OBRA-required assessments that include the completion of both the MDS and the CAA process, as well as care planningAdmission Assessment
What is a COMPREHENSIVE ASSESSMENT
100
Aplastic, iron deficincy, pernicious, sickle cell
What is ANEMIA
100
Look back period for J0100
What is 5 DAYS
100
Not coded in Section O0100D, suctioning, on the MDS 3.0
What is ORAL SUCTIONING
Code only tracheal and/or nasopharyngeal suctioning in this item.
100
Wrtten to cover different dosages 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.
200
Mr. S. was admitted to the nursing home on February 5, 2011 following a stroke. He regained most of his function and was discharged to his home on March 29, 2011.
What is DISCHARGE RETURN NOT ANTICIPATED
200
Loss of range of motion, contractures, muscle weakness, fatigue, decreased ability to perform ADLS, paresis, or paralysis
What is FUNCTIONAL LIMITATIONS
200
Scheduled and implemented non-pharmacological interventions that include bio-feedback, application of heat/cold, and massage
What is NON-MEDICATION PAIN INTERVENTION
Themedical 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
200
Administered via mask, cannula, etc., delivered to a resident to relieve hypoxia. Also used in Bi-level Positive Airway Pressure/Continuous Positive Airway Pressure (BiPAP/CPAP)
What is OXYGEN THERAPY (O0100C)
200
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 CONSEQUENCE
300
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 ERROR
A significant error differs from a significant change because it reflects incorrect coding of the MDS and NOT an actual significant change in the resident’s health status.
300
Lewy body, Vascular, Multi-infarct, Mixed, Frontotemporal such as Pick's disease.
What is NON-ALZHEIMER'S DEMENTIA
300
The section of the MDS that determines if the resident interview for pain should be conducted
What is B0700
300
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
300
The total amount/strength/concentration of a medication given at one time or over a period of time
What is a DOSE
400
Four types of Comprehensive Assessments are:
What is
• Annual Assessment
• Significant Change in Status Assessment
• Significant Correction to Prior Comprehensive Assessment
400
Section for adding additional active diagnoses
What is I8000
400
Includes bone fractures, joint dislocations, closed head injuries with altered consciousness, subdural hematoma
What is FALL WITH MAJOR INJURY
400
Code when the resident's care program involves a short-term stay in the facility for the purpose of provideing relief to a primary home-based caregiver(s) in this item
What is RESPITE CARE (O0100L)
400
Warfarin, heparin, or low-molecular weight heparin
What is ANTICOAGULANT
500
Required when the resident was classified in a RUG-IV Rehabilitation Plus Extensive Services or Rehabilitation group and continues to need Part A SNF-level services after the planned or unplanned discontinuation of all rehabilitation therapies for three or more consecutive days.
What is END OF THERAPY (EOT) OMRA
ARD (Item A2300) must be set on day 1, 2, or 3 after all rehabilitation therapies have been discontinued for any reason
500
The four conditions that must be met to code UTI on the MDS
What is
1.Diagnosis of a UTI in last 30 days
2.Sign or symptom attributed to UTI
3.Significant laboratory findings
4.Current medication or treatment for a UTI in the last 30 days.
500
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
500
Subcutaneous pumps are not coded in this item.
What is IV MEDICATIONS
500
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