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Section O Special Treatments, Procedures, and Programs

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Rena Shephard

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All right, well, let's talk about Section O because I know that's what you

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really want to hear about from me right now. And this section obviously

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documents - it says, "Special Treatments, Procedures, and Programs" - and so it

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has a lot of familiar stuff in it, the "Special Treatments, Procedures, and

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Programs" from MDS 2.0, Section P1 - A, you know most of that's what's in

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Section O on the 3.0. And then, of course, the therapies in O0400, and there are

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some significant changes compared to 2.0 there. And, so, we'll definitely be

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spending some time talking about those changes, and you can certainly read the

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objectives for yourself.

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So, the intent of Section O is to identify any of these special treatments,

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procedures and programs that are listed there that the resident received. And

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you know, by the way, let's all turn to Section O in our item set because we're

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all going to need to refer to it. So, if you haven't done that, please turn to

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that section right now - and the second bullet under the intent - document the

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type and duration of treatments during specified time periods.

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So, this slide is just -- it's almost a sort of disclaimer to just remind

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everybody that it's not an all-inclusive list of everything that a nursing home

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resident could be receiving. And the question does often come up about, you

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know, different things - where do I code this on the MDS, where do I code that

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-and, sometimes the answer is just, "You don't." And so, if you don't find it

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there and you're reading the definitions and it doesn't meet any of the

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definitions then, whatever it is, you're not coding it on the MDS 3.0. And so,

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that's why, you know, it says many more therapies and procedures and programs

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are available that play a vital role in health and quality of life. And, you

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know, just because it's not captured on the MDS doesn't mean that you don't

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still do all the assessment and the care planning that we all know we need to

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do. It just means that you don't do it using the MDS.

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So, there are several criteria that define the types of procedures that are

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documented in the MDS 3.0. So, they include services provided by, or under, the

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direction of qualified occupational or physical therapists, skilled therapy

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services only, and there's also respiratory, psychological and recreational

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therapy. And I don't know where speech therapy went, but we certainly capture

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speech language pathology on the MDS 3.0. And, you know, Chapter 3 of the 3.0

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Manual - the instructions for these items - there's a lot more detail in there

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about the requirements and, you know, what's captured and all that sort of

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thing. And a lot of times we start to get into regulatory requirements in terms

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of what Medicare requires in order for a service to be considered to be skilled.

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And we're really not going to talk a lot about that. You're going to see some

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information on the slides about that, but, really, if you go into Chapter 3 and

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you look at the instructions for Section O, you'll see a lot more information

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about that. And, of course, the Medicare Benefit Policy Manual - and I think we

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have the website for that -- Chapter 8 has all of that laid out for you. And so

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for all of that detail, don't count on this session. We're really talking more

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about what's captured on the MDS and how to code it, given that everybody

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understands what "skilled" means. And, certainly, applicable treatments and

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procedures do not include services provided solely in conjunction with surgical

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services, and that's not new is what I'm trying to say. And non-skilled services

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also. And I'll talk a little bit more about that as we go along.

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So, let's start with item O0100. So, this is the special treatments and

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procedures and programs; and, you can see what's listed there and documenting a

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variety of different special treatments and procedures. And what it does, and

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what most people are interested in hearing about these days, is the fact that it

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actually separates into two columns. So, I just want to preface this by saying

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you do capture these treatments and procedures that are listed here in O0100A

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through M regardless of where the resident was when he or she received it and

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even -- you know, as long as it fell into the look-back period for the

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assessment. You do capture it. It's just a question of which column do you put

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it in which, of course, is what we're going to talk about. But, you know, this

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slide is just to remind us of how important these treatments and procedures are

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to nursing home residents or, in fact, to anybody who receives them. Certainly,

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they can be critical to the health status, the self-image, the dignity and the

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quality of life of individuals, and so, they do require some sort of special

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attention when they're receiving these in terms of assessment and care planning,

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in addition, obviously, to just, you know, marking them on the MDS.

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So, as far as conducting the assessment is concerned, you know, where do you get

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the information from to decide whether you're going to mark something in O0100?

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Well, obviously, review the resident's medical record. There is a 14-day

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look-back period for this item, and so you want to look in the medical record

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and see if it reflects that the resident received any of these treatments or

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procedures during that time. And consider, as I said, treatments that were

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received, at any time, that fell into the 14-day look-back period, even if it

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was pre-admission. In other words, before the resident was admitted to the

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nursing home. And, again, do not code services provided solely in conjunction

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with the surgical procedure. So, that would be you know, anything that you see

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listed there. If it was during the surgical procedure, or during routine pre-

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and post-operative procedures, you would not capture it. And of course that word

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"routine" - if it was routine. Obviously, if somebody had surgery and they were

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getting IV antibiotics in the recovery room because they actually have an

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infection, obviously you're going to be able to capture that. But, if it's just

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prophylactic, that's just routine then. You know, as they do with hip surgeries,

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other joint surgeries and many other surgeries. So, that's just an example of

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what that means. And, okay. So, we talked about the look-back period there.

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So, there are three possible codes that you can enter in, looking at Column 1

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first. Column 1 is, "While NOT a resident." So, this would be services that were

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received either before the resident was a resident of the facility and it was

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captured in the look-back period. Or sometimes it happens that the resident is a

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resident of your facility and he's actually discharged, and then he comes back

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again and you actually end up capturing that - the time that he was not a

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resident in your look-back period. So, that would go in Column 1, as well. So,

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take that literally. He wasn't a resident of your facility at the time. So, as

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the slide says, check all treatments received by the resident. We talked about

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that. That would be the first one.

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And the code 2 -- the second one is the code Z, and that would be "None of the

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above." If the resident was admitted or re-entered during the look-back period,

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but did not receive any of the treatments listed, that's the code Z. Okay? So,

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it's a "Check all that apply," just to review. "Check all that apply." But if it

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doesn't -- if the resident did not receive it, but the resident was admitted or

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re-entered during the look-back period, that's when you use the code Z.

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And then number three - leave Column 1 blank if the resident was admitted or

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re-entered to the facility more than 14 days ago. In other words, if none of

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this falls into the look-back period at all, that's when you leave Column 1

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blank. Okay? So, hopefully that helps to make sense.

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And for Column 2 - now, this is where you document treatments that were received

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after becoming a resident of the facility. Now, the resident doesn't have to

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have received it in your facility, as long as he was a resident of your facility

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at the time. So, let's just say that he went out to a doctor's appointment, and

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while he was at the doctor's appointment, he received one of these things. He's

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still a resident of your facility, right? So, you would be able to capture that

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in the "While a resident" column. So, check all treatments received by the

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resident after admission or re-entry to the facility that fall within the 14-day

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look-back period. Once again, check "Z. None of the above," if none of the

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treatments apply during the look-back period, and you would not leave this

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column blank.

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So, that's -- let's just cut to the chase. Why do we have these two different

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columns? Well, you know why, don't you? Yeah, because if you check "While a

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resident," then it can contribute to your reimbursement, and if you check "While

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NOT a resident," then it doesn't. So, some people say, "Well, why do we put that

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on there at all?" Well, because there were some concerns with the MDS 2.0 that

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you didn't capture certain things when they should, you know, should have been

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captured for care planning purposes. So, that column brings in all of the

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treatments and procedures from that list that, actually, the resident received

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during the look-back period, but it divides them into -- for care planning

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purposes versus for reimbursement and care planning purposes. So, that's Column

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2.

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Okay, so you see the whole long list of treatments and procedures there, and

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we're not going to go through -- excuse me -- each and every one of those. The

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manual has, I think, really good definitions for each one of those, and you know

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what I always say: you can't do this without having the manual in front of you

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because you have to know all the definitions and, you know, to be completely

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accurate. But, we did want to review a few of them with you, and they tend to be

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the ones that questions come up about.

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So, for example, A is Chemotherapy. So, here you would code any type of

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chemotherapy agent administered as an antineoplastic drug given by any route.

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So, in other words, if he's getting it because he's being treated for cancer,

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you code it here, and that's different from another section where the

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instructions are "Code according to the classification of the drug and not the

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use." So, that's another, you know, of the many standing rules about the MDS,

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and one of them is that you really shouldn't cross-reference one item definition

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with another unless the manual tells you to because they do have different

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definitions, and they were intended to. So, always know what the instructions

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are for the specific item that you're dealing with at the time.

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The next one that we're looking at is oxygen -- oh, I wanted to give you an

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example. Sorry, but, you know, the classic example about the chemotherapy - you

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can have somebody who's taking Megastrol, the - it's an antineoplastic drug

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which has the side effect of, what? That's right. It's an appetite stimulant,

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and so there are many nursing home residents who take this drug. They don't have

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cancer. They never did, but they're taking it to stimulate their appetite. So,

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would you capture that here? No. That's right because the rule is that you're

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going to code it only if the resident is receiving it for cancer. Didn't want to

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forget that.

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Okay, now on to Oxygen. So, you're coding continuous or intermittent oxygen

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administered via mask, canula, et cetera, that's delivered to relieve hypoxia.

