Questions and Answers/Wrap-Up – August 16, 2019

»» Good afternoon everyone. So I’m going to do the first few Q&As for
you and then I’m going to have my colleague Anne to come up and she will do the last remaining
Q&As. So for our first one regarding the pressure
ulcer being a Stage 4 in the acute facility and now the IRF admits with a Stage 3, continue
to code on the IRF-PAI as a Stage 4 is not going to accurately match documentation which
is going to be used to assign ICD-10 codes. And the answer for that is, if a patient is
admitted with an ulcer that is documented as a Stage 4 and when admitted to the IRF,
the same ulcer appears to be a Stage 3, you would still code this ulcer as a Stage 4 as you
do not reverse stage. Your ICD code would also be coded as a Stage
4 until the wound is healed. All right. For our question Number 2. So if the patient routinely wears socks and
shoes prior to admission and will need to at discharge, if only socks are available
and tested on admission in the 3-day window due the lack of shoes, how do you code? 10 because both items are not available? And the answer for that is, the activity of
putting on/removing footwear refers to footwear that is appropriate for safe transfer and/or
ambulation mobility. If the patient wears footwear that is safe,
for example like grip socks, then the data element may be coded. If the patient’s socks are not considered
safe for mobility, then code — sorry it’s on the next page — then code appropriate
activity not attempted code. Let me do this so I can easily turn my pages. We’re going to move on to question number 3. If a patient is admitted from the acute — hold
on. Sorry. If a patient is admitted from the acute hospital
and their pressure ulcer is staged correctly and then the admitting nurse at the IRF stages
the ulcer incorrectly, we are then permitted to use the acute care notes for appropriate
staging of the wound on the IRF-PAI? I just wanted to clarify this. So the answer for this is, in this example,
if you have documentation that a pressure ulcer/injury is staged from the acute care
hospital and the nurse in the IRF has staged the wound at a lesser stage due to the pressure
ulcer healing, you would choose the code documented staged from the acute care hospital. If in this example the nurse coded the pressure
ulcer at an increased stage then correct the code to the observed stage. So question 4, sit to stand. Some stroke patients are “pushers.” During transfer activities they’re attempting
to transfer but they are pushing against the therapist and actually hurt progress towards
the transfer. They are attempting, but it is not meaningful
to the completed activity. Is this total assist? Okay. And the answer for that is, use clinical judgment
to determine the level of effort that the patient is contributing. In this scenario you described, we interpret
that the patient did not meaningfully contribute to the transfer and that the helper provided
all of the effort. Therefore, you would code the item as 01,
dependent. Okay. So our next question. So upper body dressing, how do you score
if the patient normally wears a bra but doesn’t have one to assess this during the first 3
days — sorry the first 3 days if you are able to assess don, I’m assuming that’s supposed
to be doff shirt, but no to the bra? So when coding Section GG activities, code
based on type and amount of assistance with the clothing used at the time of assessment. In the scenario you describe, assess item
GG0130F, Upper Body Dressing with a shirt. So question number 6. What timeframe would be appropriate to say
the wound was likely present in admission? The skin assessment should be completed as
close to admission and pressure ulcer/injuries that are assessed
to be present at the time should be coded in Section M.
