In MDS 3.0 Section B (Hearing, Speech, and Vision), nurse assessment coordinators (NACs) might be surprised by the importance of two items: B0700 (Makes Self Understood) and B1000 (Vision). Here’s why they should matter to interdisciplinary team members who code these items—and what NACs should check to ensure coding accuracy:
B0700: QM covariate plus more
B0700 is a covariate for three claims-based publicly reported quality measures (QMs) that are used in the Five Star Quality Rating System, according to the technical specifications:
· Percent of Residents Who Were Rehospitalized After a Nursing Home Admission (Short Stay);
· Percent of Residents Who Have Had an Outpatient Emergency Department Visit (Short Stay); and
· Percent of Residents Who Were Successfully Discharged to the Community (Short Stay).
In addition, this item will be a covariate for the four Skilled Nursing Facility Quality Reporting Program (SNF QRP) outcome-based functional QMs that SNFs will begin collecting data for on Oct. 1, 2018, according to the technical specs:
· Application of IRF Functional Outcome Measure: Change in Self-Care Score for Medical Rehabilitation Patients (NQF #2633);
· Application of IRF Functional Outcome Measure: Change in Mobility Score for Medical Rehabilitation Patients (NQF #2634);
· Application of IRF Functional Outcome Measure: Discharge Self-Care Score for Medical Rehabilitation Patients (NQF #2635); and
· Application of IRF Functional Outcome Measure: Discharge Mobility Score for Medical Rehabilitation Patients (NQF #2636).
For care planning, B0700 is part of the Review of Indicators for eight care area assessments (CAAs) in Appendix C, “CAA Resources,” of the RAI Manual:
· Cognitive Loss/Dementia;
· ADLs – Functional Status/Rehabilitation Potential;
· Psychosocial Well-Being;
· Nutritional Status; and
· Dehydration/Fluid Maintenance.
On the payment side, B0700 is a qualifier for the little-used RUG-IV category Behavioral Symptoms and Cognitive Performance under the Medicare Part A skilled nursing facility prospective payment system (SNF PPS). However, the current version of the Patient-Driven Payment Model (PDPM), which is slated to replace RUG-IV in the SNF PPS, uses B0700 to help calculate a resident’s cognitive level. The draft PDPM for SNFs explains what that means.
The cognitive level score utilized in the PDPM resident classification is used for the SLP payment components. The cognitive score is calculated based on scores for two other cognitive measures, the Brief Interview for Mental Status (BIMS) and the Cognitive Performance Scale (CPS) using elements of the staff assessment. The cognitive score process assigns one of four cognitive performance levels based on a resident’s BIMS or CPS score.
NACs can prepare for resident classification under the PDPM by focusing on MDS coding accuracy, says Carol Maher, RN-BC, RAC-MT, CPC, director of education for Hansen, Hunter & Co. PC based in Vancouver, WA. “Accurately coding B0700 and other resident characteristics on the MDS will be very important toward resident classification. All of these items have to be accurate—as every item always has to be accurate on the MDS.”
Key coding issue for B0700
B0700 assesses a resident’s ability to express needs and wants. The definition for “makes self understood” from the RAI Manual (page B-6) is as follows:
Able to express or communicate requests, needs, opinions, and to conduct social conversation in his or her primary language, whether in speech, writing, sign language, gestures, or a combination of these. Deficits in the ability to make one’s self understood (expressive communication deficits) can include reduced voice volume and difficulty in producing sounds, or difficulty in finding the right word, making sentences, writing, and/or gesturing.
The item asks assessors to code residents as 0 (understood), 1 (usually understood – difficulty communicating some words or finishing thoughts but is able if prompted or given time), 2 (sometimes understood – ability is limited to making concrete requests), or 3 (rarely/never understood).
In addition to being important for QMs and care planning, “B0700 is important for deciding whether the resident is capable of being interviewed,” says Maher. “However, the interviews need to be attempted on or before the assessment reference date, and the B0700 question is answered after reviewing the entire seven-day look-back. So the interviews are actually done or attempted before answering B0700.”
This sometimes causes a coding disconnect, says Maher. “On MDS review, often I will see that the resident has been capable of answering, for example, the PHQ-9 or the activity interview, yet B0700 is coded as they are rarely or never understood. The two answers are not compatible. If the resident is capable of answering interview questions, then they are more than rarely or never understood.”