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And you would code the oxygen in BiPAP and CPAP and, you know, that question has

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come up a lot with the 2.0. And so, now, you might have noticed that BiPAP and

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CPAP are actually on the list, so you can capture that. Because one of the two

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questions has always been, "Well, do I capture BiPAP and CPAP as 'ventilator or

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respirator'," and that answer has always been no. But, it's even clearer now,

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and there could, yeah -- and so, that can be helpful, you know, to separate

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those out. But, the other thing is the question always came up, "Well, what if

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he's getting oxygen through the CPAP or the BiPAP?" So now, we have the answer

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to that as well, and just like with the 2.0, do not code hyperbaric oxygen for

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wound therapy in this item.

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The next one is IV medications, and it's really kind of interesting. I mean,

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this says, "Code any drug or biological given by IV push, epidural pump or drip

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through a central or peripheral port," but if you look in the manual -- you know

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the whole thing about the biologicals and the contrast material? 2.0 folks who

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have been around for a while, you know what I'm talking about. It was in and

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then it was out. Currently, with MDS 2.0, you do not capture contrast material.

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With MDS 3.0, you will be capturing contrast material. Okay? So that -- I mean,

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it's clearly stated in the manual, but still, you know, do not code flushes to

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keep an IV access port patent. IV fluids without medications, of course, are not

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IV medications. Subcutaneous pumps are not IV. They're subcutaneous. Medications

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administered during dialysis or chemotherapy are still not captured and, you

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know, this is a reimbursement thing. So, some folks say, "Well, you know, they

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gave it to him right after they administered his chemo at the chemo center. So,

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I'm going to capture it." Well, that's not really the intent. The intent is it

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was administered in conjunction with the chemo at the chemo center, and so you

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wouldn't capture it. So, you know, sometimes it's looked at more literally -

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that, you know, the chemo has to be running at the time. It's not quite that

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literal. And then dextrose 50% or lactated ringers given by IV- this is a

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question that has come up a lot, and CMS has kindly given us instruction on

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that. And, of course, these are not IV medications, and so they're not captured

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here.

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And the next one is "Dialysis" - so, peritoneal or renal dialysis. And that's

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whether it occurs at the nursing home or another facility. It doesn't matter.

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You still capture it, and also you would record treatments of hemofiltration and

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the other treatments and procedures that you see listed there.

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And IVs - IV medications and blood transfusions, one more reminder, are -- that

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are administered during dialysis or chemo -- are considered to be a part of that

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procedure, and so they are not captured in their respective items under K0500A;

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O0100H; and O0100I and that's no different than what we have with 2.0.

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Okay. So, we have a scenario here, and so if you take a look at your MDS and

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maybe code it, you know -- let's take a look at what the scenario is and see how

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you would code it. The scenario is a resident received the following treatments

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one week prior to entering the facility. So, he received chemo for cancer and IV

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medications, and then after entering the facility, the resident continued

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radiation treatments for cancer 10 days after entering the facility and stopped

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IV medications after three days in the facility. So, taking a look at the

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coding, see what you think - what you would do with that. So, would you capture

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the chemo for cancer? [Audience: Yes.] And which column? [Audience: One.] Column

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1, right, because it was captured in the look-back period, but it was before he

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came into the facility. And what about IV medications? Same thing, right? Unless

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it was given with the chemo, right? If it was given with the chemo, then we

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don't capture it. But, if it's a completely separate thing from the chemo, then

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we would. [Audience asking questions] Prior to entering the facility -

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[Audience asking questions] No, no, no. I'm talking about the one week prior to

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entering the facility. I'm still on the first -- [Audience asking questions]

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You're jumping ahead past me. You're faster than I am. So, do you see what my

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point is about the IV medications in the first part? Because it says it was just

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one week prior to entering the facility and the chemo, we know we're going to

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capture. The IV medications, we actually need to know a little bit more about

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that to know whether or not we can capture that.

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Okay, now let's go to the next one. After entering the facility -- okay, so this

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was IV medications after three days, and you already told me. What do we do with

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that? So, if it was in conjunction with chemo, again we're not going to capture

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it. Right? But if it was separate - yeah, if he received it in the facility

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because he's got pneumonia, it's separate from the chemo. And what else do we

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have there? Radiation for cancer ten days after entering the facility. Are we

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going to capture that? Sure. Okay, well, here's the coding. There it is. And the

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IV medications, obviously, because we captured it, were not in conjunction with

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the chemo because we would never make that mistake. [Laughter]

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All right, so what is O0250? Oh, the infamous vaccinations. And there really

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isn't very much different here from the 2.0. There's really just kind of one

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difference but, you know. There really is a lot of emphasis on this for nursing

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homes. Look at the statistics that you see there. Sixty percent of the -- an

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outbreak can result in 60% of the population becoming ill and 25% develop

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complications severe enough to result in hospitalization or death - and this is

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specific to institutional Influenza A. And, of course, it's the complications of

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the influenza that result in the death. So, whatever we can do to keep residents

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from getting it in the first place is a really good thing. So, conducting the

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assessment. Well, review the medical record to determine if the resident

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received an influenza vaccination and, if so, where it was administered. And

235
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then, we also need to ask the resident if he received the flu vaccination

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outside of the facility for this year's influenza season. And also, you know, if

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you're still not sure, ask the responsible party or the legal guardian. In other

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words, search the entire universe and see if you can find out if this guy

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received the flu vaccine during -- for the current flu season. And, the rule is,

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if you have searched the universe over and you have no clue about whether he had

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the flu vaccination, give it. Because the CDC assures all of us that getting an

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extra flu vaccination isn't going to hurt anybody. And, of course, not receiving

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it at all can certainly cause all kinds of complications, as we talked about, if

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the person does get the flu.

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The thing that has changed a little bit, you know how it's always -- the manual,

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the 2.0 Manual has always said the influenza season starts, when? October 1?

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Right. Well, it doesn't say that with the 3.0 Manual. Did you notice that? And I

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think, I'm just guessing here, but I think this has something to do with

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situations that occur like happened last year - that the influenza vaccine was

250
00:25:00,809 --> 00:25:09,000
available before October 1 and because of what was going on with flu in general,

251
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folks were giving it and that was perfectly fine. They were giving it before

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October 1, and that's fine. It was for the current season that, you know, that

253
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was coming, but it was a little confusing for folks to try to figure out what to

254
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do with that in terms of -- all they really needed to say was, "Yes, he received

255
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it." But I -- my guess is, that to alleviate that problem in the future, the CDC

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is going to set the flu season date every year, and they'll let us know what it

257
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is, and so it will, you know, I'm sure, be posted by the CDC and by CMS so that

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we know when, you know, the flu season officially starts. So, that's just about

259
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the only difference, and it will be posted on a regular basis. So, and then,

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this last bullet point: administer the vaccination according to the standards of

261
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clinical practice if the status can't be determined, and that's what I was

262
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referring to.

263
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So, the other question that often comes up is, "What about H1N1," because there

264
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was so much of a flurry of trying to get that vaccine. Probably, what's going to

265
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happen is, it's just going to be rolled into the seasonal flu vaccine. I mean,

266
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that's what the plan is. So it'll just be -- you know, they often have more than

267
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one type of influenza covered in the vaccines that we give. So, they'll just add

268
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it to that.

269
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The O0250 coding. This documents actually three aspects of the administration of

270
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the vaccine, and there really isn't anything particularly tricky about this. A

271
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-- O0250A: and if you look at the question on the form it says, "Did the

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resident receive the influenza vaccination in this facility for this year's

273
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influenza season?" So, if the answer is yes, you see it there on the form, code

274
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1. Yes. Then, you're going to continue to O0250B and enter the date, and then,

275
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see where it says -- you always have to read the skip patterns. It says, "Date

276
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vaccine received," and then it says, "Complete date and then skip to O0300A"

277
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because, obviously, you don't need to do O0250C that says, "If influenza vaccine

278
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not received, state the reason," because it was received. So, you just skip that

279
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one. So, that makes it kind of easy.

280
00:27:53,619 --> 00:27:58,500
Okay, but let's go back to O0250A: "Did the resident receive the influenza

281
00:27:58,519 --> 00:28:03,119
vaccine in this facility for this year's influenza season," and let's say the

282
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answer is no. So, in this case, what we're going to do is skip O0250B because we

283
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don't have a date to put in there because it wasn't received. And, just reading

284
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the skip pattern, it just says, "Skip to O0250C," and that's when you need to

285
00:28:26,119 --> 00:28:33,179
come up with a reason for why it wasn't received in the facility for this flu

286
00:28:33,199 --> 00:28:44,809
season. So, this is just what we're talking about. Okay. So -- and this is --

287
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looking at O0250 more closely and the instructions -- and of course all these

288
00:28:51,569 --> 00:28:56,220
instructions are in the manual. Enter the date. Use 0 to complete any single

289
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digit value. So, instead of January being a blank and a "1" or a "1" and a

290
00:29:02,339 --> 00:29:08,389
blank, it's "01." You know that. You've seen that before, and enter a dash if

291
00:29:08,409 --> 00:29:16,541
part of the date is unknown.

