When the nurse assessment coordinator (NAC) prepares to code the MDS, the process starts with data collected during the lookback period. However, one frequently-asked question is, “When can services that occurred prior to admission to the skilled nursing facility (SNF) be captured on the MDS?” There is no simple answer, because it depends on the coding instructions for each MDS item. Let’s take a look at the particulars of coding preadmission data, why it is collected, and how preadmission data is used under PDPM.
Chapter 3 of the RAI User’s Manual contains the coding instructions for each MDS item; however, the overview of chapter 3, pages 3-1 through 3-6, are often overlooked. This brief section discusses coding conventions, which apply to all MDS items, and includes the instructions on preadmission data:
With the exception of certain items (e.g., some items in Sections K and O), the lookback period does not extend into the preadmission period unless the item instructions state otherwise. In the case of reentry, the lookback period does not extend into time prior to the reentry, unless instructions state otherwise.
MDS Item Set 1.17.1 Preadmission Data and Why It Is Collected