MDS FAQs

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MDS

Acronyms
Admission Date
Ampersands in Version 5.0
Assessment Internal ID
Assessment Requirements Section W
Error -399: Inconsistent NPI
Error Summary Report by Facility-blank
Errory Summary Report by Facility-calculated
Incorrect Sub_Req
MDCN 800 Dial-up Number
Medicare PPS (OM) Assessments
MDS Monthly QI Comparison Report-Dates
MDS Monthly QI Comparison Report-Sample Size
Non-Certified beds
Rejection with blank fields
Sub_Req
Using Hyphens
W2b Fatal Record Error
W2b and W3b Questions

NHQI

Account Is Locked
Accuracy of Quality Measures

Modification Explanation
QIO Staff Contacts for the Nursing Home Quality Initiative
Quality Measure score looks differently from the preview
Quality Measures Suppressed-Low Denominators
Tips on Checking the Accuracy

QUALITY INDICATORS (QI)

Assessments Used to Calculate QI's
Erroneous Data
Prevalence vs. Incidence QI Indicators
Resident Listing Report

MDS Frequently Asked Questions

05/03/2007

Question:Since I have received my NPI I am now entering this value into Item W1 in my data entry software however, when I submit I have received a warning message -399: Inconsistent NPI: The NPI number submitted in W1 is not consistent with the NPI number submitted in the header record. Why am I receiving this warning message?

Answer: The MDS Version 1.30 Data Specifications state that the NPI in the header record should match the NPI in the body records. If the two values are different such as, the header is blank and the body record contains the NPI then Warning Message -399 is generated.

To avoid this error in the future, it is recommended that you contact your vendor to ensure that the NPI number is being entered into both the header in bytes 577-586 and each body record in bytes 1626-1635 when the assessments are exported.


04/21/2006

Question: When should a Fatal Record Error -404 be generated?

Answer: Fatal Record Error –404 should be generated where:
-The W2a (Did the resident receive the influenza vaccine in this facility for this year’s influenza season?) is marked as ‘No’ AND
-W2b is marked as ‘1’ (Not in facility during this year’s flu season) AND
-The A3a (Assessment Reference) date or R4 (Discharge) date is between 10/1 and 3/31.


10/25/2005
When responding to W2b and W3b first read and consider all the responses listed for each. If none of the listed responses apply, a response of "unable to determine" (a dash) is allowable, as is the case with most MDS items.

W2b
Question: How do I code item W2b on the MDS if the resident has not received an influenza vaccine by the ARD, and none of the reasons in W2b apply?

Answer: As is the case with most of the MDS items, item W2b allows an "unable to determine" value (a dash). If none of the reasons in item W2b apply, the "unable to determine" value (a dash) should be coded.

W3b
Question: How do I code item W3b on the MDS if the resident's PPV status is not up to date by the ARD, and none of the reasons in W3b apply?

Answer: As is the case with most of the MDS items, item W3b allows an "unable to determine" value (a dash). If none of the reasons in item W3b apply, the "unable to determine" value (a dash) should be coded.

W2b
Question: If the facility knows that their supply of flu vaccine won't be available by the ARD date, how should item W2b be coded?

Answer: Before choosing a response determine whether the vaccine is unavailable because of a declared vaccine shortage (as described in the RAI manual) or because the vaccine supply is expected to be delivered after the ARD.


If the resident was offered the vaccine by the ARD but the vaccine is unavailable at the facility due to a declared vaccine shortage (as described in the RAI manual), then code response 6, "Inability to obtain vaccine"

If the resident was not offered the vaccine by the ARD because the vaccine is unavailable due to a declared vaccine shortage (as described in the RAI manual), then code response 6, "Inability to obtain vaccine"

If the resident was offered the vaccine by the ARD, and the facility knows it will receive its supply of vaccine after the ARD, a response of "unable to determine" (a dash) is allowable.



09/08/2005
Question: What assessments require Section W?


Answer: Section W is included on all assessments with an assessment reference date (A3a) on or after October 1, 2005, all discharge tracking forms with a discharge date (R4) on or after October 1, 2005 and all reentry tracking forms with a reentry date (A4a) on or after October 1, 2005. However, not all Section W fields are required at all times. Below is a breakdown that explains what fields in Section W are required with each Reason for Assessment (RFA).