292
00:29:16,561 --> 00:29:29,750
Okay, so now on to these coding instructions for O0250C. Code a reason that the

293
00:29:29,769 --> 00:29:36,439
vaccine was not administered in the facility, and if you don't know the reason

294
00:29:36,459 --> 00:29:41,439
or you know the reason and none of the listed ones apply, that's where you enter

295
00:29:41,459 --> 00:29:46,349
the 9. So, let's take a little bit closer look at the reasons.

296
00:29:46,369 --> 00:29:58,240
So, the code O0250C coded as a 1 - the resident was not in the facility during

297
00:29:58,259 --> 00:30:02,849
this year's influenza season. So, that's pretty easy to figure out, if that's

298
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the case. The code 2, "Received outside of this facility," and that could be

299
00:30:07,259 --> 00:30:12,309
anywhere. He received it, but it wasn't in the facility, and so it could have

300
00:30:12,329 --> 00:30:17,589
been at a physicians' office or a health fair or the grocery store. I know I got

301
00:30:17,609 --> 00:30:24,549
mine at the grocery store this year, which seemed really weird, but it was so

302
00:30:24,569 --> 00:30:27,819
easy. So, you know, they're springing up. I remember running through the Atlanta

303
00:30:27,819 --> 00:30:33,429
airport at one point during the flu season last year, and they had stations. You

304
00:30:33,449 --> 00:30:37,109
know, I was kind of running between terminals instead of taking the tram, and so

305
00:30:37,109 --> 00:30:41,631
I ran across these flu vaccine stations. So, if that's where your resident got

306
00:30:41,651 --> 00:30:46,769
it, that's the answer that you put. And then, of course, the code 3 is the "Not

307
00:30:46,789 --> 00:30:55,859
eligible because of a medical contraindication" like the infamous egg allergy.

308
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And then, if there is a contraindication - not like an egg allergy, which

309
00:31:03,589 --> 00:31:09,121
doesn't resolve - but a contraindication, that does resolve, then, of course,

310
00:31:09,141 --> 00:31:13,881
the individual should receive the vaccine. The code 4 is "Offered and declined"

311
00:31:13,901 --> 00:31:18,991
and that's pretty straightforward. They just choose not to accept it. The code 5

312
00:31:19,011 --> 00:31:24,402
is "Not offered," and some people are really hesitant to use this one because

313
00:31:24,422 --> 00:31:29,211
they say that's going to look bad. But, it just may be that your facility hadn't

314
00:31:29,231 --> 00:31:34,109
received the vaccine yet by the time the resident was discharged. So, you know,

315
00:31:34,129 --> 00:31:41,609
it just wasn't offered. That's - that's the truth. The code 6 is that "Inability

316
00:31:41,629 --> 00:31:46,379
to obtain the vaccine due to a declared shortage," and there again, once the

317
00:31:46,399 --> 00:31:53,169
shortage is over, then it's important to get the vaccine to anybody who wants

318
00:31:53,189 --> 00:31:57,869
it. And then the code 9, as I mentioned, is "None of the above," if the answer

319
00:31:57,889 --> 00:32:04,519
is unknown or none of the answers apply.

320
00:32:04,539 --> 00:32:11,339
Okay. So, here's a scenario and think about how this would be coded. Mr. K.

321
00:32:11,359 --> 00:32:16,069
wanted to receive the influenza vaccine if it arrived prior to his scheduled

322
00:32:16,089 --> 00:32:20,980
discharge on October 5th. Mr. K. was discharged prior to the facility receiving

323
00:32:21,000 --> 00:32:24,409
their annual shipment of influenza vaccine, and therefore, he didn't receive it

324
00:32:24,429 --> 00:32:30,740
in the facility. And, of course, they encouraged him to receive it by some other

325
00:32:30,759 --> 00:32:34,759
means, but he wasn't going to be able to be receiving it in the facility. So,

326
00:32:34,759 --> 00:32:46,809
the question is how would you code that? Well, how would you code O0250A?

327
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[Audience: Zero.] That's a zero, right? That's a no. And then, what do we do

328
00:32:50,579 --> 00:32:56,369
with B? Skip it, right. That's a good thing to do. And then what would we code

329
00:32:56,389 --> 00:33:12,899
C? That's a "None of the above." Well, let's see. He was discharged before

330
00:33:12,919 --> 00:33:20,432
receiving it. They did not receive their annual shipment yet. They may have

331
00:33:20,451 --> 00:33:25,649
offered it. So, not -- and some facilities do that, don't they? Before the flu

332
00:33:25,669 --> 00:33:29,559
vaccine comes in, they go around and they -- they're setting things up to see

333
00:33:29,579 --> 00:33:38,019
who they're going to be administering it to. So, in that case, if they asked him

334
00:33:38,039 --> 00:33:47,849
and he wanted it, the facility didn't have it yet, then where does that go? So

335
00:33:47,869 --> 00:33:54,220
the 6 would be -- not the 6, because that's a shortage -- but the 5, the "Not

336
00:33:54,240 --> 00:34:01,240
offered," would be we didn't even offer it to him yet, and he left before we

337
00:34:01,259 --> 00:34:09,929
offered it. But, if we offered it and the facility just didn't have it yet,

338
00:34:09,949 --> 00:34:18,079
that's the 9. Okay? You see the difference? Take these things very literally. We

339
00:34:18,099 --> 00:34:24,889
offered it. We didn't give it yet. That's not not offered. We did offer it. So,

340
00:34:24,909 --> 00:34:51,000
you have the answer there on the next slide. Okay. Where are we here?

341
00:34:51,019 --> 00:35:00,279
Okay, here's another one. Now, this is -- let me catch up here. This is Mr. R.

342
00:35:00,299 --> 00:35:05,360
He didn't receive the flu vaccine during this year's flu season because of his

343
00:35:05,380 --> 00:35:11,989
known allergy to egg protein. That's too easy. What's the answer there? That's

344
00:35:12,009 --> 00:35:28,139
the medical contraindication. So, O0250A is coded as a no, right? And then we

345
00:35:28,159 --> 00:35:32,539
skipped B because we don't have a date to put in there. And then C would be

346
00:35:32,539 --> 00:35:49,289
coded as what? Yeah, that's the "Not eligible." Very good. Okay. So, that's the

347
00:35:49,309 --> 00:35:54,739
influenza vaccine. So, you might notice that there aren't all those dates there.

348
00:35:54,759 --> 00:35:59,329
You know how it is with the 2.0 that says don't complete these items between

349
00:35:59,349 --> 00:36:03,329
these particular - I mean, I'm not going to talk about that, but just for you

350
00:36:03,329 --> 00:36:07,039
2.0 folks, I'm just pointing out that's not there.

351
00:36:07,059 --> 00:36:14,049
Okay, so the next one is the pneumococcal vaccine, and this also documents

352
00:36:14,069 --> 00:36:20,239
whether the resident received, in this case, the pneumococcal vaccine. And if he

353
00:36:20,259 --> 00:36:24,259
didn't, then that lets you know that you need to figure out whether or not he

354
00:36:24,259 --> 00:36:31,440
should receive it. A little bit of information here about the importance of this

355
00:36:31,460 --> 00:36:36,360
vaccine: pneumococcal disease accounts for more deaths than any other

356
00:36:36,380 --> 00:36:45,029
vaccine-preventable bacterial disease. Case fatality rates for pneumococcal

357
00:36:45,049 --> 00:36:50,670
bacteremia are approximately 20% and they can be as high as 60% in the elderly,

358
00:36:50,690 --> 00:36:55,309
and anybody who worked in a nursing home has seen this go through a facility,

359
00:36:55,329 --> 00:37:00,779
haven't you? With the flu season and people start getting the flu and they start

360
00:37:00,799 --> 00:37:08,610
getting pneumonia? So, you know what -- what we're talking about.

361
00:37:08,630 --> 00:37:16,440
Okay. So, the pneumococcal vaccine, the decision about whether or not to give it

362
00:37:16,460 --> 00:37:19,710
-- everybody always says, "Oh! It's only once in a lifetime." Well, that sounds

363
00:37:19,710 --> 00:37:23,839
really easy, right? So, you search the world over, you know, you read the

364
00:37:23,859 --> 00:37:27,391
medical record. You talk to the resident; you talk to the family; you talk to

365
00:37:27,391 --> 00:37:31,920
the family doctor; whatever you have to do to try to find out if the resident

366
00:37:31,940 --> 00:37:38,250
received the pneumococcal at some time. And, if you find the answer is yes, then

367
00:37:38,269 --> 00:37:45,061
you're done. Well, no. You're not. It's sort of implied when they say it's once

368
00:37:45,081 --> 00:37:50,632
in a lifetime, but you're not done because there are situations where people

369
00:37:50,652 --> 00:37:57,559
need to get a booster and that has to do with the age the person was when he got

370
00:37:57,579 --> 00:38:02,099
it and whether or not five years have passed since then and also if he's

371
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immune-compromised.

