Section I: Diagnoses

The coding instructions for I2300, Urinary Tract Infection, have been updated. As a review, UTI is the single diagnosis with unique coding rules, beginning on page I-8:

Item I2300 Urinary tract infection (UTI):

  • The UTI has a look-back period of 30 days for active disease instead of 7 days.
  • Code only if both of the following are met in the last 30 days:

1. It was determined that the resident had a UTI using evidence-based criteria such as McGeer, NHSN, or Loeb in the last 30 days,

AND

2. A physician documented UTI diagnosis (or by a nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws) in the last 30 days.

The change comes in the addition of a third and fourth bullet under “Coding Tips” on page I-9:

  • If the diagnosis of UTI was made prior to the resident’s admission, entry, or reentry into the facility, it is not necessary to obtain or evaluate the evidence-based criteria used to make the diagnosis in the prior setting. A documented physician diagnosis of UTI prior to admission is acceptable. This information may be included in the hospital transfer summary or other paperwork.
  • When the resident is transferred, but not admitted, to a hospital (e.g., emergency room visit, observation stay) the facility must use evidence-based criteria to evaluate the resident and determine if the criteria for UTI are met AND verify that there is a physician-documented UTI diagnosis when completing I2300 Urinary Tract Infection (UTI).

 

Section N: Medications

CMS corrected a spelling error, updated a web-link and changed wording on page N-11 to update the explanation accompanying the list of resources and tools:

The following resources and tools provide information on medications including classifications, warnings, appropriate dosing, drug interactions, and medication safety information.

The above resource list is not all-inclusive, and use of these resources is not required for MDS completion. The resources are being provided as a convenience, for informational purposes only, and CMS is not responsible for their accessibility, content, or accuracy. Providers are responsible for coding each medication’s pharmacological/therapeutic classification accurately. Caution should be exercised when using lists of medication categories, and providers should always refer to the details concerning each medication when determining its medication classification.

NOTE: References to non-CMS sources do not constitute or imply endorsement of these organizations or their programs by CMS or the U.S. Department of Health and Human Services and were current as of the date of this publication.

N0410: Medications Received

When an opioid, like Fentanyl, is delivered via a transdermal patch delivery system, code “days medication received” in N0410H for the number of times the patch was placed in the seven day lookback period. On page N-8 a new first bullet has been added:

  • A transdermal patch is designed to release medication over a period of time (typically 3–5 days); therefore, transdermal patches would be considered long-acting medications for the purpose of coding the MDS, and only the days the staff attaches the patch to the skin are counted for the MDS. For example, if, during the 7-day look-back period, a fentanyl patch was applied on days 1, 4, and 7, N0410H Opioid would be coded 3, because the application occurred on 3 days during the look-back period.

A coding tip concerning coding antipsychotics was relocated from page N-17 to the first bullet on page N-13:

  • Any medication that has a pharmacological classification or therapeutic category of antipsychotic medication must be recorded in this section, regardless of why the medication is being used.
     

N0450: Antipsychotic Medication Review

The coding tips for N0450B and N0450C were revised, and is now found on pages N-13 and N-14. Many new instructions were included and should be read carefully. Many are not new but were previously located later in the chapter.

Coding Tips and Special Populations (N0450B and N0450C)

  • Within the first year in which a resident is admitted on an antipsychotic medication or after the facility has initiated an antipsychotic medication, the facility must attempt a GDR in two separate quarters (with at least one month between the attempts), unless physician documentation is present in the medical record indicating that a GDR is clinically contraindicated. After the first year, a GDR must be attempted at least annually, unless clinically contraindicated (see F758 in Appendix PP of the State Operations Manual).
  • In N0450B and N0450C, include GDR attempts conducted since the resident was admitted to the facility, if the resident was receiving an antipsychotic medication at the time of admission, OR since the resident was started on the antipsychotic medication, if the medication was started after the resident was admitted.
  • Do not include gradual dose reductions that occurred prior to admission to the facility (e.g., GDRs attempted during the resident’s acute care stay prior to admission to the facility).
  • If the resident was admitted to the facility with a documented GDR attempt in progress and the resident received the last dose(s) of the antipsychotic medication of the GDR in the facility, then the GDR would be coded in N0450B and N0450C.
  • If the resident received a dose or doses of an antipsychotic medication that was not part of a documented GDR attempt, such as if the resident received a dose or doses of the medication PRN or one or two doses were ordered for the resident for a specific day or procedure, these are not coded as a GDR attempt in N0450B and N0450C.
  • Discontinuation of an antipsychotic medication, even without a GDR process, should be coded in N0450B and N0450C as a GDR, as the medication was discontinued. When an antipsychotic medication is discontinued without a gradual dose reduction, the date of the GDR in N0450C is the first day the resident did not receive the discontinued antipsychotic medication.
  • The start date of the last attempted GDR should be entered in N0450C, Date of last attempted GDR. The GDR start date is the first day the resident received the reduced dose of the antipsychotic medication.
  • In cases in which a resident is or was receiving multiple antipsychotic medications on a routine basis and one medication was reduced or discontinued, record the date of the reduction attempt or discontinuation in N0450C.
  • If multiple dose reductions have been attempted since admission OR since initiation of the antipsychotic medication, record the date of the most recent reduction attempt in N0450C.
  • Federal requirements regarding GDRs are found at 42 CFR 483.45(d) Unnecessary drugs and 483.45(e) Psychotropic drugs.

Under coding tips for N0450E, what is now the second bullet was added on page N-14:

  • In N0450D and N0450E, include physician documentation that a GDR attempt is clinically contraindicated since the resident was admitted to the facility, if the resident was receiving an antipsychotic medication at the time of admission, OR since the resident was started on the antipsychotic medication, if the medication was started after the resident was admitted to the facility.

Please note that many coding tips previously listed in this section were moved to the correct location as noted earlier.

Section P: Alarms and Restraints

In the coding instructions for P0100: Physical Restraints, a new coding tip was added as the fourth bullet on page P-5:

  • When coding this section, do not consider as a restraint a locked/secured unit or building in which the resident has the freedom to move about the locked/secured unit or building. Additional guidance regarding locked/secured units is provided in the section “Considerations Involving Secured/Locked Areas” of F603 in Appendix PP of the State Operations Manual.

A few revisions were made in the coding instructions for P0200: Alarms. On page P-9, under “Planning for Care” a new fourth bullet has been added:

  • When an alarm is used as an intervention in the resident’s safety strategy, the effect the alarm has on the resident must be evaluated individually for that resident.

On page P-10, under “Coding Tips” there are a few revisions. The first bullet has been revised as follows:

  • Wander/elopement alarm includes devices such as bracelets, pins/buttons worn on the resident’s clothing, sensors in shoes, or building/unit exit sensors worn by/attached to the resident that activate an alarm and/or alert the staff when the resident nears or exits a specific area or the building. This includes devices that are attached to the resident’s assistive device (e.g., walker, wheelchair, cane) or other belongings.

The eight bullet revision is below:

  • Bracelets or devices worn by or attached to the resident and/or his or her belongings that signal a door to lock when the resident approaches should be coded in P0200E Wander/elopement alarm, whether or not the device activates a sound or alerts the staff.

A tenth bullet, that did not appear in the original version, has been added:

  • When determining whether the use of an alarm also meets the criteria of a restraint, refer to the section “Determination of the Use of Position Change Alarms as Restraints” of F604 in Appendix PP of the State Operations Manual.