MDS 3.0 is Less than a Year Away
News update: since press time, we have learned the Senate version of the national health care reform bill contains a one-year delay in the implementation of RUG-IV. Also, the RAI Manual chapters expected to be released in December 2009 were not posted. Watch the Keane Care blog for news about these important developments: www.keanecare.com

The year-long countdown to MDS 3.0 implementation has started. You can begin studying the RAI Manual, become familiar with the MDS 3.0 forms, and plan your facilitys implementation. Keane Care has begun the final stage of design and programming of software for MDS 3.0.

CMS has released the pieces needed to implement MDS 3.0 on October 1, 2010 except for Chapters 2, 4, 6, and Appendix C of the RAI Manual, due to be posted in December 2009. The Medicare payment system is on schedule to begin using a revised payment system, RUG-IV, at the same time.

On October 30, 2009 CMS released the final format -- MDS 3.0, Version 1.0. It includes changes compared to previous versions such as how therapy is counted, renaming RAPs to CAAs (Care Area Assessment), addition of OMRAs, and deletion of Section T.

This article is an overview of the changes. Keane Care's MDS 3.0 White Paper provides more information: click here to read it at www.keanecare.com/products/pdf/mds30-flyer.pdf.

Payment Changes
When CMS tested RUG-IV against RUG-III using 2007 claims data, they found that RUG-IV would produce lower payments. CMS will adjust the weights so total payment is the same under both systems. Rates will be released in May and August 2010 in the SNF PPS Proposed and Final Rules.

An excerpt from the Final Rule released August 2009, page 40324: "For FY 2011, the system is being designed so that overall payments under RUG-IV will be the same as overall payments would have been under RUG-III. Although aggregate payments do not change, the distribution does change, which is why payment rates for complex medical groups (Extensive Care, Special Care, and Clinically Complex) will increase significantly."

Therapy: Changes Due with RUG-IV
In developing RUG-IV and MDS 3.0, CMS looked at utilization patterns and changes in the practice of therapy. CMS then made changes in how data is collected with MDS 3.0 that will affect payment.

One modification changes how residents qualify for Rehab Plus Extensive Services RUGs by eliminating the look-back periods in MDS 2.0 Section P1a. Under MDS 3.0 items received while not a resident, such as oxygen therapy and IVs, would be used only for care planning and not payment.

Another proposed change is to count therapy in three types:

  • Individual
  • Concurrent - treatment received with one other resident
  • Group - with 2 to 4 residents performing similar activities

    Section T was deleted. In MDS 2.0, it is used to record therapy that is ordered and scheduled, but not necessarily delivered during first 14 days

    Data Submission Changes
    Changes in submission requirements under MDS 3.0 are detailed in Chapter 5 of the 2009 RAI Manual. For MDS 3.0, assessments must be submitted to the national CMS system instead of state systems.
    Another change is that for all Federal/OBRA and PPS assessments, the MDS Completion Date (Z0500B) may be no later than 7 days from the Assessment Reference Date (A2300), rather than 14 days for MDS 2.0.

    Transmitting Data: under MDS 3.0, comprehensive assessments must be transmitted within 14 days of the Care Plan completion date (V0200C2). All other MDSs must be submitted within 14 days of the Completion Date (Z0500B). Under MDS 2.0, it's 31 days.

    Entry and discharge information must be transmitted within 14 (31 under MDS 2.0) days of the Entry or Discharge Date. MDS 3.0 submission files will be in a compressed ZIP file.

    Correcting assessments: To correct minor errors in an MDS 3.0 item after it is accepted in the CMS system, you submit a single Modification record. To correct a major error you submit a new Significant Correction or Significant Change in Status assessment.

    OMRA Changes
    Technical files released October 30, 2009 include four OMRA (Other Medicare Required Assessment) forms instead of one MDS 2.0 OMRA that must be completed 8-10 days after cessation of all therapies for residents in Rehab RUGs. The MDS 3.0 OMRAs:
  • Start of Therapy (12 pages)
  • Start of Therapy and Discharge (29 pages)
  • OMRA (20 pages)
  • OMRA-Discharge (32 pages)

    Rules for the use of OMRAs will be in chapters of the RAI Manual due to be released later in December 2009.