372
00:38:03,759 --> 00:38:11,279
So, in your handout packet, you know the CMS folder that you have. You will find

373
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this in there. If you want to pull it out and take a look at it because this

374
00:38:16,980 --> 00:38:23,409
will get you to the right answer every time - the right answer about whether or

375
00:38:23,429 --> 00:38:38,420
not the person needs a second -- needs a pneumococcal vaccine. So, you can see

376
00:38:38,440 --> 00:38:44,089
-- and you know the rule about flow charts and algorithms. You have to start at

377
00:38:44,109 --> 00:38:49,829
the top where it says, "Start here." You can't sort of be impatient and say,

378
00:38:49,849 --> 00:38:54,219
"Well, I think I'll start down here," because then you won't get to the right

379
00:38:54,239 --> 00:38:59,500
answer. Okay, so the question is, "Has the person been vaccinated previously?"

380
00:38:59,519 --> 00:39:07,110
So, let's say yes, he was. Is the person immuno-compromised? Let's say no, he

381
00:39:07,130 --> 00:39:12,079
wasn't -- isn't. Was the person less than 65 years at the time of their last

382
00:39:12,099 --> 00:39:16,730
vaccine? No. Okay, "Vaccine not indicated." That's the simple case that I

383
00:39:16,750 --> 00:39:19,641
described to you, but let's go the other way.

384
00:39:19,661 --> 00:39:26,000
Let's say has -- back up to the top. Has the person been previously vaccinated?

385
00:39:26,019 --> 00:39:32,860
Let's say, yes. Is the person immune-compromised? Let's say, yes. Well, have

386
00:39:32,880 --> 00:39:39,920
five years or more elapsed since the first dose? Well, if the answer is no, then

387
00:39:39,940 --> 00:39:46,612
you see it takes you to "Vaccine not indicated." But, if the answer is yes, then

388
00:39:46,632 --> 00:39:52,159
it takes you back to "Was the person less than 65 years at the time of the last

389
00:39:52,179 --> 00:40:01,869
vaccine" and -- I'm sorry, it takes you -- yeah. It takes you up -- I'm sorry --

390
00:40:01,889 --> 00:40:08,639
to, "Vaccine indicated." Sorry about that. We already did the age.

391
00:40:08,659 --> 00:40:14,219
But, let's say, is the person immunocompromised? No. It goes down to, "Was the

392
00:40:14,239 --> 00:40:19,469
person less than 65 years at the time of their last vaccine?" Let's say, yes.

393
00:40:19,489 --> 00:40:24,809
Now, that takes us back up to, "Have five or more years elapsed since the first

394
00:40:24,829 --> 00:40:30,589
dose," and if the answer is yes, we're back up to he needs another vaccination.

395
00:40:30,609 --> 00:40:34,920
So, if you just keep this on hand when you're trying to work these things out,

396
00:40:34,940 --> 00:40:39,809
that will be a big help to you, I think.

397
00:40:39,829 --> 00:40:45,779
So, Mr. T. received the pneumococcal vaccine at age 62 when he was living in a

398
00:40:45,799 --> 00:40:51,059
congregate care community. Because if he was younger than 65 and he was living

399
00:40:51,079 --> 00:40:55,369
in his own home, he probably wouldn't have received it, right? But because he

400
00:40:55,389 --> 00:41:02,811
was in congregate care or an institution, it might be a different story ---or it

401
00:41:02,831 --> 00:41:06,581
is a different story. All right, he's now 65 years old. He's being admitted to

402
00:41:06,581 --> 00:41:15,029
the nursing home for chemo and respite care. So, should Mr. T. receive a

403
00:41:15,049 --> 00:41:19,869
pneumococcal vaccine? So, use the algorithm and work your way through the

404
00:41:19,889 --> 00:41:30,400
algorithm and tell me yes or no. Okay, well, let's work our way through it then.

405
00:41:30,420 --> 00:41:39,000
Let's back up here. He received the pneumococcal vaccine at 62 and he's now 65,

406
00:41:39,019 --> 00:41:43,360
being admitted to the nursing home. Okay, has he been previously vaccinated?

407
00:41:43,380 --> 00:41:53,269
Yes. So we go down to, "Is he immuno-compromised?" It doesn't say that he's

408
00:41:53,289 --> 00:42:02,210
immuno-compromised. It said he's-- he's being admitted for chemo and respite.

409
00:42:02,230 --> 00:42:07,909
So, you want to assume that -- okay. Let's assume that he is, but you would need

410
00:42:07,929 --> 00:42:13,809
that information before you could make a decision, wouldn't you? Okay, but let's

411
00:42:13,829 --> 00:42:18,730
say that he is because at least the group over here votes for that. So, and I'll

412
00:42:18,750 --> 00:42:22,500
come over here so I can hear over here, too. Okay, so, let's say he's

413
00:42:22,500 --> 00:42:26,069
immuno-compromised. So, have five years or more elapsed since the first dose?

414
00:42:26,089 --> 00:42:31,150
[Audience: No.]No. So, we're going to go down to "Vaccine not indicated." Okay?

415
00:42:31,170 --> 00:42:44,059
All right [Laughter.] Okay and of course the answer is spelled out here on this

416
00:42:44,079 --> 00:42:48,940
slide.

417
00:42:48,960 --> 00:42:57,239
Okay, so we talked about how to collect the information for -- to determine

418
00:42:57,259 --> 00:43:04,250
whether or not he had a pneumococcal vaccine in the past and it's the same rule

419
00:43:04,269 --> 00:43:11,960
as it is with the flu vaccine. If you search the entire universe and you have no

420
00:43:11,980 --> 00:43:17,429
idea whether he's ever had a pneumococcal vaccine, give it to him, because

421
00:43:17,449 --> 00:43:23,789
again, the CDC assures all of us that an extra pneumococcal vaccine won't hurt

422
00:43:23,809 --> 00:43:29,529
anybody, and the benefits are certainly documented.

423
00:43:29,549 --> 00:43:37,359
Okay. So, the coding instructions, looking at O0300: "Is the resident's

424
00:43:37,379 --> 00:43:43,369
pneumococcal vaccination up to date?" Code, 0. No if it's not up to date, code

425
00:43:43,389 --> 00:43:52,719
1. Yes if it is, and you see the skip pattern there on the form. If it's no,

426
00:43:52,739 --> 00:43:59,429
it's not up to date, then you're going to continue to B to state the reason. But

427
00:43:59,449 --> 00:44:05,659
if it is up to date, you're just going to skip out of the rest of this. And then

428
00:44:05,679 --> 00:44:14,299
if the answer is no, you do go to B and the possible -- the answer options are

429
00:44:14,319 --> 00:44:23,230
very simple. Either "Not eligible" due to medical contraindication or, you know,

430
00:44:23,250 --> 00:44:29,572
any other reason that the physician has or "Offered and declined" or "Not

431
00:44:29,592 --> 00:44:30,592
offered."

432
00:44:30,592 --> 00:44:36,152
So, Mr. L. - 72 years old. He received the pneumococcal vaccine at the

433
00:44:36,172 --> 00:44:44,230
physician's office last year. So, O0300A would be coded yes, and we just skip

434
00:44:44,250 --> 00:44:49,130
out of the rest of it, right, because he's over 65. He received it in his

435
00:44:49,150 --> 00:44:57,659
physician's office last year at age 71, and so he's in good shape.

436
00:44:57,679 --> 00:45:07,389
So, here's Mrs. A. Let me find Mrs. A. Mrs. A received the pneumococcal vaccine

437
00:45:07,409 --> 00:45:13,380
at age 62 when she was hospitalized for a broken hip. Now, she's 78 and being

438
00:45:13,400 --> 00:45:17,329
admitted to the nursing home. Her covering physician offered the pneumococcal

439
00:45:17,349 --> 00:45:24,359
vaccine during her last visit. She accepted and - hmm. The facility administered

440
00:45:24,379 --> 00:45:38,359
the pneumococcal vaccine to Mrs. A. Hmm. So, what do you think? How do we code

441
00:45:38,379 --> 00:45:46,289
O0300? Is her vaccination up to date? [Audience: Yes.] Yes, and so we're done.

442
00:45:46,309 --> 00:45:58,859
Right? So, there's the rationale. At first when you read it, it sounds like she

443
00:45:58,879 --> 00:46:04,179
received it in his office; but, she actually got it in the facility. All right.

444
00:46:04,199 --> 00:46:15,900
That's that. [Audience: Applause] [Laughter.] Okay, we're done. No, I'm kidding.

445
00:46:15,920 --> 00:46:16,920
[Laughter.]

446
00:46:16,920 --> 00:46:26,359
So, you seem to want to talk about therapies? Okay, if you're sure, I'm with

447
00:46:26,379 --> 00:46:33,549
you. No, really I just think that once everybody gets used to this -- now, I

448
00:46:33,569 --> 00:46:38,670
just want to say right up front that, you know, we're talking about the coding

449
00:46:38,690 --> 00:46:45,739
here, and I totally, completely understand that some of you have some questions

450
00:46:45,759 --> 00:46:51,349
and issues about policy changes and things like that. But, this is what we have,

451
00:46:51,369 --> 00:46:55,949
and so, we're going to talk about how to code it, given the policy changes. And

452
00:46:55,969 --> 00:47:00,069
of course I'm going to talk about all of that.

