To: All Indiana Medicaid Nursing Facility Providers Subject


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Indiana Title XIX

MEDICAID BULLETIN

BT199932

OCTOBER 1, 1999

To:

All Indiana Medicaid Nursing Facility Providers

Subject: Supportive Documentation Guidelines Related to Resource Utilization Group (RUG)-III Version 5.01

Overview

The purpose of this bulletin is to remind Medicaid-certified nursing facilities of the requirements for Minimum Data Set (MDS) supportive documentation. Please be advised that supportive documentation for all MDS data elements that are utilized to classify nursing facility residents in accordance with the RUG-III resident classification system must be routinely maintained in each resident’s medical chart. Such supportive documentation shall be maintained by the nursing facility for all residents.
Attached are revised Supportive Documentation Guidelines that will assist you in identifying and documenting all MDS data elements that are utilized to classify nursing facility residents in accordance with the RUG-III resident classification system.
Note: Revisions have been bolded for your convenience.
If you have any questions regarding the information contained in this bulletin, please contact the Myers and Stauffer help desk at (317) 8164122. For questions about the Supportive Documentation Guidelines and the EDS review process, please contact the EDS Long Term Care Unit at (317) 488-5099.

NOTE: Beginning October 1, 1999, an MDS record will not be considered inaccurate unless the audited MDS values result in a new RUG-III classification for the resident record.

Prepared by the Office of Medicaid Policy and Planning, October 1, 1999 (Version 2)

EDS

1

P. O. Box 68420

Indianapolis, IN 46268-0420

Indiana Title XIX BT199932

Supportive Documentation Guidelines Related to RUG-III Version 5.01 October 1, 1999

Table 1.1 – Special Rehabilitation

MDS 2.0 Location G1a,b,i Col. A,B and G1h,A ADL ONLY
K5a ADL ONLY
K5b ADL ONLY
P1b a,b,c Col. A,B
P3a-i LOW INTENSITY ONLY

Field Description Physical Functioning and Structural Problems ADLs Parenteral/IV
Feeding Tube
Therapies
Nursing Rehab/ Restorative

MDS 2.0 VERSION 5.01
SPECIAL REHABILITATION
Charting Guidelines
Four ADLs must be addressed in the medical chart for purposes of validating the MDS responses. These ADLs include bed mobility, transfer, toileting, and eating. Consider the resident’s self-performance and support provided during all shifts, as functionality may vary.
Evidence of an IV or heparin lock where IV fluids have been given continuously or intermittently must be cited in the medical chart.
Documented evidence of a feeding tube that can deliver food/nutritional substances/fluids/medications directly into the gastrointestinal system.
Days and minutes of each therapy must be cited in the medical chart on a daily basis to support the total days and minutes of direct therapy provided.
Days of restorative nursing must be cited in the medical chart on a daily basis. Minutes of service must be provided daily to support the total time that is then converted to days on the MDS.

Possible Chart Location
NN, SSN, SN, CP, NR
NN, SN, PO, PPN, CP, Hospital records NN, SN, DN, PO, PPN, CP
TN, PO
NR, NN, SN, CP

Very High Intensity

450 minutes or more of therapy per week and one type of therapy at least five days a week and two or more therapies delivered.

ADL Score

RUG-III

14-18 RVC

8-13 RVB

4-7

RVA

High Intensity
300 minutes or more of therapy per week and one type of therapy at least five days a week delivered.

ADL Score 15-18 12-14 8-11 4-7

RUG-III
RHD RHC RHB RHA

Medium Intensity
150 minutes or more of therapy per week and five days or more of one or a combination of therapy delivered.

ADL Score 16-18 8-15 4-7

RUG-III
RMC RMB RMA

Low Intensity

45 minutes or more of therapy per week and three days or more of one or a combined therapy and two types or more of nursing restorative, five or more days per week.

ADL Score

RUG-III

12-18

RLB

4-11

RLA

NOTE: Beginning October 1, 1999, an MDS record will not be considered inaccurate unless the audited MDS values result in a new RUG-III classification for the resident record.

