To centralize or decentralize the MDS department: That is the question

There are pros and cons to most decisions we make. How to organize the MDS department is no exception. A centralized structure focuses on having one or two MDS nurse coders for the entire resident population. Decentralizing the MDS office puts the responsibility for MDS coordinating and coding on a nurse manager in charge of one or more resident units. Each of these types of organizational structure has its pros and each structure can put organizations at risk for survey deficiencies, lost revenue and poor satisfaction among residents and staff.

In a recent AANAC online poll question, we asked our members whether they used a centralized or decentralized MDS department structure. 0ver 85 percent of respondents indicated that their facility used the centralized organizational structure, which has one or two nurses coordinating and coding the MDS for the entire facility. The benefit of this method is that the nurses are usually provided strong support for learning the MDS manual instructions as well as Medicare and Medicaid reimbursement system guidelines. Accuracy of reimbursement is enhanced because the coder is knowledgeable about coding constructs. Third-party audit recoupment is reduced because the coder is focused on coding the MDS according to the medical record.

The downside of this structure is that it is difficult for one nurse to know all 100 residents or two nurses to know 150 residents (whatever the census and however the duties are divided). The higher the Medicare population, with frequent admissions and discharges, the more difficult it is for one or two nurses to know the residents and ensure that each MDS reflects the true picture of the actual resident’s strengths, problems and risks.

Decentralizing the MDS nurse functions is a growing trend in facilities. The primary reason for this is to ensure that each resident’s MDS, care area assessments and care planning directly reflect the resident’s truest status.  Nurse managers and care coordinators know their residents well and therefore have a firsthand picture of the resident in the look-back period.

However, the downside to nurse managers coding the MDS is that they may not have the time to ensure that the medical record truly supports their coding and knowledge of the resident. Under audit, the medical record can easily lack the supporting documentation, and discrepancies are less likely to be addressed, putting the facility at audit risk.

Multiple unit coders, on the other hand, may not be given the time and resources to keep their MDS knowledge and skills current. Inaccurate coding, poor chart support, and lower revenues can be extremely detrimental to the facility.

To centralize or decentralize the MDS department? That is still the question. Regardless of which structure you choose, ensure that the MDS nurse coordinators for the building and for the individual resident units have the skills they need to code accurately. Here are some essentials for any nurse assessment coordinator:

  • Ensure that all MDS team members have a current RAI coding manual at their fingertips.
  • Support the MDS coder(s) to attend regular trainings outside the facility that will provide them with opportunities to get the latest information on updates and allow them to ask questions.
  • Create an environment where regular, random auditing of MDS and charting systems is conducted. Auditing that is focused on accuracy and charting system quality is essential to regulatory compliance.
  • Conduct time studies to determine the coding caseload as well as other duties, to ensure that the designated MDS coders have enough time to do their job well. The survey, Quality Measure, reimbursement and audit outcomes are too important to have the coders rushing to get the job done.

Judi Kulus is Vice President of Curriculum Development, American Association of Nurse Assessment Coordination (AANAC). She can be reached at

Topics: Articles , Executive Leadership , Facility management , MDS/RAI