This monthly blog will discuss all the components of quality clinical documentation with a comprehensive approach to cover all areas of the healthcare industry.
By Jennifer Gross, BSN, RN-BC, RAC-CT
The minimum data set (MDS) coordinator is a key player in a skilled nursing facility’s (SNF’s) team. More formally known as registered nurse assessment coordinators (RNACs), they run the show for collecting assessment data on all the residents in the SNF, ensuring that these data elements are encoded in the MDS and submitted to the Centers for Medicare and Medicaid Services (CMS)—all according to a strict mandated schedule. A successful RNAC needs to be meticulous, organized, skilled in communicating with and coordinating the interdisciplinary team (a.k.a. “herding cats”), and able to learn on the job as CMS updates its regulatory requirements.
I speak from experience—I was the sole MDS coordinator in an SNF early in my career, and in my current role, I work with these busy professionals to help them do their jobs effectively. And I mean it when I mentioned learning on the job: When I first started in the role in the late ’90s, I had little training and needed to get up to speed quickly to tackle a three-month backlog of MDSs. Needless to say, I didn’t know much beyond the “paper compliance” of scheduling and completing the assessments. As I grew into the position, I got to know the finer points of capturing the right information for reimbursement under the Medicare prospective payment system (PPS), as well as clinical reporting through CMS’ quality measures (QMs). I quickly learned that very small errors—even one item on the MDS—can have a big impact on reimbursement, quality reporting, and having an effective and up-to-date resident care plan.
In the nearly two decades (yikes!) since then, I’ve seen the MDS come to be more important in the role SNFs play in the post-acute-care space. The hot topic in healthcare is the drive toward improving quality throughout the care continuum, spurred by CMS’ shift toward value-based reimbursement. “Big data” is a big part of the future in healthcare, with the focus on using patient data to measure quality and drive clinical decision-making. The specialty of health informatics is growing in post-acute care; informatics makes the connection between the technology in the electronic health record (EHR), the data output of that technology, and the clinical decision-making that drives care delivery and good patient outcomes. The RNAC is (figuratively) up to their elbows in data every day, and growth and professional development to incorporate an informatics perspective is a natural evolution of the role.
MDS coordinators, take a moment to think about the expertise you bring to the table and how it can dovetail into both an overall informatics system and a more specific clinical documentation improvement (CDI) program. Like Dorothy learning that she had the power to get home from Oz all along, you also have the skills and knowledge to bring about improvement in your organization. You know the details of how the MDS works, the various sources that feed into the data, and what happens when there is a disconnect in that information flow. Own your expertise!
The concept of a formal CDI program has not been very widespread in the SNF world when compared to acute care. While most MDS coordinators would not think of themselves as CDI specialists, that is effectively what they are doing every time they need to ask a colleague for more details about their documentation or educate the interdisciplinary team about the specific MDS coding definitions for an item. Let’s put a little more structure around this informal process with a few practice tips:
- Identify patterns of documentation issues: MDS coordinators know where to find the source documentation for the MDS; they also know where the gaps are. Audit your MDSs and address recurrent issues with the responsible discipline. An example would be a chronic diagnosis that “disappears” between MDSs because the MDS definition of an active diagnosis requires physician documentation in the record within the last 60 days. If this happens frequently, address the underlying process or workflow issue with the department head (or in this case, the medical director).
- Clarify documentation misconceptions: The MDS is an interdisciplinary assessment, and that may lead to discrepancies related to the different disciplines’ areas of focus. For example, activities of daily living (ADLs) are looked at very differently by the therapy department and the nursing department; therapy tends to document the resident’s abilities while nursing documents dependencies. Neither of these is wrong; you should work with the two disciplines to make sure the progress notes and ADL documentation show the entire picture of the resident’s functioning.
- Ensure skilled services are backed up by the documentation: Federal regulations in the Medicare Benefit Policy Manual require documentation of the necessity for daily skilled services for Medicare reimbursement. This requires interdisciplinary collaboration and communication. Consider incorporating a documentation review into your triple-check process as you prepare to submit claims; more proactively, work with your admissions department to identify each resident’s drivers of skilled care (PT/OT, medication management, wound care, etc.) at the beginning of the stay to prevent gaps in the documentation.
It’s especially important to think of CDI in the context of what lies ahead: the patient-driven payment model (PDPM) for Medicare, which CMS published in the FY 2019 SNF Final Rule. The intent of PDPM is to reimburse SNFs based on each resident’s clinical needs rather than the volume of therapy provided. The PDPM doesn’t go into effect until October 1, 2019, but between now and then, SNFs will need to prepare. An informatics approach is ideal, by using your data (from the MDS, other applications in your EHR, pharmacy, therapy, etc.) to get a full picture of the residents in your facility. A key driver in PDPM will be ICD-10 codes, which have had less importance on the MDS until now. MDS coordinators can lead the charge to improve documentation and communication so that the resident’s specific diagnoses are captured on the MDS. The MDS tells a story about each resident in an SNF. These challenges are an opportunity to take a second look at your residents with a more complete perspective.
Jennifer Gross is senior healthcare specialist at PointRight Inc.