453
00:47:00,089 --> 00:47:09,789
So, wow. You know, I don't think that there's anybody in this room that needs a

454
00:47:09,809 --> 00:47:16,299
sales pitch on how important it is to help residents maintain as much

455
00:47:16,319 --> 00:47:23,121
independence as possible. We may or may not do a stellar job of that 100% of the

456
00:47:23,141 --> 00:47:28,449
time, but I think we all understand how important it is and really want to do

457
00:47:28,469 --> 00:47:33,739
that for our residents. And there's just no question that functional decline can

458
00:47:33,759 --> 00:47:38,449
lead to all of these things that you see listed on the slide. I mean, I can just

459
00:47:38,469 --> 00:47:43,429
imagine -- I don't even like to think about it. I start to block it off, but I

460
00:47:43,449 --> 00:47:50,179
think about what would happen to me and how it would affect my life if I simply

461
00:47:50,199 --> 00:47:54,819
-- I know it's not that simple -- but, if I simply lost the ability to move from

462
00:47:54,839 --> 00:48:00,569
a sitting to standing position independently. You know, just that one functional

463
00:48:00,589 --> 00:48:06,389
change would just be devastating, and of course, our residents have that and

464
00:48:06,409 --> 00:48:11,929
much more. So, but, it's like I said, I know that you don't really need a sales

465
00:48:11,949 --> 00:48:14,859
pitch on that particular issue.

466
00:48:14,879 --> 00:48:26,819
So, as far as O0400 is concerned, you know, there are regulations that I

467
00:48:26,839 --> 00:48:31,349
referred to about what makes something skilled, and, you know, you need orders

468
00:48:31,369 --> 00:48:36,500
from the physician and all of that stays the same. Those are Medicare

469
00:48:36,519 --> 00:48:41,259
requirements, and, you know, requirements for not only Medicare, some of them,

470
00:48:41,279 --> 00:48:46,739
but for other reasons as well. And that all stays the same, but the slides do

471
00:48:46,759 --> 00:48:50,589
review some of that. So, it's the qualified therapist, physician and nursing

472
00:48:50,609 --> 00:48:54,819
administration are responsible for determining the necessity for therapy

473
00:48:54,839 --> 00:49:00,369
services to be provided and the frequency and duration of the therapy services.

474
00:49:00,389 --> 00:49:06,469
And rehabilitation and respiratory, psychological and recreational therapy -

475
00:49:06,489 --> 00:49:11,429
which are captured here - can help residents to attain or maintain their highest

476
00:49:11,449 --> 00:49:15,359
level of well-being. Which, I mean those are the marching orders for nursing

477
00:49:15,379 --> 00:49:22,529
homes, right? That's the core of OBRA '87, that we will do that and also can

478
00:49:22,549 --> 00:49:26,719
help to improve their quality of life. Certainly, quality of life is hugely

479
00:49:26,739 --> 00:49:32,420
impacted by functional problems.

480
00:49:32,440 --> 00:49:40,190
So, the purpose of O0400 Therapies is to determine therapies the resident

481
00:49:40,210 --> 00:49:44,889
received, the mode for each therapy received, how many minutes the resident

482
00:49:44,909 --> 00:49:48,929
spent in each mode - and I'm going to define mode for you here - during the

483
00:49:48,949 --> 00:49:53,309
look-back period, and the number of days of therapy during the look-back. And

484
00:49:53,329 --> 00:49:57,619
the definition of days, as you'll see on the slides coming up, hasn't changed.

485
00:49:57,639 --> 00:50:03,440
There still has to have been 15 minutes of whatever the particular therapy

486
00:50:03,460 --> 00:50:11,139
discipline is in order for it to be captured as a day.

487
00:50:11,159 --> 00:50:19,349
The applicable therapies: medically necessary therapies that occurred after

488
00:50:19,369 --> 00:50:23,279
admission/re-admission to the facility. That's an important point. You don't

489
00:50:23,299 --> 00:50:28,549
capture anything that occurred prior to admission. Ordered by qualified staff,

490
00:50:28,569 --> 00:50:33,190
based on a qualified therapist's assessment and treatment plan. Documented in

491
00:50:33,210 --> 00:50:37,960
the resident's medical record. Care plan. Periodically evaluated. And, of

492
00:50:37,980 --> 00:50:43,420
course, as long as as the individual is a resident of your facility, you count

493
00:50:43,440 --> 00:50:50,299
it whether it occurred in your facility or outside of your facility as long as

494
00:50:50,319 --> 00:50:52,681
it's captured in the look-back period.

495
00:50:52,701 --> 00:50:56,871
So, as far as conducting the assessment is concerned, of course, reviewing the

496
00:50:56,891 --> 00:51:03,519
medical record and, you know, making sure there has to be a therapy eval to be

497
00:51:03,539 --> 00:51:09,629
able to have therapy minutes. So, you review the eval, the treatment records,

498
00:51:09,649 --> 00:51:14,159
recreation therapy notes, mental health professional notes - in other words, any

499
00:51:14,179 --> 00:51:21,579
documentation that pertains to the category that you're capturing here in O0400,

500
00:51:21,599 --> 00:51:25,789
the discipline. And, of course, consulting with each of the qualified care

501
00:51:25,809 --> 00:51:36,799
providers - and then include only services provided. We talked about that. After

502
00:51:36,819 --> 00:51:41,869
-- once the resident was actually a resident of your facility, do not include

503
00:51:41,889 --> 00:51:46,900
therapies that occurred while the resident was an inpatient at a hospital or

504
00:51:46,920 --> 00:51:52,199
recuperative rehabilitation center or other long-term care facility. And, of

505
00:51:52,219 --> 00:51:59,179
course, you don't capture any therapy that was provided as home care or

506
00:51:59,199 --> 00:52:06,989
community-based services.

507
00:52:07,009 --> 00:52:18,639
So, back to that issue of include only therapies provided after re-admission, if

508
00:52:18,659 --> 00:52:24,349
the resident returns from a hospital stay. So, this is just to clarify - a new

509
00:52:24,369 --> 00:52:30,199
initial evaluation has to be done each time a resident is re-admitted to the

510
00:52:30,219 --> 00:52:37,170
hospital -- to a hospital inpatient stay and then returns to your facility. And

511
00:52:37,190 --> 00:52:41,829
count only therapies, again, that occurred since re-admission, re-entry and

512
00:52:41,849 --> 00:52:47,179
after the initial evaluation because, as most of you know, you don't count the

513
00:52:47,199 --> 00:52:53,009
minutes from the initial evaluation itself.

514
00:52:53,029 --> 00:53:00,250
So, these are the applicable therapies that you see here. Respiratory,

515
00:53:00,269 --> 00:53:04,429
psychological, recreational therapy must meet the requirements for skilled

516
00:53:04,449 --> 00:53:09,349
therapy outlined in Chapter 3 of the RAI Manual. And, you know, we're not going

517
00:53:09,369 --> 00:53:14,460
to go through all of those now, but of course, providers of Medicare Part A

518
00:53:14,480 --> 00:53:19,920
services, Medicare Part B, Medicaid - you know, we're all required to know what

519
00:53:19,940 --> 00:53:26,000
constitutes skilled care, if we're going to be providing skilled care, and we

520
00:53:26,019 --> 00:53:29,569
need to know what the rules are for all of this.

521
00:53:29,589 --> 00:53:33,730
Second bullet includes services provided by a qualified physical occupational

522
00:53:33,750 --> 00:53:40,389
therapy assistant employed by the facility only if under the direction of a

523
00:53:40,409 --> 00:53:46,339
qualified therapist. Medicare does not recognize speech language pathology

524
00:53:46,359 --> 00:53:52,349
assistance. That's why they're not included there and do not include therapeutic

525
00:53:52,369 --> 00:53:58,129
services that are not specifically listed in the RAI Manual or on the MDS item

526
00:53:58,149 --> 00:54:11,509
set, even if provided by specialists.

527
00:54:11,529 --> 00:54:20,049
On the next slide, include only skilled therapy services for speech, PT, and OT,

528
00:54:20,069 --> 00:54:27,569
and you see some of the criteria here. Skilled therapy services must meet all of

529
00:54:27,589 --> 00:54:31,339
the following, and there are probably even more, you know, when you get into the

530
00:54:31,339 --> 00:54:39,259
Medicare Benefit Policy Manual. Ordered - if it's Part A, it has to be ordered

531
00:54:39,279 --> 00:54:43,639
by a physician; if it's Part B, it has to be certified by a physician, directly

532
00:54:43,659 --> 00:54:48,119
and specifically related to that active written treatment plan we talked about.

