MDS 3.0: Changes in Rules, Process, and Philosophy
By Wilma Wheeler, RA, WOCN, RLNC, RAC-CT

With revisions still coming ahead of and up to the implementation date deadline and providers catching the latest educational forums for the most current releases, Minimum Data Set (MDS) 3.0 has arrived. The MDS, a core set of items, definitions, and response categories, assesses all nursing home residents who live in facilities that participate in Medicare or Medicaid programs.

Nearly every section of MDS 2.0 has been revised, and some parts have had total overhauls in rules and definitions. Everything about MDS 3.0 represents a radical shift in focus from 2.0; changes have been made not only in coding and rules but also in process and philosophy. MDS 3.0 will have a major impact on the clinical assessment process, state survey outcomes, quality measures reporting, and reimbursement. It is imperative for providers to understand these changes and implement them correctly. This article takes an in-depth look at the categories of major change.

Changes in Rules and Definitions
One goal of MDS 3.0 is to improve the assessment tool’s reliability, accuracy, and usefulness. Many of the tool’s definitions and instructions have changed so it will be important for facility staff to pay close attention to these. Among the major changes that have occurred within these specific sections are the following:  

• Section C: Cognitive Patterns — Relies on the screener of the Brief Interview for Mental Status (BIMS) to identify levels of cognitive impairment and uses the Confusion Assessment Method to detect delirium. These help identify a resident’s ability to competently yield valuable information.

• Section D: Mood and Depression — Utilizes an interview process involving the Patient Health Questionnaire with a checklist of nine symptoms to be conducted as near to the Assessment Reference Date (ARD) as possible, preferably the day before or on the last day of the observation period. The outcome yields a total severity score based on the total responses and reflects degrees of depression severity from minimal to severe. This has significant care plan implications for facility staff and residents. There is also a question in section D that asks the assessor to notify a provider of a resident’s potential risk to harm him or herself (D0650).

• Section E: Behavior — The assessor is directed to determine a code based on the “behaviors observed or thoughts expressed in the last seven days rather than the presence of a medical diagnosis.” The terms “wandering” and “rejection of care” are officially defined in this section.

• Section F: Customary Routine — This section includes a resident interview that replaces the “Customary Routine” and “Section N: Activity Pursuits” from MDS 2.0. This information may also be provided by a family member and is integral to successful care planning.

• Section G: Activities of Daily Living (ADL) — There are relatively few changes to this section, but this is still one of the most difficult for providers to perform accurately. It is also one of the most important sections for the Resource Utilization Group (RUG) score due to the ADL index. Instruction on Rule of Three coding is now outlined in the Resident Assessment Instrument (RAI) manual, and a new option of code 7 exists for situations in which a targeted activity has occurred only once or twice but not three times. The new ADL flow sheet included in MDS 3.0 can be very useful. Some definitions within the tool have changed such as “bed mobility.” This term now includes “alternate sleep furniture” for residents who sleep in chairs. Dressing is no longer specific to street clothes. Eating instructs the assessor not to consider eating or drinking during medication pass. Toileting does not include emptying of bedpans, urinals, bedside commodes, or ostomy or catheter bags.

• Section H: Bowel and Bladder — Fecal impaction was dropped from this section, and constipation is addressed with a “yes” or “no” answer. New information now exists about a toileting program including a trail. New coding options for residents with an ostomy or catheter are to be categorized as “not rated.”

• Section I: Active Diagnosis — The Centers for Medicare & Medicaid Services (CMS) plans to introduce an algorithm to the RAI user manual to help determine whether a diagnosis is active or inactive.

• Section J: Falls — This section now includes coding for injuries from falls in addition to the extent of such injuries. A clinical crossover to Section G 0300 now features balance issues that define a resident as a fall risk.

Pain is now an interview section to be completed by the resident, if possible, or by a staff member if the resident is unable to do so. It does not have to agree with information in the record; coding should be based on a resident’s response.