“Like Section C (Cognitive Patterns) and Section E (Behavior), Section B is often completed by social workers,” adds Kristin Bernard Breese, BSN, RN, CPC, RAC-MT, owner of Post-Acute Clinical Advisors LLC in North Granby, CT. “Sometimes when social workers who code this item say that residents are rarely or never understood, you get a different picture when you ask the CNAs about those same residents. For example, the CNA will say, ‘I know when this resident wants X because this is what she does.’ That suggests the resident is at least sometimes understood.”
Many social workers don’t understand how big an impact Section B has, points out Breese. “As a result, social workers are probably not going to the CNAs and asking questions. They frequently don’t even look at the nursing notes for the last seven days. They code solely based on what they know. So while MDS coordinators don’t want to be in the position of checking everyone’s work, they do need to educate the social workers on the assessment process and the coding definitions and then keep track of big-ticket items like B0700 to make sure they are correct before the MDS goes out the door.”
B1000 counts for QMs and care planning
B1000 is a covariate for two QMs:
· The claims-based publicly reported Five Star QM, Percent of Residents Who Were Successfully Discharged to the Community (Short Stay); and
· The MDS-based publicly reported Five Star QM, Percent of Residents Whose Ability to Move Independently Worsened (Long Stay). Note: Access the technical specs for MDS-based Five Star/CASPER QMs here.
In addition, for care planning, B1000 is part of the Review of Indicators for the following eight CAAs in Appendix C of the RAI Manual:
· Cognitive Loss/Dementia;
· Visual Function;
· ADLs - Functional Status/Rehabilitation Potential;
· Psychosocial Well-Being;
· Behavioral Symptoms;
· Fall Risk; and
· Nutritional Status.
Coding issues for B1000
B1000 assesses a resident’s ability to see in adequate light with glasses or other visual appliances. The RAI Manual (page B-9) defines adequate light as “lighting that is sufficient or comfortable for a person with normal vision to see fine detail.”
Assessors are asked to use the following coding methodology, according to the RAI Manual (page B-10):
• Code 0, adequate: if the resident sees fine detail, including regular print in newspapers/books.
• Code 1, impaired: if the resident sees large print, but not regular print in newspapers/books.
• Code 2, moderately impaired: if the resident has limited vision and is not able to see newspaper headlines but can identify objects in his or her environment.
• Code 3, highly impaired: if the resident’s ability to identify objects in his or her environment is in question, but the resident’s eye movements appear to be following objects (especially people walking by).
• Code 4, severely impaired: if the resident has no vision, sees only light, colors or shapes, or does not appear to follow objects with eyes.
However, most assessors don’t realize that B1000 is an interview item, says Breese. “They think this item is just asking if the resident’s vision is impaired or not, but during the national training for the introduction of the MDS 3.0, we received laminated cue cards with a 12-point car and a 16-point airplane for the vision interview. Unfortunately, some assessors cut corners on items like B1000, thinking ‘What does it really matter?’ But accuracy does matter. Assessors need to actually go in and test the resident’s vision.”
The steps for assessment and coding tips for B1000 in the RAI Manual (pages B-9 – B10) are as follows:
1. Ask direct care staff over all shifts if possible about the resident’s usual vision patterns during the 7-day look-back period (e.g., is the resident able to see newsprint, menus, greeting cards?).
2. Then ask the resident about his or her visual abilities.
3. Test the accuracy of your findings:
• Ensure that the resident’s customary visual appliance for close vision is in place (e.g., eyeglasses, magnifying glass).
• Ensure adequate lighting.
• Ask the resident to look at regular-size print in a book or newspaper. Then ask the resident to read aloud, starting with larger headlines and ending with the finest, smallest print. If the resident is unable to read a newspaper, provide material with larger print, such as a flyer or large textbook.
• When the resident is unable to read out loud (e.g. due to aphasia, illiteracy), you should test this by another means such as, but not limited to:
— Substituting numbers or pictures for words that are displayed in the appropriate print size (regular-size print in a book or newspaper).
§ Coding Tips and Special Populations:
• Some residents have never learned to read or are unable to read English. In such cases, ask the resident to read numbers, such as dates or page numbers, or to name items in small pictures. Be sure to display this information in two sizes (equivalent to regular and large print).
• If the resident is unable to communicate or follow your directions for testing vision, observe the resident’s eye movements to see if his or her eyes seem to follow movement of objects or people. These gross measures of visual acuity may assist you in assessing whether or not the resident has any visual ability. For residents who appear to do this, code 3, highly impaired.
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