Industry Insights

MDS 3.0 RAI Manual Update Effective October 1

October 2014
Author:  Suzy Harvey

Suzy Harvey

Managing Consultant


Health Care

910 E. St. Louis Street, Suite 200
P.O. Box 1190
Springfield, MO 65801-1190 (65806)


The Centers for Medicare & Medicaid Services (CMS) released the updated Resident Assessment Instrument (RAI) manual on September 15, 2014, with a very brief overview of the updates on September 17 during the Skilled Nursing Facility – Open Door Forum (SNF-ODF). CMS offered some clarification to the Change of Therapy (COT) transition policy and confirmed the RAI manual changes would be effective October 1, 2014. Facilities need to ensure software vendors have updated to the new Minimum Data Set (MDS) 3.0 version 1.12.0 by October 1, 2014, as new items have been added to the MDS assessments.

Several chapters of the RAI manual only had wording changes and new coding tip examples. The phase “progress notes” was replaced throughout the manual with “clinical record.” The RAI manual and change table can be found at the CMS website. Below is an overview of the most pertinent changes to the MDS assessment and RAI manual.

Chapter 2

Page 2-6:  Clarification was added on maintaining RAI records in the clinical record. The RAI states that when thinning after 15 months have passed, the demographic information in Section A of the most recent admission assessment must be maintained in the active clinical record.

Page 2-10:  A bullet point was added related to discharge requirements and terminology and supports the August 25, 2014, Survey and Certification Memo on completing discharge assessments when a resident is transferred from a Medicare- or Medicaid-certified bed to a noncertified bed. Facilities only would need to complete a discharge assessment if the beds are not Medicare- or Medicaid-certified. A change in payor source in a dually certified facility does not warrant the need for a discharge assessment.

Page 2-21 & 22:  Clarification was provided related to the need to complete a Significant Change in Status Assessment (SCSA) for hospice election or revocation that occurs prior to the completion of an admission assessment.

Page 2-52:  The COT policy revision enacted by the FY2015 Final Rule has been updated in the RAI manual. In certain circumstances, providers now can complete a COT when a resident is not currently classified into a RUG-IV therapy group or receiving therapy sufficient for classification into a RUG-IV therapy group. BKD recently published an article offering a more in-depth review of the COT policy changes.

Chapter 3

Several changes to Chapter 3 of the RAI manual relate to the MDS 3.0 item set changes on the assessment form and the addition of previous clarifications not previously in the manual.

A0310B = 06:  The Medicare readmission/return scheduled assessment has been removed from the MDS assessments and deleted from the RAI manual. The five-day scheduled assessment will be used for all Medicare admissions and readmissions/returns.

A0410:  This item has been renamed Unit Certification or Licensure Designation with changes to the response coding. During the SNF-ODF, several comments were made concerning the RAI guidelines for coding response Number 3, “Unit is Medicare and/or Medicaid certified.” There was much confusion, as the guidelines found in Chapter 3 of the RAI manual state if the resident is in a Medicare- and/or Medicaid-certified bed, regardless of payor source, the facility is required to submit these MDS records to Quality Improvement and Evaluation System Assessment Submission and Processing (QIES ASAP) system. Chapter 5 states—and CMS confirmed— assessments completed for purposes other than the Omnibus Budget Reconciliation Act (OBRA) and skilled nursing facility prospective payment system (SNF PPS) are not to be transmitted; this includes assessments completed for Medicare Advantage, Managed Care and private insurance.

A1900 Admission Date:  This is a new item added to the MDS assessment. The admission date for coding item A1900 is the date the current “episode of care” in the facility began. Neither CMS nor the RAI manual provides clear guidance on the definition of “episode of care.” Based on the software development/vendor call with CMS in January 2014, the definition is the same as in the Quality Measures manual, which says an episode is a series of one or more stays that may be separated by brief interruptions in the resident’s time in the facility. The episode of care definition also mirrors the 90-plus days of episode of care from the Program for Evaluating Payment Patterns Electronic Reports (PEPPER). Further clarification from CMS is pending.

Activity of Daily Living (ADL) definitions from the MDS 3.0 assessment form were added to the RAI manual. On Page G-20, the rationale for coding personal hygiene as extensive assistance expanded to offer an explanation that better corresponds to the ADL algorithm.

Chapter 6

A new example of the relationship between the assessment and claim related to changing the Assessment Indicator (AI) has been added on page 6-12. Example 7 relates cases where an EOT-R would be completed but the EOT falls on the first grace day following a scheduled assessment completed within the normal ARD window. For the EOT-R, the resident must resume therapy at the same RUG-IV therapy level in effect prior to the break in therapy, but the most recent assessment completed has not been used for payment. CMS guidelines in this circumstance state the resumption of therapy should occur using the previous RUG-IV therapy level (which should be the same as the therapy level determined on the scheduled PPS assessment if the resumption is appropriate) but using the ADL score from the most recent PPS assessment. According to the RAI manual, this presents the only occasion where the three-character RUG-IV therapy code may differ from RUG billed prior to the break in therapy, and the difference may only be in the third character in the therapy RUG code related to the resident’s ADL score.

A variety of typographical issues in the revised RAI manual were noted by callers to the SNF-ODF. CMS is in the process of identifying how to address typographical issues identified in the revised RAI manual and have stated an errata document would be provided.

In reviewing and reading the RAI manual changes effective October 1, 2014, nursing facilities need to remember accurate coding of the MDS assessments is key to proper and appropriate Medicare and Medicaid reimbursement as well as Quality Measures, PEPPERs, quality of care and survey outcomes.

For questions or guidance on MDS 3.0 or RAI manual changes, contact your BKD advisor.

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