Prepared by the Office of Medicaid Policy and Planning, October 1, 1999 (Version 2)

EDS

2

P. O. Box 68420

Indianapolis, IN 46268-0420

Indiana Title XIX BT199932

Supportive Documentation Guidelines Related to RUG-III Version 5.01 October 1, 1999

Table 1.2 – Extensive Services

MDS 2.0 VERSION 5.01

EXTENSIVE SERVICES

MDS 2.0 Location

Field Description

Charting Guidelines

Possible Chart Location

G1a,b,i
Col. A,B and
G1h,A
ADL ONLY

Physical Functioning and Structural Problems
ADLs

Four ADLs must be addressed in the medical chart for purposes of validating the MDS responses. These ADLs include bed mobility, transfer, toileting, and eating. Consider the resident’s self-performance and support provided during all shifts, as functionality may vary.

NN, SSN, SN, CP, NR

K5a*

Parenteral/IV

Evidence of an IV or heparin lock must be cited in the medical chart.

NN, SN, PO, PPN, CP, Hospital records

K5b
ADL ONLY

Feeding Tube

Documented evidence of a feeding tube that can deliver food/nutritional substances/fluids/medications directly into the gastrointestinal system.

NN, SN, DN, PO, PPN, CP

P1a,i*

Suctioning

Evidence of nasopharyngeal or tracheal aspiration must be cited in the medical chart.

NN, SN, PO, PPN, CP, TN, Hospital records

P1a,j*

Tracheostomy Care

Evidence of tracheostomy and cannula cleansing administered by staff must be cited in the medical chart.

NN, SN, PO, PPN, CP, TN, Hospital records

P1a,l*

Ventilator or Respirator

Evidence of ventilator or respirator assistance must be cited in the medical chart. Any resident who was in the process of being weaned off the ventilator or respirator in the last 14 days should be coded. Neither CPAP nor BiPAP are considered ventilator devices and are not considered for audit validation.

NN, SN, PO, PPN, CP, TN, Hospital records

*At least one of the above treatments must be coded and have an ADL score of 7 or more. If the ADL score is 6 or less, the record will classify in the Clinically Complex group.

TREATMENTS

RUG-III

3 or more

SE3

2

SE2

1

SE1

NOTE: Beginning October 1, 1999, an MDS record will not be considered inaccurate unless the audited MDS values result in a new RUG-III classification for the resident record.

Prepared by the Office of Medicaid Policy and Planning, October 1, 1999 (Version 2)

EDS

3

P. O. Box 68420

Indianapolis, IN 46268-0420

Indiana Title XIX BT199932

Supportive Documentation Guidelines Related to RUG-III Version 5.01 October 1, 1999

MDS 2.0 Location G1a,b,i Col. A,B and G1h,A ADL ONLY I1w* I1z*
I2g*
K5a ADL ONLY K5b*
M2a*
M4b*
P1a,c*

Field Description Physical Functioning and Structural Problems ADLs Multiple Sclerosis Quadriplegia
Septicemia
Parenteral/IV
Feeding Tube
Pressure Ulcer (stage 3 or 4)
Burns
IV Medications

Table 1.3 – Special Care
MDS 2.0 VERSION 5.01
SPECIAL CARE
Charting Guidelines
Four ADLs must be addressed in the medical chart for purposes of validating the MDS responses. These ADLs include bed mobility, transfer, toileting, and eating. Consider the resident’s selfperformance and support provided during all shifts, as functionality may vary.
An active physician diagnosis must be present in the medical chart.
An active physician diagnosis must be present in the medical chart. Paralysis of all four limbs must be cited in the medical record. Usually caused by cerebral hemorrhage, thrombosis, embolism, tumor, or spinal cord injury.
An active physician diagnosis must be present in the medical chart. Septicemia is a morbid condition associated with bacterial growth in the blood. Urosepsis is not considered for audit validation. Evidence of an IV or heparin lock must be cited in the medical chart.
Documented evidence of a feeding tube that can deliver food/nutritional substances/fluids/medications directly into the gastrointestinal system.
All pressure ulcers must be described and staged as they appear during the observation period on the MDS. This may require the stage to be increased or decreased from the previous MDS.
All second and third degree burns must be documented in the medical chart.
Documentation must be present in the medical chart.