    RAPs now CAAs - Section V
    MDS 3.0 Section V is now titled Care Area Assessment (CAA) Summary instead of RAPs. The 20 Care Area problem areas are the same as the 18 RAPs with the addition of Pain and Return to Community Referral.

    MDS items that trigger CAAs are listed on CMS' MDS 3.0 Website, under "Data Technical Files" in "MDS 3.0 CAT Specifications." Chapter 4 of the RAI Manual, due for release later in December 2009, will provide instructions on the CAA process.

    Look-backs
    Look-back periods do not appear on some sections of the form, however many are specified in the instructions in Chapter 3 of the 2009 RAI Manual.

    Instructions by Section

    Chapter 3 of the 2009 RAI Manual includes detailed instructions on each MDS 3.0 Section. The following sections received major revisions:

    Cognitive Patterns - Section C The MDS 3.0 Cognitive Patterns section includes two assessment tools: the Brief Interview for Mental Status (BIMS) is used to test memory in a resident interview. The Confusion Assessment Method© (CAM) is a standard instrument completed by staff.

    Mood - Section D
    MDS 3.0 uses the PHQ-9©, Patient Health Questionnaire for depression screening. It's a checklist of nine symptoms of depression that is completed as a resident interview.

    Behavior - Section E
    MDS 3.0 Section E, Behavior, includes items on Psychosis, Rejection of Care, Wandering, and an assessment of all behavioral symptoms compared to the prior assessment.

    Customary Routine - Section F
    The new section F is a resident interview that may be completed by a family member or significant other.

    Gait and Falls - Sections G and J
    Experts agreed that the MDS could be improved to help reduce the number of falls. MDS 3.0 Section J includes a Fall History on Admission looking back 180 days prior to admission. Other items cover any falls and fall-related injuries since admission or prior assessment.

    Balance - Section G
    Input from experts on falls resulted in adding balance items that relate to fall risk. The 2009 RAI Manual, Chapter 3(G) calls for a 7-day look-back.

    Pain Items - Section J
    MDS 3.0 Section J includes a resident interview. The November 2009 RAI Manual, Chapter 3(J), devotes 20 pages to this section.

    Other Areas with Changes

    ADLs and Bathing - Section G
    Additions to Section G include "Instructions for Rule of 3" and a new coding level of "Activity occurred only once or twice." Chapter 3(G) of the 2009 RAI Manual contains 34 pages of information and instructions.

    Diagnoses - Section I
    Chapter 3(I) of the 2009 RAI Manual describes two look-back periods: Step 1, diagnosis identification, has a 30-day look-back. To qualify, disease conditions require a physican-documented diagnosis. After identified, a diagnosis must be determined to be active or not (Step 2).

    Swallowing/Nutritional - K
    A Swallowing Disorder item (K0100) was added. Weight Gain was dropped. K0300 - Weight Loss compares residents' weight in the current observation period with 30 and 180 days preceding.

    Skin Changes - Section M
    Changes made to MDS 3.0 that were designed to deliver necessary pressure ulcer information include:
  • Reverse staging is not allowed
  • Unstageable ulcers assessed separately
  • Staging is based on deepest anatomical change
  • Data is collected on ulcers present on admission
  • Pressure Ulcer Scale for Healing items was added
  • An item on Determination of Pressure Ulcer risk was added

    Special Treatments - Section O
    MDS 3.0 Section O combines MDS 2.0 Section P, W, and part of T. The list of special treatments includes two columns: one to check if received "while Not a resident" and one for "while a resident." Starting and Ending dates for therapy are required.

    Restraints - Section P
    Restraint information now has its own section. Items are divided into Used in Bed and Used in Chair/Out of Bed.

    Participation/Goals - Section Q A response of yes in Q0500 - Return to Community will trigger contact with the designated local contact agency within 10 business days. Appendix C (to be released in December 2009) will contain a list of designated local contact agencies.

    MDS 3.0 Resources
    CMS' MDS 3.0 Website includes the MDS 3.0 form, technical files, and the RAI Manual: www.cms.hhs.gov/NursingHomeQualityInits/25_NHQIMDS30.asp or click here.