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.
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.
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.
What is the definition of fall with MAJOR injury?
Includes bone fractures, joint dislocations, closed head injuries with altered consciousness, subdural hematoma.
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.
What excludes a resident from ADL decline and DC function score?
Hospice.
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.