Active Diagnosis
MDS ARD 9/10/25. Physician progress note lists the following: HTN, HLD, Asthma. MAR for Sept look back indicates resident is taking 25mg metoprolol, SOB flat r/t Asthma, and an inhaler used. Which diagnosis codes would you code on the MDS?
HTN and Asthma. Hyperlipidemia not active per RAI- no treatment/monitoring.
Name an NTA point.
100 points to all teams with a correct answer.
MAR lists metoprolol, melatonin, Hydroxyzine, tylenol given during the look back of your MDS. What is coded in section N?
None of the above.
Resident initial skin assessment indicates skin is intact. On day 3 of admission a stage II pressure ulcer to coccyx is documented in skin/wound. How do you code section M?
Stage II pressure ulcer: 1
Number of pressure ulcers present on admission: 0
What triggers a resident for short stay antipsychotic?
A resident who has been in the facility for less than 100 days, no diagnosis of schizophrenia, Huntington's or Tourette's, and did not have an antipsychotic coded on their initial MDS but was later coded as taking antipsychotic on a DC, Quarterly, end of PPS assessment.
Resident admitted 1/1/25 Medicare A for a left hip fracture s/p ORIF, required therapy services until 3/2/25. Ended up staying in facility LTC. Resident is due for a quarterly 7/2/25. Resident is no longer on therapy, full weight bearing status, requires assist with ADLs per her baseline, no pain, no longer following up with ortho. Would you code Hip fracture in section I?
No. Not active per this assessment look back.
Resident admitted to the facility following acute respiratory failure, new oxygen, COPD exacerbation, HTN, diabetes. What are some items that contribute towards PDPM? What should we do to make sure we have documentation for the MDS?
Respiratory failure (NTA pt and NSG CMG with oxygen), oxygen (NSG, NTA), COPD (with SOB flat order). Should enter SOB flat monitoring order.
Resident MAR for your look back includes albuterol inhaler q6 hrs, lasix, metoprolol, trazodone. What medications are we coding in section N?
Diuretic, & Antidepressant.
Skin and wound picture/assessment states a wound was present on admission. The last MDS in June the wound was coded at stage II, the UDA also list the wound as stage II. The current assessments stage the wound as stage IV? How do you code the wound for the September MDS?
Stage IV, not present on admission.
How many days do you have to wait to complete another assessment to remove a resident from ADL decline?
45 days
What is the look back for a UTI?
30 days
In what situations could you adjust the ARD to maximize reimbursement through PDPM? (only need to list 1 to get points)
2. Diabetes with 7 days of insulin and 2 order changes
Resident is taking gabapentin for neuropathic pain. How is this coded in section J? How is this coded in Section N?
Scheduled pain medication in J. Anticonvulsant in Section N.
Admitted with a surgical wound to top of foot. Order is to clean incision with normal saline, wrap with kerlix. What is coded in the MDS?
Surgical wound care, Application of dressings to feet (with or without topical medications)
What is the definition of fall with MAJOR injury?
Includes bone fractures, joint dislocations, closed head injuries with altered consciousness, subdural hematoma.
Resident admitted 2/4/25 with diagnosis of Sepsis, elevated CRP, elevated WBC, acidosis, Afib. Quarterly MDS ARD is 5/10/25. Receiving xarelto and was given during look back period. MDS has coded Septicemia. In section I8000, elevated CRP, elevated WBC, acidosis and afib pulled into the MDS. What diagnosis is active during the look back period?
Afib
MDS 5 day has a nursing CMG of HBC1 with coding SOB lying flat d/t COPD and documentation during the look back period. Resident has a flat affect and is not participating in their usual activities. Resident is tearful and seems more down than usual. A PHQ2-9 is completed with the resident and the score is a 13. What is the next step?
Open an IPA and ensure all the rest of the interviews are completed for the IPA timely.
Resident is receiving Trazodone 50 mg at bedtime for insomnia. Which drug class is coded in section N?
Antidepressant. Always coded by class and not indication.
Admitted with a stage III sacral pressure injury which was coded in the admission MDS as Stage 3 POA. Now it is time for the quarterly MDS to be completed, the Stage III pressure injury is now unstageable d/t eschar. How is this coded in the MDS?
It is coded as unstageable- Slough and/or eschar not present on admission.
FYI-If the wound later becomes stageable and is staged at a stage III, then it is present on admission but if staged at a stage IV then it is not present on admission.
What excludes a resident from ADL decline and DC function score?
Hospice.
2 part question: MDS Annual assessment has ARD 5/29/25. Has diagnosis of CKD, HTN, anxiety, depression, and GERD. During the look back period, resident received omeprazole and Lipitor. The order for Lipitor was signed by a provider and had the hyperlipidemia diagnosis in the order. The MDS had HTN, anxiety, CKD, depression and GERD coded. Are these diagnosis coded in the MDS active? What diagnosis is missing in the MDS?
First part:No, not all are active-CKD, HTN, anxiety, depression should not have been coded in the MDS d/t no tx received.
Second part: Hyperlipidemia should have been added to the diagnosis list and also coded in the MDS d/t receiving treatment and provider signature on the order.
Name the 2 of the 4 clinical categories in the PT and PT component
What are Major Joint Replacement, Other Orthopedic, Medical Management or Acute Neurologic?
Antianxiety and anticonvulsant. Code all drug class as available.
resident discharges to the hospital with a facility acquired stage II pressure ulcer to coccyx. Readmits 2 weeks later with a stage IV pressure ulcer to coccyx. How is this coded in section M?
Stage IV pressure ulcer present upon admission/readmission. The wound worsened in stage outside of the facility, no longer facility acquired.
What exclusions are there for long stay pressure ulcers?
None. (dashing section M but we don't do that). any resident in the facility for 100 days or more with a stage II or greater will trigger for long stay pressure ulcer regardless if we grew it in house or not.