W1 : An Optional Data Item
Assessments (RFA 01, 02, 03, 04, 05, 10 and 00)
W1 is optional on all assessments with an assessment reference date (A3a) on or after October 1, 2005.

Discharge Tracking Forms (RFA 06, 07, 08)
W1 is optional on all discharge tracking forms with a discharge date (R4) on or after October 1, 2005.

Reentry Tracking Forms (RFA 09)
W1 is optional on all reentry tracking forms with a reentry date (A4a) on or after 10/1/2005.

W2
Assessments (RFA 01, 02, 03, 04, 05, 10 and 00)
W2 is required on all assessments with an assessment reference date (A3a) between October 1 and June 30.

Discharge Tracking Forms (RFA 06, 07, 08)
W2 is required on all discharge tracking forms with a discharge date (R4) between October 1 and June 30.

Reentry Tracking Forms (RFA 09)
W2 is inactive on Reentries.
Sections W2 can be submitted with a Reentry Tracking Form but the data will not be edited or stored in the state database. Therefore, the user will not receive any error messages due to including W2 on a reentry tracking form.

W3
Assessments (RFA 01, 02, 03, 04, 05, 10 and 00)
W3 is required on all assessments with an assessment reference date (A3a) on or after October 1, 2005.

Discharge Tracking Forms (RFA 06, 07, 08)
W3 is required on all discharge tracking forms with a discharge date (R4) on or after October 1, 2005.

Reentry Tracking Forms (RFA 09)
W3 is inactive on Reentries.
Sections W3 can be submitted with a Reentry Tracking Form but the data will not be edited or stored in the state database. Therefore, the user will not receive any error messages due to including W3 on a reentry tracking form.



12/23/2002 - Corrected January 19,2003

Question: I have noticed that the percentage appears to be rather high when I run the CASPER Provider report entitled Error Summary by Facility report. How is this report calculated?

Answer: The Error Summary by Facility report is calculated by dividing the number of records processed in the requested timeframe into the number of times an error was received in the same time frame. Currently, if the facility submitted assessments on the last day of their request period, the number of assessments processed is not included in the calculations. Thus, this results in the percentages being skewed. This will be corrected with a future release.


12/23/2002

Question: I am trying to request the CASPER Provider report entitled Error Summary by Facility in a date range of 11/15/2002 to 11/30/2002; each time the report comes back blank. I successfully submitted assessments during this timeframe and know I had some warning errors. Why is it blank?

Answer: The CASPER Provider report, Error Summary by Facility, can only be requested in full calendar month time frames. For example, a one-month time frame would be entered including the first and the last day of the month (i.e. 11/1/2002 to 11/30/2002). In a future release, we will be updating the data criteria for requesting this report to allow a request by month time frames only. You will be able to request by just one month or several months at a time.


07/02/2002

Question: I know that the admission date is not an item on the new MPAF, but I need to know what the admission date is for calculating when my Medicare assessments are due? What should I do?

Answer: Although the MDS Face Sheet item AB1 (admission date) is not included on the new MPAF form, this should not pose any new problem for you in tracking the beneficiary's admission date. As has always been the case, the AB1 admission date is only required to be entered and submitted once for each new admission. AB1 is required either on the Initial Admission Assessment record (reason for assessment at AA8a = 01) or on a Discharge Tracking Form record for a discharge occurring before completion of the admission assessment (reason for assessment at AA8a = 08). The AB1 admission date is not required on any other assessment, discharge tracking form, or reentry tracking form. The requirements concerning AB1 have not changed and facilities can continue to use their existing method for tracking the beneficiary's admission date.

Prior to July 1, 2002, Medicare PPS assessments were required to use the Full Assessment Form. The new, shorter MPAF assessment form is being implemented on July 1, 2002 as an optional form that can be used instead of the Full Assessment Form for Medicare PPS assessments. Note that the AB1 admission date is not present on either form allowed for Medicare PPS assessments (Full Assessment Form or MPAF). The absence of AB1 on the MPAF form should not require any change in facility practice concerning the admission date.