533
00:54:48,139 --> 00:54:52,799
It has to require the judgment, knowledge and skills of a therapist, and that's

534
00:54:52,819 --> 00:55:00,659
something, you know, to be very much aware of. I kind of think of it as if

535
00:55:00,679 --> 00:55:06,920
somebody trained in restorative nursing practices could safely do it, then it's

536
00:55:06,940 --> 00:55:13,219
not skilled for rehab and it should be provided -- and these are the, you know,

537
00:55:13,239 --> 00:55:16,449
the regulations, provided with the expectation that the condition of the

538
00:55:16,469 --> 00:55:20,629
resident will improve materially in a reasonable and generally predictable

539
00:55:20,649 --> 00:55:25,359
period of time. And this is one of those regulations that I find that a lot of

540
00:55:25,379 --> 00:55:29,811
people really aren't aware of. You know, we all know that from week to week,

541
00:55:29,831 --> 00:55:36,460
we're looking for improvement, but, you know, a lot of folks just weren't real

542
00:55:36,480 --> 00:55:39,650
clear that that was actually written into the regulations somewhere and, of

543
00:55:39,670 --> 00:55:45,670
course, there it is. Consider it to be specific and effective treatment for the

544
00:55:45,690 --> 00:55:51,239
resident's condition. In other words, it has to meet the standard of practice,

545
00:55:51,259 --> 00:55:55,920
or the standard of care, for that particular condition and it has to be

546
00:55:55,940 --> 00:55:59,480
reasonable and necessary for the treatment of the resident's condition,

547
00:55:59,500 --> 00:56:05,199
including the amount, frequency, duration of services and furnished by qualified

548
00:56:05,219 --> 00:56:07,989
personnel.

549
00:56:08,009 --> 00:56:14,079
And I just really encourage everybody to be sure to check out the Medicare

550
00:56:14,099 --> 00:56:18,839
Benefit Policy Manual. You can always ask your Medicare contractor, the fiscal

551
00:56:18,859 --> 00:56:25,719
intermediary, or the Medicare Administrative Contractor if you have questions,

552
00:56:25,739 --> 00:56:33,319
but obviously, being intimately familiar with the criteria for understanding

553
00:56:33,339 --> 00:56:38,679
what something -- what makes something skilled is critical. And non-skilled

554
00:56:38,699 --> 00:56:44,650
services do not include services provided at the request of the resident or

555
00:56:44,670 --> 00:56:47,920
family that are not medically necessary. And you know that -- what that means

556
00:56:47,920 --> 00:56:51,719
is, you know, sometimes you'll have somebody who is on Part A and they meet

557
00:56:51,719 --> 00:56:56,079
their goals or they plateau, and they come off of Part A because they don't seem

558
00:56:56,099 --> 00:57:00,349
to have any more potential for improvement, but the family wants to continue

559
00:57:00,369 --> 00:57:05,329
with skilled therapy. Well, and they're going to pay for it. Well, in that case

560
00:57:05,349 --> 00:57:09,039
you would not count those minutes, because they're not considered to be

561
00:57:09,059 --> 00:57:12,971
medically necessary at that point. Of course, don't include maintenance

562
00:57:12,991 --> 00:57:19,529
treatments or supervision of aides performing maintenance services, and do not

563
00:57:19,549 --> 00:57:24,250
include services provided after the resident has been discharged from rehab.

564
00:57:24,269 --> 00:57:30,739
That might be their transition to restorative nursing program and the

565
00:57:30,759 --> 00:57:35,250
therapists, or the therapy assistants, can continue to do the treatments if they

566
00:57:35,269 --> 00:57:39,849
want to, but they can't capture them here. It would have to be captured as

567
00:57:39,869 --> 00:57:44,059
restorative, if, you know - if all of those criteria are met.

568
00:57:44,079 --> 00:57:54,859
So, let's get down to business here. There are three modes of therapy that have

569
00:57:54,879 --> 00:58:06,509
to be captured, and you can see that under O0400A, B and C. You see 1, 2 and 3;

570
00:58:06,529 --> 00:58:12,250
individual, concurrent and there's a different definition -- actually, Medicare

571
00:58:12,269 --> 00:58:17,259
Part A recognizes concurrent. Part B does not. So, it's important to keep that

572
00:58:17,279 --> 00:58:21,719
in mind, and we'll talk a little bit more about that and group therapy. And Part

573
00:58:21,739 --> 00:58:27,411
A and Part B have a little bit different take on those as well.

574
00:58:27,431 --> 00:58:36,750
So, wait a minute -- sorry, individual therapy. I think we all know what

575
00:58:36,769 --> 00:58:43,799
individual therapy is, right? That's one therapist or therapy assistant - except

576
00:58:43,819 --> 00:58:52,399
for speech - and one resident, and that therapist or therapy assistant isn't

577
00:58:52,419 --> 00:59:01,471
doing anything else. That's one-to-one, right? And the last bullet point there,

578
00:59:01,491 --> 00:59:08,239
the treatment may be provided at intermittent times throughout the day, and it's

579
00:59:08,259 --> 00:59:12,831
still individual therapy as long as these criteria are met.

580
00:59:12,851 --> 00:59:20,129
Now, concurrent therapy. There's a definition for this, a very specific

581
00:59:20,149 --> 00:59:25,849
definition now. Two residents treated at the same time, not performing the same

582
00:59:25,869 --> 00:59:30,341
or similar activities, both residents must be in line of sight of the treating

583
00:59:30,361 --> 00:59:34,969
therapist or assistant; and, it doesn't matter who the payer is. It's still

584
00:59:34,989 --> 00:59:38,569
concurrent. So, remember, I said Part B doesn't recognize concurrent therapy,

585
00:59:38,589 --> 00:59:45,869
but if you have somebody who's on Part A and he's being treated under this

586
00:59:45,889 --> 00:59:51,309
definition of concurrent therapy? But, the other person has Part B, it's still

587
00:59:51,329 --> 00:59:56,461
concurrent therapy for the Part A person, even though Part B doesn't recognize

588
00:59:56,481 --> 01:00:00,761
it. For Part B, it would actually be group, but looking at that Part A person,

589
01:00:00,781 --> 01:00:07,230
he's getting concurrent therapy. Okay? So, then for Part B, you can see

590
01:00:07,250 --> 01:00:12,250
concurrent therapy - treatment of two or more residents at the same time is

591
01:00:12,269 --> 01:00:16,710
documented as group treatment regardless of payer source. In other words,

592
01:00:16,730 --> 01:00:21,791
regardless of what other payer sources are in the group, it's still group for

593
01:00:21,811 --> 01:00:29,889
Part B and group therapy for Medicare Part A. This definition hasn't changed,

594
01:00:29,909 --> 01:00:40,199
and you see what it is there on the slide. For Part B, it's a little bit

595
01:00:40,219 --> 01:00:45,109
different and you can see there's just a little bit of a difference there.

596
01:00:45,129 --> 01:00:57,710
The thing about group therapy is that there is a 25% cap. In other words, per

597
01:00:57,730 --> 01:01:03,139
discipline, when you add up the total therapy minutes, group therapy can be no

598
01:01:03,159 --> 01:01:09,609
more than 25% of that total. And right now, the therapists are having to

599
01:01:09,629 --> 01:01:14,449
calculate that cap and make sure they don't go over it. They're not going to

600
01:01:14,469 --> 01:01:20,129
have to do that anymore. What's going to happen with all of this, and the reason

601
01:01:20,149 --> 01:01:28,069
you have the three different modes, is because the software that calculates the

602
01:01:28,089 --> 01:01:38,980
RUG category is going to add 100% of the individual minutes; one-half of the

603
01:01:39,000 --> 01:01:44,549
concurrent minutes; and then it's going to add, if there are group minutes

604
01:01:44,569 --> 01:01:51,181
entered there, it's going to add the group minutes not to exceed the cap. So,

605
01:01:51,201 --> 01:01:55,929
it's going to do all the math. So, I really want to emphasize, whoever is

606
01:01:55,949 --> 01:02:01,949
filling out the section and the individual concurrent and group, you're putting

607
01:02:01,969 --> 01:02:06,849
in the actual number of minutes that the resident received.

608
01:02:06,869 --> 01:02:13,369
So, for concurrent - and this is really important - for concurrent, let's say

609
01:02:13,389 --> 01:02:19,909
that a therapist was doing concurrent therapy with two residents for 60 minutes.

610
01:02:19,929 --> 01:02:28,409
Each resident gets 60 minutes towards the total on the MDS. The software will

611
01:02:28,429 --> 01:02:36,201
come along and cut it in half for each one for Part A, okay? So, that means that

612
01:02:36,221 --> 01:02:40,519
the therapists do not cut it in half before they enter the minutes because then

613
01:02:40,539 --> 01:02:45,361
the software is going to come along and it'll cut it in half again. That's what

614
01:02:45,381 --> 01:02:53,230
I call a bad outcome for the facility. And the same thing with group therapy -

615
01:02:53,250 --> 01:02:57,879
whatever actual number of minutes each resident spends in group, that's what

616
01:02:57,899 --> 01:03:02,750
goes on the MDS and the grouper software will take care of the math.