Possible Chart Location
NN, SSN, SN, CP, NR
PO, PPN, NN, CP, SN, NR PO, PPN ,NN, CP, SN, NR
PO, PPN, NN, LAB, SN
NN, SN, PO, PPN, CP, Hospital records NN, SN, DN, PO, PPN, CP
NN, SN, PO, PPN, CP, DN, TN, Wound record
NN, SN, PO, PPN, CP, DN, TN, Skin sheet NN, MAR, PO, CP, Hospital records (Continued)

NOTE: Beginning October 1, 1999, an MDS record will not be considered inaccurate unless the audited MDS values result in a new RUG-III classification for the resident record.

Prepared by the Office of Medicaid Policy and Planning, October 1, 1999 (Version 2)

EDS

4

P. O. Box 68420

Indianapolis, IN 46268-0420

Indiana Title XIX BT199932

Supportive Documentation Guidelines Related to RUG-III Version 5.01 October 1, 1999

MDS 2.0 VERSION 5.01

SPECIAL CARE

MDS 2.0 Location

Field Description

Charting Guidelines

Possible Chart Location

P1a,h*

Radiation

Includes radiation therapy or a radiation implant. Documentation must be available in the medical chart.

NN, SN, PO, PPN, SSN, DNCP, Hospital records

B1**

Comatose

Must have a documented neurological diagnosis of PO, PPN, NN, CP, coma or persistent vegetative state from physician. SN

N1d**

Time Awake (None of Above)

Evidence of time awake or nap frequency should be cited in the medical chart to validate the response.

NN, SN, PPN, CP, SSN, NR, CNAN

J1h**

Fever

Recorded temperature 2.4 degrees greater than the baseline temperature. The route (rectal, oral, etc…) of temperature measurement must be consistent between the baseline and the elevated temperature.

NN, SN, Vital sign sheet

I2e**

Pneumonia

An active physician diagnosis must be present in the medical chart. Often there is a chest x-ray, medication order and notation of fever and symptoms.

PO, PPN, NN, SN, X-RAY

J1c**

Dehydration; output exceeds input

Supportive documentation might include intake/output records and thorough nurses’ documentation describing the resident’s symptoms and/or fluid loss that exceeds intake.

PO, PPN, NN, CP, SN, LAB

J1o**

Vomiting

Evidence must be cited in the medical chart.

NN, SN, SSN, PPN

K3a**

Weight Loss

Documented evidence in the medical chart of the resident’s weight loss as defined on the MDS.

NN, SN, DN, CP, SSN ,PPN, Weight sheet

**Special combination considerations: When B1=coma, all ADL self-performance (G1a,b,h,i) are coded with a 4 or 8 and time awake (N1d-None of Above) is checked.

When J1h, fever is checked, one of the following must also be checked; I2e, pneumonia; J1c, dehydration; J1o, vomiting; K3a, weight loss.

*At least one of the above conditions must be coded and have an ADL score of 7 or more. If the ADL score is 6 or less, the record will classify in the Clinically Complex group.

ADL Score

RUG-III

17-18

SSC

14-16

SSB

7-13

SSA

NOTE: Beginning October 1, 1999, an MDS record will not be considered inaccurate unless the audited MDS values result in a new RUG-III classification for the resident record.

Prepared by the Office of Medicaid Policy and Planning, October 1, 1999 (Version 2)

EDS

5

P. O. Box 68420

Indianapolis, IN 46268-0420

Indiana Title XIX BT199932

Supportive Documentation Guidelines Related to RUG-III Version 5.01 October 1, 1999

Table 1.4 – Clinically Complex

MDS 2.0 VERSION 5.01

CLINICALLY COMPLEX

MDS 2.0 Location

Field Description

Charting Guidelines

Possible Chart Location

G1a,b,i
Col. A,B and
G1h,A
ADL ONLY

Physical Functioning and Structural Problems
ADLs

Four ADLs must be addressed in the medical chart for purposes of validating the MDS responses. These ADLs include bed mobility, transfer, toileting, and eating. Consider the resident’s self-performance and support provided during all shifts, as functionality may vary.