It is important to make a few additional clarifications. First, the AB1 admission date is on the Background (Face Sheet) Form. The entire Face Sheet is required on an Initial Admission Assessment. However, the entire Face Sheet (including AB1) can also be optionally submitted by the facility on any non-admission assessment (including a Medicare PPS assessment using either the Full Assessment Form or the MPAF form). When the Face Sheet is optionally submitted on a non-admission assessment, then all Face Sheet items (all Section AB and Section AC items) must be completed and submitted. Optional submission of the Face Sheet must be in "all or none" fashion. If item AB1 is completed and submitted with a non-admission assessment, then all Face Sheet items must be completed and submitted.

A second clarification has to do with the AB5a through AB5f Face Sheet items. These 6 items involve prior institutional history and have been included on the MPAF form. In the future, these items may be used in Quality Measures being developed for Medicare SNF care. The items have been added to the MPAF form to allow use of these items on PPS, non-admission assessments without requiring the entire Face Sheet. With the July 1, 2002, implementation of the MPAF, the AB5 items are optional on PPS, non-admission assessments with plans to make them required in the future. Since they are optional, the AB5 items may be left blank on a PPS, non-admission assessment. Note that if the AB5a through AB5f items are optionally submitted on a PPS, non-admission assessment, then all 6 items must be submitted. Optional submission of the AB5 items must be in "all or none" fashion.

Submission of AB5a through AB5f is not optional on a PPS assessment coupled with an Initial Admission Assessment. The entire Face Sheet (all items in Sections AB and AC) is required on all Initial Admission Assessments, including combined PPS and Initial Admission assessments.

A second clarification involves PPS assessments that are combined with comprehensive assessments. On a PPS assessment coupled with any comprehensive assessment (admission with AA8a = 01, annual with AA8a = 02, significant change with AA8a = 03, and significant correction of prior full with AA8a = 04), the MPAF form is not allowed. All comprehensive assessments require use of the Full Assessment Form, as well as the RAP Summary Form (Section V).

A final clarification involves use of the AB1 admission date for calculating when Medicare PPS assessments are due. The Medicare PPS assessment schedule is actually based on the day that Medicare Part A coverage begins for the current covered stay and not the admission date. For instance, the PPS 5-day assessment window is Day 1 through Day 5 (with a grace period from Day 6 to Day 8), where Day 1 is the start of a covered stay rather than the admission date. There may be confusion about the starting point for the PPS assessment schedule, because the start of coverage and the admission date are the same for about 75% of all covered SNF stays.

While the admission to the facility and the start of coverage usually coincide, they are different for about 25% of SNF stays. Examples are:

  • An existing long-term care resident in the facility has a hospitalization and then a SNF covered stay. Admission to the facility may have been years before the start of coverage. A new Initial Admission Assessment is not appropriate and the AB1 admission date will predate the start of coverage (perhaps by years).
  • A new resident is admitted primarily to receive SNF care. On the advice of the resident's physician, the start of SNF coverage is delayed several days to allow the resident to stabilize before receiving rehabilitation therapy. The AB1 admission date may predate the start of coverage by a few days to a few weeks.
  • A new resident is admitted and SNF covered care begins immediately. The resident is then rehospitalized. The resident returns to the facility and resumes covered care with a new covered stay.

In this case, the PPS assessment schedule must be restarted based on the day that covered care is resumed. The AB1 admission date may predate the resumption of covered care by a few days to several months. In all of these cases, the AB1 admission date cannot be used for setting the PPS assessment schedule in this case. In general, the PPS assessment schedule must be based on the day that the current covered stay started, rather than the AB1 admission date.


02/26/2002

Question: Where do I look to find what a specific acronym stands for such as, CMS, CASPER, or MDS?

Answer: Acronyms can be found by going to the QTSO Website (www.qtso.com) and clicking on the Help tab located on either the dark blue bar on the left side of the page displayed and also on the light blue bar near the top of the page.


12/19/2001

Question: On my MDS Final Validation Report, my assessment was rejected. The name, SSN, and the target date are blank on the report; effective date & attes date (AT6) fields show unknown. What does this mean? Why was the assessment rejected?

Answer: The assessment was rejected because the sub_req field was blank or invalid. When an assessment is rejected due to the sub_req field, all resident identifiers are blacked out.


