coordinator, coordinating the MDS assessment, vs a clinical leader such as a director of nursing, who would oversee both the assessment process and care? I've heard it argued both ways.

Hake: The federal requirement is that each assessment must be coordinated by an RN. Facilities have the flexibility to decide how to staff this function.

Peck: Does CMS have other plans in the immediate future for addressing MDS accuracy improvement?

Hake: We have a set of "accuracy protocols," developed by Abt Associates, Inc., under contract to CMS. These protocols will be used by a program safeguard contractor (i.e., a centralized data surveillance contractor) to analyze and verify MDS data. In addition, we plan to develop a standard MDS training package. We have also been looking at ways to change and improve the MDS, and we have a goal to implement version 3.0 around year-end 2003. Naturally, these plans are subject to the approval and support of our new administration. NH

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