Coding Instructions

for V0200A, CAAs
•
Facility staff are to use the RAI triggering mechanism to determine which care areas
require review and additional assessment. The triggered care areas are checked in
Column A “Care Area Triggered” in the CAAs section. For each triggered care area, use
the CAA process and current standard of practice, evidence-based or expert-endorsed
clinical guidelines and resources to conduct further assessment of the care area.
Document relevant assessment information regarding the resident’s status. Chapter 4 of
this manual provides detailed instructions on the CAA process, care planning, and
documentation.
•
For each triggered care area, Column B “Care Planning Decision” is checked to indicate
that a new care plan, care plan revision, or continuation of the current care plan is
necessary to address the issue(s) identified in the assessment of that care area. The “Care
Planning Decision” column must be completed within 7 days of completing the RAI, as
indicated by the date in V0200C2, which is the date that the care planning decision(s)
were completed and that the resident’s care plan was completed. For each triggered care
area, indicate the date and location of the CAA documentation in the “Location and Date
of CAA Documentation” column. Chapter 4 of this manual provides detailed instructions
on the CAA process, care planning, and documentation.
Coding Instructions for V0200B, Signature of RN Coordinator for CAA
Process and Date Signed
V0200B1, Signature
•
Signature of the RN coordinating the CAA process.
V0200B2, Date
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Date that the RN coordinating the CAA process certifies that the CAAs have been
completed. The CAA review must be completed no later than the 14th day of admission
(admission date + 13 calendar days) for an Admission assessment and within 14 days of
the Assessment Reference Date (A2300) for an Annual assessment, Significant Change in
Status Assessment, or a Significant Correction to Prior Comprehensive Assessment. This
date is considered the date of completion for the RAI.
V0200: CAAs and Care Planning (cont.)
Coding Instructions for V0200C, Signature of Person Completing Care
Plan Decision and Date Signed
V0200C1, Signature
•
Signature of the staff person facilitating the care planning decision-making. Person
signing does not have to be an RN.
V0200C2, Date
•
The date on which a staff member completes the Care Planning Decision column
(V0200A, Column B), which is done after the care plan is completed. The care plan must
be completed within 7 days of the completion of the comprehensive assessment (MDS
and CAAs), as indicated by the date in V0200B2.
•
Following completion of the MDS, CAAs (V0200A, Columns A and B) and the care
plan, the MDS 3.0 comprehensive assessment record must be transmitted to iQIES within
14 days of the V0200C2 date.
Clarifications
•
The signatures at V0200B1 and V0200C1 can be provided by the same person, if the
person actually completed both functions. However, it is not a requirement that the same
person complete both functions.
•
If a resident is discharged prior to the completion of Section V, a comprehensive
assessment may be in progress when a resident is discharged. Although the resident has
been discharged, the facility may complete and submit the assessment. The following
guidelines apply to completing a comprehensive assessment* when the resident has
been discharged:
1. Complete all required MDS items from Section A through Section Z and
indicate the date of completion in Z0500B. Encode and verify these items.
2. Complete the care area triggering process by checking all triggered care areas
in V0200A, Column A.
3. Sign and enter the date the CAAs were completed at V0200B1 and V0200B2.
4. Dash fill all of the “Care Planning Decision” items in V0200A, Column B,
which indicates that the decisions are unknown.
5. Sign and enter the date that care planning decisions were completed at
V0200C1 and V0200C2. Use the same date used in V0200B2.
6. Submit the record.
*Please see Chapter 2 for additional detailed instructions regarding options for when
residents are discharged prior to completion of the RAI.
SECTION X: CORRECTION REQUEST
Intent: The purpose of Section X is to identify an MDS record to be modified or inactivated.
The following items identify the existing assessment record that is in error. Section X is only
completed if Item A0050, Type of Record, is coded a 2 (Modify existing record) or a 3
(Inactivate existing record). In Section X, the facility must reproduce the information EXACTLY
as it appeared on the existing erroneous record, even if the information is incorrect. This
information is necessary to locate the existing record in the Internet Quality Improvement and
Evaluation System (iQIES).
A modification request is used to correct an iQIES record containing incorrect MDS item values
due to:
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transcription errors,
•
data entry errors,
•
software product errors,
•
item coding errors, and/or
•
other error requiring modification
The modification request record contains correct values for all MDS items (not just the values
previously in error), including the Section X items. The corrected record will replace the prior
erroneous record in iQIES.
In some cases, an incorrect MDS record requires a completely new assessment of the resident in
addition to a modification request for that incorrect record. Please refer to Chapter 5 of this
manual, Submission and Correction of the MDS Assessments, to determine if a new assessment
is required in addition to a modification request.
An inactivation request is used to move an existing record in iQIES from the active file to an
archive (history file) so that it will not be used for reporting purposes. Inactivations should be
used when the event did not occur (e.g., a discharge was submitted when the resident was not
discharged). The inactivation request only includes Item A0050 and the Section X items. All
other MDS sections are skipped.
The modification and inactivation processes do not remove the prior erroneous record from iQIES.
The erroneous record is archived in a history file. In certain cases, it is necessary to delete or
change a record and not retain any information about the record in iQIES. This requires the facility
to complete an MDS 3.0 Individual Correction Request or MDS 3.0 Individual Deletion Request in
iQIES. Additionally, in situations in which the state-assigned facility submission ID (FAC_ID) or
state code (STATE_CD) is incorrect, an MDS 3.0 Manual Assessment Move Facility Request is
required. The policy and procedures for these special requests are provided in Chapter 5 of this
Manual.
These special requests are required only in the following four cases:
1. Item A0410 Submission Requirement is incorrect. Submission of MDS assessment
records to iQIES constitutes a release of private information and must conform to privacy
laws. Only records required by the State and/or the Federal governments may be stored in
the iQIES. If a record has been submitted with the incorrect Submission Requirement
value in Item A0410, then the facility must request correction of A0410 via an MDS 3.0
Individual Deletion Request or MDS 3.0 Individual Correction Request in iQIES. Item
A0410 cannot be corrected by modification or inactivation. See Chapter 5 of this Manual
and the iQIES Assessment Management: Assessment Submitter Manual for details.
2. Record was submitted with the incorrect state-assigned facility submission ID
(FAC_ID) or state code (STATE_CD). If a record was submitted to iQIES for an
incorrect facility or with an incorrect state code, the record must be manually corrected
by the State Agency. In these situations, the facility must complete an MDS 3.0 Manual
Assessment Move Facility Request and send the request via certified mail to the State
Agency.
3. Record submitted was not for OBRA or Medicare Part A purposes. When a facility
erroneously submits a record that was not for OBRA or Medicare Part A purposes, CMS
does not have the auth