11/29/2001

Question: What do I do if an assessment was submitted with an incorrect SUB_REQ and the assessment was accepted at the State?

Answer: This situation cannot be corrected using the automated modification or inactivation process. You must make a written request to your State help desk. This written request will be evaluated by your State and, if appropriate, will be forwarded to IFMC where the manual correction will be done.


11/26/2001

Question: I have a final validation report and it shows an Assessment Internal ID for my rejected records. If I have an Assessment Internal ID does that mean my record was actually accepted? What is the Assessment Internal Id used for?

Answer: The Assessment Internal ID is used in the State System to track assessments. Even when an assessment is rejected, it is assigned an ID number. This can track the order the assessments were processed in when they were submitted to the State System.


11/26/2001

Question: I submitted an assessment with the Sub_Req of 3 and then realized the resident was in a non-certified bed. Should I just inactivate this assessment?

Answer: No. Any time a record with an incorrect Sub_Req is submitted to and accepted by the State System, that record must be deleted manually. A form with the deletion request information must be submitted to the State RAI Automation coordinator.


11/26/2001

Question: I am in a state that requires submission of assessments for residents in non-certified beds. I submitted an assessment with a Sub_Req of 2 and it should have been 3. I sent a manual deletion request to the state and have resubmitted the assessment with the Sub_Req = 3. The record was rejected as a duplicate. Why was it a duplicate? If it is because the record was not yet deleted, how will I know when to send it again?

Answer: The record was rejected because Sub_Req is not part of the duplicate record check. This means you really submitted the same record twice. In this scenario, the manual request is to modify the Sub_Req. The record with the incorrect Sub_Req is not deleted, the Sub_Req is modified. The record should not be resubmitted. The manual request you submitted is all that is necessary.


04/05/2001

Question:How is the Sample Size determined on the MDS Monthly QI Comparison Report?

Answer: The Sample size refers to how many resident assessments that had QI calculations done during the six-month time period. If multiple assessments were submitted for a resident during that time period, QI calculations will only be done on the assessment with the most current A3a (Assessment Reference Date).


04/05/2001

Question:What do the dates on the MDS Monthly QI Comparison report mean?

Answer: The dates on the report reflect the following:

  • Run Date: The date that the program runs on the state server.
  • Report Date: The last month of the six-month report period.

The report date is four months prior to the run date. The four-month lag time allows facilities to complete and submit late assessments to ensure comprehensive data in the report. It is also the last month of the six-month report period. For example, if the run date is 03/28/01, the date on the top of the report will be 11/2000. The report will be comprised of six months of data from assessment submissions, which in this case would be the months of 06/2000-11/2000.


12/06/2000

Question: Do Medicare PPS only (OM) assessments count when timing for when the quarterly assessment is due? I have the following assessments completed:

  • AB1 (date of admission) = 10/1/2000
  • AA8a = 00, AA8b = 1, R2b = 10/5/2000
  • AA8a = 01, AA8b = 7, R2b = 10/14/2000
  • AA8a = 00, AA8b = 2, R2b = 10/30/2000
  • AA8a = 00, AA8b = 3, R2b = 11/29/2000
  • Skilled care discontinued on 12/8/2000

Do I schedule the quarterly assessment within 92 days of the date 10/14/2000 or the date 11/29/2000?

Answer: No, Medicare PPS only (OM) assessments do not count for the timing requirements. The current Data Specifications of the MDS 2.0, specify the minimum requirements for record timing. The Record Timing section states: "A standard MDS assessment (comprehensive or quarterly) is due every quarter unless the resident is no longer in the facility." An OM record type occurs when AA8a = 00 and AA8b = 1, 2, 3, 4, 5, 7, or 8. The data specifications go on to state: "Every record of Type A, AM, AO, Y, YM, YO, Q, QM, or QO is expected to be followed by a record of type A, AM, AO, Y, YM, YO, Q, QM, or QO within 92 days if the resident is still in the facility at that time. Date R2b from the previous assessment is expected to be within 92 days of date R2b from the subsequent assessment." The OM record types are not considered for timing edits. In the scenario you describe calculate 92 days from 10/14/2000 because it is the latest assessment where AA8a does not equal 00. All the other assessments were OM records (AA8a = 00) and are not considered for timing edits.


