Quick Assessment Reference Pocket Guides were released on November 10, 2021, by the Centers for Medicare & Medicaid Services. The pocket guides are intended to assist providers in assessing and coding self-care and mobility, falls, and pressure ulcers/injuries.
These pocket guides provide a quick reference for important terms and definitions that can help with increasing the accuracy of coding. The pocket guides are approximately 2 x 3.5 inches and are intended to be worn behind a person’s identification badge for quick reference.
The topics covered by the pocket guides include:
- Pocket Guide #1: Coding for Self-Care and Mobility Items.
- Pocket Guide #2: Definitions for Coding Section J Fall Items.
- Pocket Guide #3: Pressure Ulcers/Injuries Stages and Definitions.
Any questions accessing the pocket guides or feedback regarding the trainings can be sent to the PAC Training Mailbox at PACTraining@EconometricaInc.com.
The pocket guides are available on CMS’s Quality Reporting Program (QRP) Training pages download section for each of the following settings:
- Home Health QRP Pocket Reference Guides can be accessed at Home Health Quality Reporting Training | CMS.
- Inpatient Rehabilitation Facility QPR Pocket Reference Guides can be accessed at Inpatient Rehabilitation Facility (IRF) Quality Reporting Program (QRP) Training | CMS.
- Long Term Care Hospital QRP Pocket Reference Guides can be accessed at Long-Term Care Hospital (LTCH) Quality Reporting Program (QRP) Training | CMS.
- Skilled Nursing Facility QRP Pocket Reference Guides can be accessed at Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) Training | CMS.
Issue:
Correct coding of the MDS is absolutely crucial to ensure accuracy of quality measures for your facility and accurate billing. Quality Measures (QMs) are available online to your residents, their families, and potential customers, and provide them with information regarding the quality of care being delivered by your staff. These QMs should guide your facility to determine the areas of your quality improvement efforts that need additional attention. Inaccurate coding will lead to inaccurate QMs, which may be seen as fraud in billing practices, and could lead to a deficiency for F641 – Accuracy of Assessments. Facility leadership, including the MDS coordinators, should be trained and knowledgeable on accurate coding and the importance of quality measures, and should have access to the most current version of the Resident Assessment Instrument (RAI) Manual available at MDS 3.0 RAI Manual v1.17.1_October 2019 (cms.gov).
Discussion Points:
- Review your policies and procedures to determine if revisions are needed to ensure accurate coding of the MDS. Revise your policy as needed when updates are published.
- Train all appropriate staff on how to code the MDS accurately, how your quality measures are formulated, and document that the training occurred.
- Periodically audit to ensure that coding is accurately completed by all individuals with responsibility for inputting data for the MDS at your facility. Determine that staff completing any sections of the MDS have the most current version of the users’ manual to guide them, and that they are using it.