617
01:03:02,769 --> 01:03:15,029
O0400 - determine the minutes. Do not include time spent on documentation or

618
01:03:15,049 --> 01:03:20,279
initial evaluation. Do include time spent on re-evaluation as a part of the

619
01:03:20,299 --> 01:03:26,480
treatment process. Do include time required to adjust equipment or otherwise

620
01:03:26,500 --> 01:03:32,649
prepare for individualized therapy. Split time as deemed appropriate, and what

621
01:03:32,669 --> 01:03:39,969
this is referring to is co-treatments. That's what this bullet point is talking

622
01:03:39,989 --> 01:03:44,389
about. So, if you have two clinicians from two different disciplines treating a

623
01:03:44,409 --> 01:03:48,969
resident at the same time. Let's say OT and PT are treating together for an

624
01:03:48,989 --> 01:03:55,960
hour. They have to decide how many minutes each gets to total no more than 60

625
01:03:55,980 --> 01:04:04,789
minutes. So, that's a co-treat. Okay, and of course, you know, a resident may

626
01:04:04,809 --> 01:04:10,269
receive therapy via different modes during the same day or treatment session.

627
01:04:10,289 --> 01:04:15,149
They could have some individual, some group, you know, some concurrent - just

628
01:04:15,169 --> 01:04:18,009
have to keep track of which is which.

629
01:04:18,029 --> 01:04:23,029
So, treatment time starts when the resident begins the first treatment activity

630
01:04:23,049 --> 01:04:27,569
or task. This is not new. It ends when the resident finishes with the last

631
01:04:27,589 --> 01:04:32,799
apparatus or intervention or task. Count the total minutes, including time spent

632
01:04:32,819 --> 01:04:38,469
for therapeutic purpose. Do not include any other type of break. So, for

633
01:04:38,489 --> 01:04:44,809
example, if the resident takes a therapeutic rest with monitoring to control the

634
01:04:44,829 --> 01:04:51,389
heart rate, for example. Then, that would be included; but, non-therapeutic,

635
01:04:51,409 --> 01:05:01,419
like a bathroom break or a non-therapeutic rest, would not be counted. Okay, so

636
01:05:01,439 --> 01:05:07,190
the therapist and assistant must determine the mode of therapy and time the

637
01:05:07,210 --> 01:05:13,139
resident received for each. Include only skilled therapy minutes - total minutes

638
01:05:13,159 --> 01:05:19,329
of intermittent individual therapy services into a daily count. So, like I said,

639
01:05:19,349 --> 01:05:24,159
the individual services could be several different times during the day. You

640
01:05:24,179 --> 01:05:29,190
just add them all up for that day. Record the actual minutes. Do not round to

641
01:05:29,210 --> 01:05:34,399
the nearest fifth minute. Do not do anything else except record the actual

642
01:05:34,419 --> 01:05:45,399
minutes.

643
01:05:45,419 --> 01:05:57,679
Now, when it comes to therapy aides and students -- and this is a big change. I

644
01:05:57,699 --> 01:06:02,639
mean, I didn't even realize how many facilities were using therapy aides to

645
01:06:02,659 --> 01:06:09,641
deliver skilled care, but it's not skilled care. So, the only time, as the

646
01:06:09,661 --> 01:06:14,231
second bullet point says, that you can -- now, this is not therapy assistants.

647
01:06:14,251 --> 01:06:18,451
Okay? Please be sure to hear me say that. This is therapy aides, not therapy

648
01:06:18,471 --> 01:06:27,389
assistants. The only time a therapy aide time can be included is when they're

649
01:06:27,409 --> 01:06:37,699
setting up for skilled services to prepare for individual therapy. And, the --

650
01:06:37,719 --> 01:06:45,009
for example, setting up for the treatment area for wound therapy or, you know,

651
01:06:45,029 --> 01:06:51,639
setting up equipment or, you know, directly in preparation for a treatment. So,

652
01:06:51,659 --> 01:06:55,500
the therapy aide must be under the direct supervision of the therapist or

653
01:06:55,519 --> 01:07:03,629
assistant, and there's a lot of information in the manual about therapy students

654
01:07:03,649 --> 01:07:08,639
in Chapter 3. I know that there have been questions, and so there's a lot of

655
01:07:08,659 --> 01:07:14,460
information that's been added in there. So, you might want to take a look at

656
01:07:14,480 --> 01:07:17,049
that.

657
01:07:17,069 --> 01:07:25,161
Well, let's do a practice scenario here. So, we have Mrs. V. -- and you might

658
01:07:25,181 --> 01:07:29,519
just want to get -- take your pencil and write these things down. I don't know.

659
01:07:29,539 --> 01:07:33,139
I just always assume everybody's as visual as I am, but that's what I have to

660
01:07:33,139 --> 01:07:39,849
do. I have to write it down to be able to see it. Mrs. V., whose stay is covered

661
01:07:39,869 --> 01:07:45,029
by Part A, begins therapy in an individual session, and after 13 minutes, the

662
01:07:45,049 --> 01:07:49,190
therapist begins working with Mr. S., whose therapy is covered by Medicare Part

663
01:07:49,210 --> 01:07:55,649
B. Mrs. V. continues with her skilled interventions as -- and is in line of

664
01:07:55,669 --> 01:08:02,629
sight of the treating therapist. The therapist provides treatment at the same

665
01:08:02,649 --> 01:08:09,929
time to Mrs. V. and Mr. S. for 24 minutes. Mrs. V.'s therapy session ends at

666
01:08:09,949 --> 01:08:14,089
this time, and the therapist continues to treat Mr. S. individually for 10

667
01:08:14,109 --> 01:08:22,159
minutes. Okay. So, the question is, "How many minutes of individual therapy did

668
01:08:22,179 --> 01:08:30,339
Mrs. V. get?" Thirteen, right? That was the only time that Mrs. V. was alone

669
01:08:30,359 --> 01:08:36,109
with the therapist receiving treatment. How about concurrent minutes for Mrs.

670
01:08:36,130 --> 01:08:42,209
V.? Twenty-four. That's the number of minutes that the therapist was treating

671
01:08:42,229 --> 01:08:48,669
both of them together. And what about group minutes for Mrs. V.? Zero. She

672
01:08:48,689 --> 01:08:49,689
didn't have any group.

673
01:08:49,689 --> 01:08:56,969
Okay, well, let's look at Mr. S. -- Mrs. S. Mrs. S.? Mr. S. I didn't mean to do

674
01:08:56,989 --> 01:09:03,509
a sex change there right in the middle. So, how many individual minutes did Mr.

675
01:09:03,529 --> 01:09:10,289
S. receive? Ten, because at the end there is the only time he was alone with

676
01:09:10,309 --> 01:09:15,319
her. Okay, how about how many concurrent minutes for Mr. S.? [Audience: Zero.]

677
01:09:15,340 --> 01:09:23,159
Zero. Very good! From all over the room, that was great! Why zero? Because Part

678
01:09:23,179 --> 01:09:28,479
B doesn't recognize concurrent. So, how many group minutes for Mr. S.?

679
01:09:28,500 --> 01:09:35,329
[Audience: 24] That's the 24. Drops down to group. Exactly. And, you know, we're

680
01:09:35,349 --> 01:09:44,449
going to do some more of these tonight, too. Let's see, what else do we have

681
01:09:44,470 --> 01:09:54,601
here? Okay. Very good. So, this is what the coding looks like, and hopefully,

682
01:09:54,621 --> 01:09:59,861
you've been looking at the MDS all along as I've been talking and following

683
01:09:59,881 --> 01:10:04,859
along, but you see where the minutes go there in the left for the three

684
01:10:04,880 --> 01:10:17,429
different modes. And then for respiratory, there aren't any entered here. And

685
01:10:17,449 --> 01:10:18,579
then -- okay.

686
01:10:18,599 --> 01:10:30,239
So, here's another one. So, Mr. E. is on Part A. Wait a minute. I've got to

687
01:10:30,260 --> 01:10:39,319
catch up here. I don't want to forget to tell you anything. Okay, Mr. E. is

688
01:10:39,340 --> 01:10:47,039
covered by Part A. Mr. E. received physical therapy for 20 minutes per day for

689
01:10:47,059 --> 01:10:54,699
four days during the look-back period, and during two of these sessions, the

690
01:10:54,720 --> 01:11:02,599
therapist began working with Mr. N. on a different activity while keeping Mr. E.

691
01:11:02,619 --> 01:11:07,599
in line of sight. Mr. E. and Mr. N. received therapy at the same time for nine

692
01:11:07,619 --> 01:11:13,169
minutes in the first session, 12 minutes in the second. Mr. N. did not receive

693
01:11:13,189 --> 01:11:20,629
any other physical therapy services at the same time as Mr. E., and Mr. N. is

694
01:11:20,649 --> 01:11:34,819
covered by Part B. So, how should O0400C be coded for Mr. E.? So, how many

695
01:11:34,840 --> 01:11:45,739
individual minutes did Mr. E. get? Okay. It's spreading. I need to hear from the

696
01:11:45,760 --> 01:11:53,139
middle of the room. [Audience: 59] How many? Everybody seems to like 59, and I

697
01:11:53,159 --> 01:11:57,989
think that's right because, remember, there were four sessions of 20 minutes

698
01:11:58,010 --> 01:12:08,809
each. But, for two of them, part of the 20-minute session was concurrent. Right?