05/24/1999

Question: It seems that whenever I code field D1 with hyphen (-), unknown, I receive error number -75, "The submitted RAP value was incorrectly calculated" for field VA03a. The same error occurs with fields K3a and VA12a. Why is this error occurring?

Answer: Visual Function RAP,VA03a, is triggered by any of the fields D1, D2s, I1jj, or I1ll. If the RAP is not clearly triggered by the response in any one of these fields and at least one of the fields, such as D1, contains a hyphen (-), unknown, then the RAP response must also be a hyphen (-), unknown. Nutritional Status RAP, VA12a, is triggered by any of eight different fields, including K3a. If the RAP is not clearly triggered by the response in any one of these eight fields and at least one of the fields, such as K3a, contains a hyphen (-), unknown, then the RAP response must also be a hyphen (-), unknown. This same convention applies to all the RAPs.


06/30/1999

Question: In MDS Version 5.0, ampersand (&) was removed as a valid value in all fields except two in Section I (HIV and STD fields) and all of Section V. Does this mean that when a field is a state option on specific record types and is not state required, those fields can no longer be ampersand (&) filled?

Answer: This depends on how the field is set in the State System. This removal of the ampersand as a valid value applies to any active fields on any record type. There are three ways each field can be set in the State System for any assessment type: inactive, active-optional, or active-required. Any active field, optional or required, must contain a value that is listed in the "range" for that field. Active-optional allows blanks as well as values in the "range". If the field is inactive, it can be ampersand (&) filled. If the field is active-optional or active-required, it cannot be ampersand (&) filled. Please be aware that most fields that are state option and not state required are set to active-optional, therefore & filled is not allowed.


NHQI


11/12/2002

Quality Measure Suppressed-Low Demoninators

Question: My quality measures were suppressed due to low denominators during the preview. Will they still be suppressed on Nursing Home Compare once it goes live on November 12th?

Answer: Since the Nursing Home Quality Initiative quality measure preview process, CMS became aware that some modified MDS assessment records were not incorporated into the files used to create the publicly reported quality measures. Specifically, we omitted some modified MDS assessments which should have been included in the sample file. All the quality measures were regenerated using the files that include these assessment modifications. These more recently calculated quality measures will be reported on Nursing Home Compare and will be used in the newspaper ads. Because of the inclusion of these modified records, some nursing homes will see a small change in their reported quality measure scores. Some facilities that were suppressed during the preview due to low denominators may now have enough data to have a rate reported on the national release of Nursing Home Compare.


11/08/2002

Modification Explanation

Download the Modification Explanation.pdf


11/07/2002

Quality Measure Score looks differently from preview

Question: Why does my quality measure score look differently from the preview I viewed in mid-October?

Answer: Thanks to all the valuable feedback we received during the Nursing Home Quality Initiative quality measure preview process, CMS found that we had failed to incorporate some modified records into the samples used to create the quality measures. CMS has now regenerated all the quality measures to include the correct records. By including these modified records, some nursing homes will see a small change in their reported quality measure scores.

The majority of facilities will see no change at all in their quality measure scores. In facilities with changes, the man change appears to be only about 1.3 points (e.g. from 10% to 11.3% or from 10% to 8.7%). Only 350 of the facilities nationwide will see changes of 5 points or more (positive or negative) in any given quality measure. CMS is contacting each of these facilities to alert them to the revised measures and allow them to re-preview their quality measures.

These new quality measure rates that incorporate the modified records will be the rates reported on Nursing Home Compare later this month. In addition, these revised measures will be used in the newspaper ads. However, no new facilities have been added to the ads. So, if a nursing home was told that it would be suppressed from the ads, this will not change. The resident-level data will still be available to each nursing home sometime in late November. These resident level files will be generated from the updated file and will reflect the quality measures posted on Nursing Home Compare.


10/25/2002

QIO Staff Contacts for the Nursing Home Quality Initiative

Question: Who do I contact for further assistance on questions regarding the Nursing Home Quality Initiative?

Answer: Please contact the QIO in your state for further assistance on questions about the Nursing Home Quality Initiative (i.e. quality measure data, quality improvement activities, etc.) Click here for QIO Contacts.