NN, SSN, SN, CP, NR

I1r*

Aphasia

An active physician diagnosis must be present NN, SSN, SN,

in the medical chart. Aphasia is defined as

CP, PPN, PO

difficulty in communicating orally, through sign,

or in writing, or the inability to understand such

communication. This difficulty must be cited in

the medical chart.

I1s*

Cerebral Palsy An active physician diagnosis must be present in PO, PPN, NN,

the medical chart. Paralysis related to

CP, SN

developmental brain defects or birth trauma.

I1v*

Hemiplegia/ An active physician diagnosis must be present in PO, PPN, NN,

Hemiparesis the medical chart. Left or right-sided paralysis is CP, SN, NR

acceptable as a diagnosis.

I2e*

Pneumonia

An active physician diagnosis must be present in PO, PPN, NN,

the medical chart. Often there is a chest x-ray,

SN, X-RAY

medication order and notation of fever and

symptoms.

I2j*

Urinary Tract Includes chronic and acute symptomatic

PO, PPN, NN,

Infection

infection(s) in the last 30 days. There must be

LAB, SN

current supportive documentation. Significant

laboratory findings in the medical chart are not

required for audit validation.

J1c*

Dehydration; Supportive documentation might include

PO, PPN, NN,

output exceeds intake/output records and thorough nurses’

CP, SN, LAB

input

documentation describing the resident’s

symptoms and/or fluid loss which exceeds intake.

J1j*

Internal

Clinical evidence must be cited in the medical

NN, SN, PO,

Bleeding

chart such as: black, tarry stools; vomiting “coffee PPN

grounds”; hematuria; hemoptysis; or severe

epistaxis.

(Continued)

NOTE: Beginning October 1, 1999, an MDS record will not be considered inaccurate unless the audited MDS values result in a new RUG-III classification for the resident record.

Prepared by the Office of Medicaid Policy and Planning, October 1, 1999 (Version 2)

EDS

6

P. O. Box 68420

Indianapolis, IN 46268-0420

Indiana Title XIX BT199932

Supportive Documentation Guidelines Related to RUG-III Version 5.01 October 1, 1999

MDS 2.0 Location J1k*
J5c*
K5a* ADL ONLY K5b ADL ONLY M2b*
P1a,a*
P1a,b*
P1a,g*
P1a,k*
P1b,d A*

Field Description Recurrent Lung Aspirations End-stage Disease Parenteral/IV
Feeding Tube
Stasis Ulcer (stage 1, 2, 3, or 4) Chemotherapy
Dialysis
Oxygen Therapy
Transfusions
Respiratory Therapy

MDS 2.0 VERSION 5.01 CLINICALLY COMPLEX
Charting Guidelines
Clinical indicators required in the medical chart might include: productive cough, shortness of breath or wheezing. A physician terminal diagnosis of a deteriorating clinical course is required in the medical chart.
Evidence of an IV or heparin lock must be cited in the medical chart
Documented evidence of a feeding tube that can deliver food/nutritional substances/fluids/medications directly into the gastrointestinal system. All stasis ulcers must be described and staged as they appear during the observation period on the MDS. This may require the stage to be increased or decreased from the previous MDS. Includes any type of chemotherapy (anticancer drug) given by any route. Evidence must be cited in the medical chart.
Includes peritoneal or renal dialysis that occurs at the nursing facility or at another facility. Evidence must be cited in the medical chart.
Oxygen therapy shall be defined as the administration of oxygen continuous or intermittent via mask, cannula, etc. Evidence must be cited on the medical chart. Evidence of transfusions of blood or any blood products administered by staff must be cited in the medical chart. Days and minutes of respiratory therapy must be cited in the medical chart on a daily basis to support the total days and minutes of direct therapy provided.