699
01:12:08,829 --> 01:12:14,209
So, there was nine minutes once and 12 minutes another time that would be

700
01:12:14,229 --> 01:12:22,159
calculated as concurrent. So, what's left is 11 and 8, and then two 20-minute

701
01:12:22,179 --> 01:12:38,879
sessions that add up to 59. And so, then, how many concurrent minutes? That's

702
01:12:38,899 --> 01:12:44,029
the 21 minutes, right? The 9 and the 12 that I talked about, that the therapy

703
01:12:44,050 --> 01:12:53,599
was between the two of them. And the -- what are we missing? Group minutes.

704
01:12:53,619 --> 01:12:59,279
[Audience: Zero] For Mr. E. Right. He didn't have any group. Okay. And so this

705
01:12:59,300 --> 01:13:06,409
is the coding. And, of course, he received therapy for at least 15 minutes on

706
01:13:06,429 --> 01:13:13,129
four days. Okay, and then for Mr. N., does he have individual minutes? How many?

707
01:13:13,149 --> 01:13:16,929
[Audience: 0] He didn't even have any individual minutes, did he? [Audience:]

708
01:13:16,949 --> 01:13:24,929
No.] How about concurrent? [Audience: Zero ] Zero? Why? Oh, he's Part B, of

709
01:13:24,949 --> 01:13:34,019
course. So, what about group? [Audience: 21 minutes.] Very good, and so this

710
01:13:34,039 --> 01:13:36,939
spells that out there.

711
01:13:36,960 --> 01:13:45,759
Okay, so the O0400 practice activity. You know, when I first started learning

712
01:13:45,779 --> 01:13:51,371
this, this made me crazy trying to figure this out. Now, some of you are saying,

713
01:13:51,391 --> 01:13:54,829
"Well, Rena, what's wrong with your brain? It's not that hard." Well, you're

714
01:13:54,829 --> 01:14:01,069
right, but we don't all think in these terms and so -- and if you come tonight,

715
01:14:01,090 --> 01:14:06,069
you know, we're going to do some practice activities as well, but what I'd like

716
01:14:06,090 --> 01:14:10,939
to do is ask you to think about the approach to this. I mean, you can be faced

717
01:14:10,960 --> 01:14:17,609
with a lot of information, and you have an activity sheet there in your handout.

718
01:14:17,630 --> 01:14:22,559
And, you know, you can feel, maybe, a little bit overwhelmed by it, but if you

719
01:14:22,579 --> 01:14:28,389
think about how we just went through those practice activities and pulled out

720
01:14:28,409 --> 01:14:33,489
the information that we wanted -- and I have to write it down. I mean, I put

721
01:14:33,510 --> 01:14:38,799
each resident's name, and I put "I," "C," and "G" and I just write them down in

722
01:14:38,819 --> 01:14:43,689
columns and add them up when I'm done, because that's what I have to do. It

723
01:14:43,710 --> 01:14:48,529
might be more intuitive to some other folks to do it a different way, but I just

724
01:14:48,550 --> 01:14:53,899
encourage you to start looking at it in terms of, you know, being able to

725
01:14:53,920 --> 01:14:58,479
identify, "Oh, yeah. That's individual." or "Oh, yeah. That's concurrent." For

726
01:14:58,500 --> 01:15:05,451
example, the example that we just looked at, where there were four 20-minute

727
01:15:05,471 --> 01:15:11,149
sessions, but for two of them, portions were concurrent. So, you have to, you

728
01:15:11,170 --> 01:15:15,449
know, be able to sort of spot that and pull it out. But I mean, it's not about

729
01:15:15,449 --> 01:15:19,489
the math. Some people have said to me, "Well, I'm just really not good at math."

730
01:15:19,489 --> 01:15:28,339
It's not about the math. It's about being able to identify the mode.

731
01:15:28,359 --> 01:15:49,641
Okay. So, let me find my practice activity. So we're reading this scenario, and

732
01:15:49,661 --> 01:15:56,129
then once you've read the scenario, I'd like to ask you to calculate the minutes

733
01:15:56,149 --> 01:16:04,209
for speech language pathology services, ending -ending up with what would go on

734
01:16:04,229 --> 01:16:08,969
the MDS for speech. Well, let's take a look at what we have here because we're

735
01:16:08,989 --> 01:16:12,929
just doing speech and we'll do the rest of it tonight.

736
01:16:12,949 --> 01:16:13,949
[Audience: We did them all.]

737
01:16:13,949 --> 01:16:21,919
Oh, good. Well, if you did them all, then you're all set and you're fast, but

738
01:16:21,939 --> 01:16:27,979
let's take a look at speech for right now. We have a lot of information there

739
01:16:28,000 --> 01:16:34,289
about the type of treatments, the dysphasia and cognitive training and

740
01:16:34,309 --> 01:16:38,109
techniques, and you know, it's wonderful that the resident's getting all of

741
01:16:38,130 --> 01:16:42,459
that, but it's really not pertinent as long as it's skilled, right? And we're

742
01:16:42,479 --> 01:16:49,979
assuming that everything is skilled here. So, what we need to do -- what I did,

743
01:16:50,000 --> 01:16:55,289
like I said, is I put an "I" for individual, a "C" for concurrent and a "G" for

744
01:16:55,309 --> 01:16:59,809
group,c and I just went down and I went down and I found, ok, where -- are there

745
01:16:59,809 --> 01:17:08,219
any individual minutes there? So, where are they? So, for the dysphasia, right?

746
01:17:08,239 --> 01:17:13,869
How many minutes there? So, it's Monday through Friday. So, that's five days for

747
01:17:13,889 --> 01:17:18,549
30-minute sessions each day. So, that's 150; and, where else do we have

748
01:17:18,569 --> 01:17:24,689
individual minutes? [Audience: Speech.] Oh, speech techniques, right. And how

749
01:17:24,710 --> 01:17:29,429
many minutes? [Audience: 40] Forty, because there are two sessions, you know,

750
01:17:29,449 --> 01:17:34,509
two days at 20 minutes. So, we just add those up and we come up with the total

751
01:17:34,529 --> 01:17:42,149
number of individual minutes. So, looking at O0400A, next to individual minutes,

752
01:17:42,170 --> 01:17:49,099
we're going to enter the number of minutes. And, so we're just going to put 190

753
01:17:49,119 --> 01:17:58,369
in there. And then, where are the minutes for -- are there any concurrent

754
01:17:58,389 --> 01:18:10,909
minutes? [Audience: Yes.] Under cognitive training, right? Anywhere else? There

755
01:18:10,929 --> 01:18:17,891
are two 35-minute sessions, right? So, that's 70. And what about group?

756
01:18:17,911 --> 01:18:25,211
[Audience: 75] Yeah, we can see under cognitive training - Tuesday, Wednesday,

757
01:18:25,231 --> 01:18:34,529
Friday, 25-minute group sessions. Okay, so then we go to O0400, and we enter the

758
01:18:34,550 --> 01:18:41,009
minutes there; and, you can see it here and how they're entered to the right -

759
01:18:41,029 --> 01:18:50,069
not justified to the left, but to the right - and the group minutes. Okay. And

760
01:18:50,090 --> 01:18:58,379
then how many days of therapy do we have for four? Five days because each one of

761
01:18:58,399 --> 01:19:05,159
the days had at least 15 minutes, right? So, we get to capture all those.

762
01:19:05,179 --> 01:19:16,669
Okay, now as far as O0400A5, "Therapy start date" - so, do you know what goes in

763
01:19:16,689 --> 01:19:27,409
there? The definition of the therapy start is the - I heard a few folks say it -

764
01:19:27,429 --> 01:19:37,829
is the date of the initial eval. So, what date is that for speech? So, that's

765
01:19:37,849 --> 01:19:44,649
10-6, right? And then the therapy end date, well, look at the definition. The

766
01:19:44,670 --> 01:19:49,799
date the most recent therapy regimen - in this case for speech - since the most

767
01:19:49,819 --> 01:19:56,629
recent entry ended. Well, it hasn't ended. So, what are we going to put in

768
01:19:56,649 --> 01:20:06,549
there? Dashes. That's what it tells us right there on the form. So -- oh. Oh,

769
01:20:06,569 --> 01:20:10,319
there they are. The dashes are on there. It's the date that is not visible.

770
01:20:10,319 --> 01:20:15,399
Okay. So, is this making sense to you?

771
01:20:15,420 --> 01:20:20,219
Okay. Although, I do understand if you're not a therapist, and you're saying,

772
01:20:20,239 --> 01:20:25,779
"I'm really glad therapy is doing this," but, I also know that there are a lot

773
01:20:25,800 --> 01:20:31,179
of MDS nurses and others in various facilities that are tasked with

774
01:20:31,199 --> 01:20:35,130
double-checking. It's like an audit, which is a really good thing to do because

775
01:20:35,130 --> 01:20:40,129
people make transcription errors, and so, it's a really good idea to understand

776
01:20:40,149 --> 01:20:44,399
how to do it. So, you can be that double-check for your facility to make sure.