10/17/2002

Account is Locked

Question: When trying to connect to view the NHQI reports, I had problems with my User ID and Password in the dialer. I get a message that my account is locked. I cannot even connect to the CMS Welcome Page. What should I do?

Answer: You will need to contact the MDCN Help Desk at 1 (800) 905-2069. Select Option 3 to reset your password. You will need to know your Facility ID and User ID. If you do not know your User ID, know the name of the person assigned that User ID. This person is usually the person who routinely submits MDS assessments. MDCN will then be able to reset your password.


10/11/2002

Tips on Checking the Accuracy

CMS did not discover any problems in calculating the MDS Quality Measures (QMs) for any facility in the six-state pilot. These TIPs outline a strategy to determine if you may have any problems with your facility's QMs. If after following these TIPs and reading the attached FAQs on Accuracy of My Quality Measures, you still have any concerns about the accuracy of your QM values (e.g. you believe your facilities QMs have been inadvertently switched with another facility), please call 1-888-676-0724 [Note: this number is operational only from Oct 14th through Oct 22nd, 2002].

1. Question: Do you have quality measure values that are not applicable to your facility?

Answer: Facilities should first review whether they have data for each of the QMs. If you were assigned another facility's QM inadvertently, you may have data for some QMs that are impossible for your facility. For example, you should not have QM for post-acute care (PAC) QMs when your facility does not provide any or minimal PAC (Note: you need to have a minimum of 20 residents with 14d SNF PPS MDS assessment completed during the six-month [January 1, 2002 though June 30, 2002] observation period used to calculate the PAC QMs] in order to have a PAC QM reported on www.medicare.gov in mid-November). Alternatively, you should not have a chronic care QM when you are a hospital based SNF with very few residents staying long enough to calculate a chronic care QM. The chronic care (CC) QMs require at least 30 assessments in the three-month observation period [April 1, 2002 through June 30, 2002] used to calculate the CC QMs

2. Question: Is your denominator size unusually large or small, given the size and admission practices of your facility?

Answer: Facilities should next look at their denominator size for each QM. You should see if your denominator size for your chronic care or PAC sample look way out of range given your facility bed size, occupancy rate and admission volume during the observation period. For example, if you have 100 bed facility with 90% occupancy, your denominator size for the chronic care sample should not be significantly larger than 100 (e.g. say >200). Conversely, if you have a large facility (e.g. >300 beds), you should not have a significantly smaller denominator size (e.g. <50). Due to exclusions from the quality measures, the denominator size may be less than the total number of residents in your facility during the three-month observation period. Alternatively, the denominator size may be larger than your bed size, as the calculation of the measures include discharged residents, as well as residents currently living in your facility.

This also applies to checking your PAC QM denominator size. [Note: many facilities will have smaller than expected PAC denominator size due to the MDS selection process for calculating the PAC QMs since only 14d SNF PPS MDS assessments are used (AA8b = 7) as target assessments. Many SNF admissions are either discharged prior to having a 14d SNF PPS MDS assessment completed, or residents are enrolled in managed care or have a non-Medicare insurance that does not require SNF PPS (Medicare) assessments. AA8b is usually left blank for these residents.

3. Question: For those QMs that have a corresponding CHSRA QI, are your QM values extremely different from your CHSRA QI?

Answer: Lastly, facilities should compare their QMs with their CHSRA QIs from the corresponding time frame used to calculate the chronic care QMs. [Note: Chronic care QMs reported in November 2002 reflect MDS assessments completed during 2nd quarter of 2002 - April through June]. Chronic QMs with corresponding CHSRA QIs include Pressure Ulcer, Restraints, and ADL Decline. Facilities should not expect their QMs to identically match their CHSRA QIs since the specifications for the QMs are not identical to the CHSRA QI specifications. A table outlying similarities and differences in the calculation of the QMs and CHSRA QIs can be found at (http://www.riqualitypartners.org/Info_For_Nursing_Homes/info_for_nursing_homes.shtml go to quality measure info and select "Overview and comparison of QMs and CHSRA QIs"). However, your QM should not be extremely different from your corresponding CHSRA QI (i.e. there should not be large absolute differences of >20% [20 percentage point difference] when you subtract your CHSRA QI from your QM. For example, a facility with a Pressure Ulcer QM without the FAP of 25% is unlikely to have a CHSRA pressure ulcer (combined high and low risk) QI of 5% (i.e. 25%-5% = a 20% absolute difference). Smaller differences may occur due to differences in MDS selection process and risk adjustment strategies, including exclusions.