Possible Chart Location
NN, SN, PO, PPN, CP, XRAY, TN PO, PPN, NN, SN, CP, SSN, Hospice notes NN, SN, PO, PPN, CP, Hospital records
NN, SN, DN, PO, PPN, CP
NN, SN, PO, PPN, CP, DN, TN, Wound record NN, SN, PO, PPN, CP, DN, SSN, MAR, Hospital records NN, SN, PO, PPN, CP, DN, SSN, Hospital records NN, SN, PO, PPN, CP, SSN, TN, Hospital records NN, SN, PO, PPN, CP, Hospital records TN, PO
(Continued)

NOTE: Beginning October 1, 1999, an MDS record will not be considered inaccurate unless the audited MDS values result in a new RUG-III classification for the resident record.

Prepared by the Office of Medicaid Policy and Planning, October 1, 1999 (Version 2)

EDS

7

P. O. Box 68420

Indianapolis, IN 46268-0420

Indiana Title XIX BT199932

Supportive Documentation Guidelines Related to RUG-III Version 5.01 October 1, 1999

MDS 2.0 VERSION 5.01

CLINICALLY COMPLEX

MDS 2.0 Location

Field Description

Charting Guidelines

Possible Chart Location

P8*

Physician

Includes written, telephone, fax, or consultation PO, PPN

Orders (4 or orders for new or altered treatment. Does NOT

more)

include admission orders, return admission orders,

or renewal orders without changes.

M4c**

Open Lesions other than ulcers, rashes, cuts

All open lesions must be documented in the medical chart. Documentation might include appearance, measurement, treatment, color, odor, etc.

NN, SN, PO, PPN, CP, DN, TN, Skin sheet

M4f**

Skin Tears or Cuts

A skin tear or cut is any traumatic break in the skin penetrating to subcutaneous tissue. Documentation might include appearance, measurement, treatment, color, odor, etc.

NN, SN, PO, PPN, CP, DN, TN, Skin sheet

M5i**

Other preventative or protective skin care (other than to feet)

Includes application of creams or bath soaks to prevent dryness, scaling; application of protective elbow pads, etc. Evidence of preventive or protective care must be documented in the medical chart.

NN, SN, PO, PPN, CP, TN, NR, Skin sheet, Treatment sheet

M6f**

Applications of Evidence of dressing changes to the feet must be Dressings (feet) documented in the medical chart.

NN, SN, PO, PPN, CP, TN, Skin sheet, Treatment sheet

M4g**

Surgical Wounds

Includes healing and non-healing, open or closed surgical incisions, skin grafts or drainage sites on any part of the body. Documentation might include appearance, measurement, treatment, color, odor, etc. Does not include healed surgical sites or stomas.

NN, SN, PO, PPN, CP, DN, TN, Skin sheet

M5f**

Surgical Wound Care

Includes any intervention for treating or protecting any type of surgical wound. Evidence of wound care must be documented in the medical chart.

NN, SN, PO, PPN, CP, DN, TN, Skin sheet

**Special combination considerations: M4c, open lesions must also include coding for M5i, other skin care or M6f, foot dressings. M4f, skin tears/cuts must also include coding for M5i, other skin care or M6f, foot dressings.

*The resident must qualify for one of the above conditions. The resident who met criteria for Extensive Services or Special Care but the ADL score was below 7 would classify as Clinically Complex. Once classified in Clinically Complex, next the resident is evaluated for Depression using the items in Table 1.5

NOTE: Beginning October 1, 1999, an MDS record will not be considered inaccurate unless the audited MDS values result in a new RUG-III classification for the resident record.

