ASSESSMENT TYPE
OBRA-required assessments that include the completion of both the MDS and the CAA process, as well as care plan completion or review.
What is a COMPREHENSIVE ASSESSMENT
Aplastic, iron deficincy, pernicious, sickle cell
What is ANEMIA
Look back period for J0100
What is 5 DAYS
Mrs JJ has an order for O2 at 2L PRN. She has not been requiring her supplemental oxygen the past week. In section O, you would or would not code "Oxygen"?
What is WOULD NOT. Oxygen was not actually used.
Written to cover different dosages of insulin depending on lab values.
What is a SLIDING SCALE DOSAGE SCHEDULE Does not count as an order change simply because a different dose is administered based on the sliding scale guidelines.
Mr. S. was admitted to the nursing home on February 5, 2023 following a stroke. He regained most of his function and was discharged to his home on March 29, 2023. This assessment would be due.
What is DISCHARGE RETURN NOT ANTICIPATED
This is required to claim a diagnosis as ACTIVE under section I.
What is 1) a physician documentation of active dx, 2) recent onset or acute exacerbation of disease or condition, 3) symptoms or abnormal signs indicating ongoing or decompensated disease in the last 7 days, 4) ongoing therapy with meds or other interventions to manage/monitor a condition.
Scheduled and implemented non-pharmacological interventions that include bio-feedback, application of heat/cold, and massage
What is NON-MEDICATION PAIN INTERVENTION The medical record must contain documentation that a non-medication pain intervention was scheduled as part of the care plan and it is documented that the intervention was actually received and assessed for efficacy
This is coded when resident has a BIPAP or CPAP machine in use.
What is NON-INVASIVE MECHANICAL VENTILATOR
An unpleasant symptom or event that is caused by or associated with a medication, impairment or decline in an individual's physical condition, mental, functional or psychosocial status
What is an ADVERSE REACTION
An error in an assessment where: 1. The resident’s overall clinical status is not accurately represented (i.e., miscoded) on the erroneous assessment; and 2. The error has not been corrected via submission of a more recent assessment.
What is a SIGNIFICANT CORRECTION TO PRIOR QUARTERLY OR TO PRIOR COMPREHENSIVE?
Lewy body, Vascular, Multi-infarct, Mixed, Frontotemporal such as Pick's disease.
What is NON-ALZHEIMER'S DEMENTIA
The section of the MDS that determines if the resident interview for pain should be conducted
What is B0700
Agents administered as an antineoplastic given by any route in this item. The drugs coded here are those actually used for cancer treatment. For example, megestrol acetate is classified in the Physician’s Desk Reference (PDR) as an antineoplastic drug. One of its side effects is appetite stimulation and weight gain. If megestrol acetate is being given only for appetite stimulation, do not code in this seciton of the MDS
What is CHEMOTHERAPY
The total amount/strength/concentration of a medication given at one time or over a period of time
What is a DOSE
Four types of Comprehensive Assessments are:
What is • Annual Assessment • Significant Change in Status Assessment • Significant Correction to Prior Comprehensive Assessment & Admission assessment
Section for adding additional active diagnoses
What is I8000
Includes bone fractures, joint dislocations, closed head injuries with altered consciousness, subdural hematoma
What is FALL WITH MAJOR INJURY
Do not code this item if the resident only has a history of infectious disease (e.g., s/p MRSA or s/p C-Diff - no active symptoms). Do not code this item if the precautions are standard precautions, because these types of precautions apply to everyone. Standard precautions include hand hygiene compliance, glove use, and additionally may include masks, eye protection, and gowns.
What is Isolation or Quarantine?
This is where you would code Victoza, Ozempic, Trulicity, or Mounjaro.
What is N0300 (INJECTIONS)? You would code the number of injections in the past 7 days, but you would NOT code these medications under INSULIN in N0350.
Required when the resident has a change in 2 areas whether improved or declined.
What is a SIGNIFICANT CHANGE ASSESSMENT?
These 2 conditions must BOTH be met in order to code UTI on the assessment.
What is 1) Loeb of 15 or greater and 2) a physician documented dx of UTI in the past 30 days
Code J1400 (Prognosis) Yes if resident meets this criteria
What is The MEDICAL RECORD INCLUDES PHYSICIAN DOCUMENTAION: 1) THAT THE RESIDENT IS TERMINALLY ILL; OR 2) THE RESIDENT IS RECEIVING HOSPICE SERVICES
Mrs P had a transfusion during her dialysis treatment in the past 7 days. Would this be coded under transfusions in section O?
What is NO. Code transfusions of blood or any blood products that are administered directly into the bloodstream in this item. Do not include transfusions that were administered during dialysis or chemotherapy.
Step-wise tapering of a dose to determine whether or not symptoms, conditions, or risks can be managed by a lower dose or whether or not the dose or medication can be discontinued
What is GRADUAL DOSE REDUCTION (GDR)