4 .Question: Are all staff coding the MDS entries in the same way, with the same understanding of how to code each entry that is included in the calculation of each QM?

Answer: In the six-state pilot, many facilities realized that MDS coding instructions were not being consistently followed on all units within a facility. In addition, there was confusion on how to properly code each item. In some circumstances, facilities discovered this as the reason their numerator values were larger than they believed they should be. Facilities should carefully check their MDS coding before assuming an error in the QMs and review the instructions in the RAI User's Manual. If coding questions some up, facilities should call their state's RAI Coordinator.


If after following these four steps and reading the attached FAQs on Accuracy of My Quality Measures, you still have any concerns about the accuracy of your QM (e.g., you believe your facilities QMs have been inadvertently switched with another facility), please call 1-888-676-0724 [Note: this number is operational only from Oct 14th through Oct 22nd, 2002].


10/11/2002

Accuracy of Quality Measures


1. Question: The number of residents used to calculate my Post-Acute Care (PAC) Quality Measure (QM) is incorrect. Shouldn't the denominator be larger because we admitted many more residents to our SNF/TCU unit?

Answer: Before concluding your PAC QM is incorrect, it is important to review how residents are included in the PAC QM calculations. The PAC sample spans a six-month period and selects resident's most recent 14d SNF PPS MDS assessment (AA8b = 7). Residents who were admitted for SNF stay, but leave before a 14d SNF PPS assessment is completed, are not included. Approximately 50% of all SNF stays leave before 14 days. Also, AA8b is not usually completed for residents with Medicare Managed Care, other insurance (e.g. indemnity insurance) or paying cash and therefore are not selected for inclusion in the PAC QM calculations. The end result of this selection process is that the denominator used to calculate the PAC measures will usually be less than the total number of residents admitted to your SNF-PAC-subacute unit. How much less will depend on your volume of non-Medicare residents and length of stay less than 14 days for your Medicare residents. If after re-examining your SNF/subacute care admissions applying these criteria you still find a large discrepancy, then you should call 1-888-676-0724, which is operational only from Oct.14th through Oct. 22nd, 2002. Small discrepancies will also occur due to exclusions applied to each QM.

2. Question: The number of residents in my Chronic Care (CC) Quality Measure (QM) is incorrect. We only have 100 beds but have more than 100 residents are used to calculate our QM?

Answer: Before concluding your CC QM is incorrect, it is important to review how residents are included in the CC QM calculations. The Chronic Care sample spans a 3 month period and selects residents with the most recent OBRA assessment during that three month period. Some facilities will have high turnover of residents and may have more than one resident occupying a bed during the three-month observation period that has an OBRA MDS assessment completed. This will cause these facilities to have more residents in their sample than total number of beds. Conversely, for each measure some residents are excluded based on their clinical characteristics. This will lower the number of residents used to calculate the measure (denominator size) and will vary by facility depending on your resident population (please review exclusion criteria for CC QMs at (http://www.riqualitypartners.org/Info_For_Nursing_Homes/info_for_nursing_homes.shtml go to quality measure info and select "Overview and comparison of QMs and CHSRA QIs"). The net effect is that your chronic care QM denominator size should be close but not identical to your bed size given your occupancy rate.

3. Question: The quality measures are different from the percentages we get when we divided the numerator by the denominator provided on the preview data.

Answer: This may occur for five of the quality measures (Delirium, Delirium with FAP, Walking Improvement, Pain [chronic care], and Pressure Ulcer with FAP) but should not for the other QMs. This occurs because these five QMs utilize a regression strategy for risk adjustment. This approach calculates an "expected" QM adjusted for facilities resident characteristics and for the facility's admission profile. The observed value (the numerator divided by the denominator) is compared to the expected value and the national mean. In general, when the observed value is less than the expected and national mean the facility is considered to be doing better than expected and the facility's adjusted QM is lower than the observed value. Conversely, when the observed value is greater than the expected value and national mean, the facility is considered to be doing worse than expected and the adjusted QM value is usually higher than the observed value. For example, if a facility has 10 residents with pressure ulcers out of 100 residents, the observed value would be 10% (10/100). If the expected value is 8% and national mean is 9% (both less than the observed value of 10%) then the facilities adjusted value is going to be higher than 10%. However, in most circumstances the observed value and the adjusted value will be very close in value.