Prepared by the Office of Medicaid Policy and Planning, October 1, 1999 (Version 2)

EDS

8

P. O. Box 68420

Indianapolis, IN 46268-0420

Indiana Title XIX BT199932

Supportive Documentation Guidelines Related to RUG-III Version 5.01 October 1, 1999

MDS 2.0 Location E2 E1a,g,j,n,o,p
E4e Col.A
N1d N1a,b,c B1 K3a I1ee I1ff

MDS 2.0 VERSION 5.01

CLINICALLY COMPLEX - DEPRESSION ELEMENTS

Field Description

Charting Guidelines

Mood Persistence (1 or 2)

Of the indicators described in E1, the medical chart must cite the results of attempts to alter the indicator(s)

Indicators of Depression, Anxiety, Sad Mood (1 or 2)

Examples of verbal and/or non-verbal expressions of distress i.e., depression, anxiety, and sad mood must be found in the medical chart. See MDS (E1) for specific details.

Behavioral Symptoms
(1, 2, or 3)

Acknowledgment and examples of the resident’s behavior symptom patterns must be provided in the medical chart. The record must reflect daily behavioral symptoms manifested by the resident.

Time Awake (None of Above)

Evidence of time awake or nap frequency should be cited in the medical chart to validate the answer.

Time Awake (total checked equal 0 or 1)

Evidence of time awake or nap frequency should be cited in the medical chart to validate the answer.

Comatose (equal 0)

Must have a documented neurological diagnosis of coma or persistent vegetative state from physician.

Weight Loss

Documented evidence in the medical chart of the resident’s weight loss as defined on the MDS.

Depression
Manic Depression (bipolar disease)

An active physician diagnosis must be present in the medical chart.
An active physician diagnosis must be present in the medical chart.

Possible Chart Location
NN, SSN, SN, NR, CP
NN, SSN, SN, NR, CP
NN, SSN, SN, NR, CP
NN, SN, PPN, CP, SSN, NR, CNAN NN, SN, PPN, CP, SSN, NR, CNAN PO, PPN, NN, CP, SN
NN, SN, DN, CP, SSN, PPN, Weight sheet PO, PPN, NN, CP, SN, SSN PO, PPN, NN, CP, SN, SSN
(Continued)

NOTE: Beginning October 1, 1999, an MDS record will not be considered inaccurate unless the audited MDS values result in a new RUG-III classification for the resident record.

Prepared by the Office of Medicaid Policy and Planning, October 1, 1999 (Version 2)

EDS

9

P. O. Box 68420

Indianapolis, IN 46268-0420

Indiana Title XIX BT199932

Supportive Documentation Guidelines Related to RUG-III Version 5.01 October 1, 1999

MDS 2.0 VERSION 5.01 CLINICALLY COMPLEX - DEPRESSION ELEMENTS DEPRESSION EVALUATION The resident is considered depressed if he/she meets either a combination of group A or group B of the following criteria: GROUP A E2 Persistent sad mood (1 or 2) and two other symptoms (only one symptom can be counted from groups 2 and 3): 1. E1a – Negative statements (1 or 2) 2. E1n – Repetitive movements (1 or 2) E1o – Withdrawal (1 or 2) E1p – Reduced interaction (1 or 2) E4eA – Resists care ( 1,2, or 3) 3. E1j – Unpleasant AM mood ( 1 or 2) N1d – Time awake (checked) N1a,b,c – Awake only morning, afternoon, or evening (total checked = 0 or 1) and B1=0 4. E1g – Terrible future ( 1 or 2) 5. K3a – Weight loss

OR

GROUP B

(I1ee) Depression and one symptom from the items above or (I1ff) Bipolar disease and one symptom from the items above.

ADL Score

Depressed

RUG-III

17-18

YES

CD2

17-18

NO

CD1

11-16

YES

CC2

11-16

NO

CC1

6-10

YES

CB2

6-10

NO

CB1

4-5

YES

CA2

4-5

NO

CA1

NOTE: Beginning October 1, 1999, an MDS record will not be considered inaccurate unless the audited MDS values result in a new RUG-III classification for the resident record.

Prepared by the Office of Medicaid Policy and Planning, October 1, 1999 (Version 2)

EDS

10

P. O. Box 68420

Indianapolis, IN 46268-0420

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To: All Indiana Medicaid Nursing Facility Providers Subject