Did you get that one? Did you get that one? Okay. So I’m going to read the question again. What timeframe would be appropriate to say
the wound was likely present on admission? So the answer is, the assessment should be
completed as close to admission and pressure ulcers/injuries should — sorry that should
be assessed — I’m sorry, that are assessed to be present at that time at admission should
be coded in Section M. Is that a little better? (Comment from the audience). Yes. Yes. Yes. Must be within — yes. As close to admission as possible. So for Q&A 7, is a discharge Code 09 recorded
as a 01 from the outcomes? An IRF should be expected to demonstrate improvement
with activities that the patient did not complete at baseline. I’m sorry — should not. Okay. So the answer to this, yes, if an activity
is coded 09 at discharge, it will be recorded to 01 for the Functional Outcome Measure if
the patient needed assistance to perform an activity prior to the current illness, injury,
or exacerbation. The prior functioning items would be coded
to indicate the patient needed assistance and any prior device use would be indicated
and these data would be used for risk adjustment. So question 8, related to Section GG, Self-Care,
I’ve seen elastic bandages indicated as lower body dressing and TEDs, antiembolic stockings
counted as footwear. What if the elastic bandages cover the foot
and are used for the same reason because TEDs don’t fit? Clothing items that cover all or part of the
foot even if it extends up the leg like a sock or ankle-foot orthosis would be considered
when coding footwear. When assessing GG0130H, Putting On/Taking
Off Footwear, an elastic bandage or compression stocking is considered footwear if it was
related to the tasks associated with putting on or taking off footwear. Please see page GG-17 of the IRF-PAI Training
Manual for information about some examples that are included in footwear. And a few examples of these footwear include
ankle sock orthosis, AFO, elastic bandages, foot orthotic, orthopedic walking boots, compression
stockings are considered footwear because a dressing is donned/doffed. Is the expected score determined by each
element or just an overall score? The expected score is calculated at the level
of self-care score and mobility score not at the item level. What is the difference between continuous
and squared scores? If the self-care score was 10 then the squared
value would be 10 times 10 which is 100. And I’m going to hand it over to my colleague
Anne to complete the rest of the Q&As. »» Okay, so number 11. The patient walks 8 feet. How would you score “Walk 10 feet”? How would you score 150 feet? For the walking activity to be coded using
the 6-point scale the activity must be completed. That is, the patient must walk the entire
distance. If with or without assistance a patient cannot
walk the entire distance, the helper cannot complete the walking activity for the patient. And you would use one of the activity not
attempted codes. Oops. Okay. Number 12, a patient is receiving the majority
of nutrition via PEG feedings but is able to drink PO clear liquids. Can we score eating when the patient is only
getting PO liquids? The intent of GG0130A, Eating is to assess
the patient’s ability to use suitable utensils to bring food and or liquid to the mouth and
swallow food and/or liquid once the meal is placed before the patient. In the example you described, the patient
only takes clear liquids. Clinicians should use clinical judgment to
determine if observing the patient taking clear liquids allows the clinician to adequately
assess the patient’s ability to complete the activity of eating. If the clinician determines an observation
of taking clear liquids is adequate, code based on the type and amount of assistance
required by the helper. If the clinician is unable to determine the
patient’s ability to eat, code one of the activity not attempted codes. What is the height of the curb step and 1
step in scoring? There are no specifications for the exact
height of the steps for activities involved in steps. If you score a 07 on discharge performance,
so that’s the patient refused code, does it get a value of 1 for calculation of the quality
indicator? Yes. A code of 07 at discharge is recorded — is
recoded, sorry, to a code of 1 for the quality measure calculation. For the GG section we use metrics. Is 150 feet, 45.7 meters or is it rounded
up to 50 meters like FIM? In the scenario you described, if you are
using the metric system to measure the distance for this activity, you would assess the patient’s
ability to walk at least 45.7 meters in a corridor or similar space. Regarding Coding Scenario 5, the ulcer will
be coded with the ICD-10 codes. Will it be a red flag when the claim form
does not match the assessment? In Scenario 5 the patient was admitted with
intact skin and on day 7 of the IRF stay a Stage 2 pressure ulcer is identified on the
coccyx and at discharge the pressure ulcer is healed. So as Ann explained, your coding, what’s going
on at admission, you’re coding what’s going on at discharge. In this scenario the Stage 2 pressure ulcer
would not be captured on the IRF-PAI because it happened outside of those two
assessment timeframes. It’s like prevalence at admission, prevalence
at discharge. There may be diagnoses that are captured in
the ICD-10 codes that may not be identified on the IRF-PAI, as this is looking at two different
time points of admission and discharge. Number 17, referring to mucosal ulcers, is a pressure ulcer in the area of a G-Tube
(PEG) considered a mucosal ulcer? The stoma area of the G-Tube is considered
mucosal but the skin portion would not be considered mucosal. Number 18, what is the rationale of having
a pressure ulcer that worsened or manifested during interrupted stay being owned by the
IRF-PAI? If the patient has an interrupted stay and
returns to the IRF with a new pressure ulcer or injury, that pressure ulcer/injury is not
considered present upon admission. For program interruptions, the two segments
of the stay are considered one stay. And when the person returns to the IRF a new
assessment is not completed. And that is the wrap up. I will turn it back over to Brigitte.

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