4.Question: We track the number of residents with each of the conditions in the quality measures (e.g. pressure ulcers or restraints) and the number of residents with these conditions in the numerator seems to be way too high.

Answer: This can occur for several reasons. The most likely reason occurs when the data collected and used by the facility to track their conditions (e.g. pressure ulcers or infections) is different from the data collected and used by the MDS coordinator or nursing home staff completing the MDS. For example, a nursing home might have a QA committee that tracks pressure ulcers or an infection control nurse who tracks infections from their own data collection process, while other staff in the facility who are completing the MDS use information from their own observations. If these groups use different definitions for pressure ulcers or infections, or different ways of collecting information from the resident, the MDS information may not match the facilities QA information. Facilities should first look at their MDS coding before assuming an error in the QM calculation. This is much more common than an error occurring in the calculation of the MDS QMs. Errors in entering MDS data should be corrected through normal mechanisms. Alternately, a facility's QM information could have been inadvertently switched with another facility's, though this is extremely unlikely. If you believe an inadvertent switch has occurred, you should call 1-888-676-0724 which is operational only from Oct 14th through Oct 22nd 2002.

5. Question: I do not have any PAC QMs reported?

Answer: A facility must have at least 20 residents over a 6-month period that have a 14d SNF PPS record available and do not have any of the exclusion criteria for each PAC QM in order for the quality measure to be reported.

6.Question: I do not have any Chronic Care QMs reported?

Answer: A facility must have at least 30 residents over a 3-month period that have an OBRA MDS and do not have any of the exclusion criteria for each chronic QM in order for the quality measure to be reported.


QI Frequently Asked Questions


03/03/2003

Question: In reviewing my MDS QI Resident Listing report in the Previous assessment column, some of the months are not appearing correctly such as October (10) only prints the 0. I also noticed that the date is not in line with the rest of the row. Why is this occurring?

Answer: In the MDS QI Resident Listing report, the previous assessment date column is dropping the first digit of a 2-digit month when the date is also 2-digits . Example: If the previous assessment date is 10/11/2002, it will appear on the Resident listing report as 0/11/2002. If the previous assessment date is 10/7/2002, it will appear on the Resident Listing report as 10/7/2002 . The Previous Assessment Date displays slightly lower than the rest of the row. Both of these issues are due to the column width of the report and will be resolved in a future release.


11/09/1999

Question: Why does my Resident Level Quality Indicator Summary Report contain assessments that are prior to my request date?
or
Why do my QI reports return with no information listed?

Answer: When requesting a Custom Date, the correct date format of mm/dd/yyyy must be used or erroneous data may be returned.


11/09/1999

Question:What is the difference between Prevalence QI Indicators and Incidence QI Indicators?

Answer: Prevalence Indicators measure a QI at a given point in time. Most of the QI Indicators are Prevalence Indicators. They provide the facility with the percentage of residents who flagged on a QI on the basis of their "current" assessment.

Note: Current assessment refers to the most recently submitted assessment.
Incidence Indicators provide a description of what new conditions have developed over the course of the last two assessments.

Note: The resident who does not have a previous assessment will be excluded from the Incidence QI calculation. A resident who meets the denominator definitions on the Incidence QI flagging criteria on the previous assessment is excluded from the Incidence QI calculation on the next assessment submission.


06/30/1999

Question: Which assessments are used for QI reports?"

Answer: The assessments used in the calculation of the various QI reports are based on the Reasons for Assessments as identified in Section AA8a (Primary Reason for Assessment) of the MDS 2.0. Follow the link below to view a table that provides a description of which assessments are used to calculate each of the distinct QI reports. MDS assessments that have Section AA8b (Codes for assessments required for Medicare PPS or the State) are included in the QI reports only if Section AA8a is coded as described in the table.
Assessments Used for QI Reports

 

 

 

 


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