• Section K: Swallowing Nutrition — A new item was added to help detect swallowing problems that may need therapy or dietary modifications (K0100). Coding instruction is available for rounding up or down for weights more or less than 0.5 lbs.

• Section M: Skin — MDS 3.0 brings major changes to Section M, including the adoption of the guidelines and definitions from the National Pressure Ulcer Advisory Panel. Reverse staging of ulcers has been eliminated. Items for the Pressure Ulcer Scale for Healing have been added for measuring and tissue type. Staging is based on deepest anatomical change, and unstageable ulcers are identified in this section. Facilities must now identify whether an ulcer was present on admission, and present on admission has a newly specific definition.

• Section N: Medications — Anticoagulants and antibiotics have been added.

• Section O: Special Treatments — Two columns were added, one for while a resident and one for not while a resident. New guidelines have been provided for therapy minutes. Actual minutes are now entered, and software calculations exist for concurrent minutes by 50% and 25% for the group.

• Section P: Restraints — New instructions are included on using a bed or a chair with frequency over a seven-day look-back period.

• Section Q: Resident Participation and Goal Setting — This section has been expanded to five queries, including a community referral requirement.

Changes in Process
Success with MDS 3.0 will require an interdisciplinary process, including the strong involvement of a resident or his or her family, drawing on the strengths of all disciplines working together to meet the resident’s needs. Many problems residents face, as outlined in the Care Area Assessments, cannot be solved or managed by only one discipline. Certain areas of the assessment, such as requiring a Significant Change in Status Assessment identifying when a resident goes to hospice, are for the intended purpose of coordinating the care between a facility and a hospice agency. 

The look-back period has become more standardized in 3.0 to allow a more consistent “snapshot in time.” Staff should become familiar with the time specification as outlined in chapter 3 of the RAI manual, as look-back periods are no longer stated in each section.  

Other process changes include those involving submission requirements. Instead of going to the state, data will now be transmitted to the CMS Quality Improvement and Evaluation System Assessment Submission and Process system. Under MDS 3.0, comprehensive assessments must be transmitted electronically within 14 days of the care plan completion date (V0200C2), with all other MDS assessments submitted within 14 days of the MDS completion date (Z0500B). This signifies a change in process from the 31 days formerly allowed by 2.0.

Changes in Philosophy
The entire emphasis of MDS has moved from an assessment based on records and observation to a focus on actually “hearing a resident’s voice.” Studies have shown that even cognitively impaired residents are able to express how they feel, and they will have an opportunity to do that via scripted interviews based on a cognitive screen called BIMS. If a resident is rarely or never understood (B0700), he or she is screened out of the interview process. Residents will be interviewed about daily preferences, mood, activity preferences, and pain. The philosophical shift of  MDS 3.0 can be summed up in federal regulation F309 (F483.29): “Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychological well-being in accordance with the comprehensive assessment and plan of care.”

Implementation Tips for Nursing Home Providers
• Train the whole team. Your staff cannot be expected to embrace what they do not know. Even if your facility has not been proactive in learning the new 3.0 changes, it is not too late to get onboard. Train a backup MDS coordinator, as a vacancy in this position can have serious negative implications from care to survey to reimbursement.

• Keep current on changes. Changes to MDS 3.0 are expected even into 2011. Stay current by going to the CMS website often and develop a process to disseminate information in the facility.

• Practice the interview process. The interview process is new, and many may not embrace it easily. Time and repeated use will prove it worthy of the effort.

• Develop self-auditing processes. This helps verify accuracy.

• Develop a strong working relationship between clinical and billing departments for processing the RUG IV.

• Increase your skill in determining an ARD. Try several and see which one offers the best reimbursement option.

• Buy the book. Make sure every team member has access to the RAI manual.

— Wilma Wheeler, RA, WOCN, RLNC, RAC-CT, is a senior risk management consultant for Risk Management Solutions.