MDS 3.0 Section K, Swallowing and Nutritional Status

Uploaded by CMSHHSgov on 13.09.2010

Hi, everyone. It's the end of the day, so everyone hopefully -- they stretched
and got their sugar from the cookies that are out there and the soda. Thank you
to the hotel for that. So, we have about an hour of scheduled time to do Section
K. I don't think it's going to take me that long; and then we're going to go
right into Section P and then as soon as we're done with that, then I guess
we'll go into the question and answers. And the goal is, when I teach, is always
to get people out a little early, and I do that for a reason >> Audience:
Applause >> and I do that for a reason because, man, have I spent many-a-time in
your seat, and this is hard. This has been a hard day. I mean, there's a lot of
great information, but who feels brain dead about now? Okay. I'm with you, I'm
with you.
All right, so we are going to -- hopefully, we'll go through this information.
You'll get what you need. So that I'll try to give you tips and ideas about
questions that we've gotten and clarifications that we've made, and maybe some
strategies when you're going back to teach this; because, in fact, what is today
but a train-the-trainer week? I shouldn't just say day, but week. So, always
remember, certainly you're trying to get the knowledge in your head, but you
want to say, "How am I going to teach this when I go back?" to wherever home is
or wherever you work or wherever you're expected to train. So, think about it
from all of those levels.
So Section K -- and this is Swallowing and Nutritional Status, and so what we're
going to do today is we're going to describe how to conduct the assessment.
We're going to learn how to calculate weight changes and gains and loss; and
we're going to know, at the end of this section, how we're going to code Section
K correctly. So, for each one of the sections, you're going to find similar
objectives for us.
So, what are we doing here? So, Section K is intended to assess the conditions
that could affect the resident's ability to maintain adequate nutrition and
hydration, and that's very similar. That's been the main idea behind Section K
when we were coding MDS 2.0, but you'll notice as we go through this -- you're
going to notice that it's changed a little bit. So, we're going to cover a few
sections here. We're going to look at the swallowing disorders. We're going to
certainly look at height and weight and what we did to finally fix that, right?
Make it make sense. We're going to talk about some weight changes, and then
we're going to talk about some nutritional approaches. And, as it should be
known, we have to make sure that we collaborate with all of the other caregivers
who may have some knowledge and understanding or impact the resident's
nutritional status, including our dietitians; any of the dietary staff;
certainly the nursing staff on the units; and, please do not forget our
ever-important nursing assistants.
So, let's look at K0100. This is the item that's called looking at the
"Swallowing Disorder," and here we are looking at the ability to swallow safely,
and it can be affected by many disease's processes and functional decline. And I
think all of us that are clinicians here, and certainly have spent any time in
the nursing home industry, will be able to attest to that. And alterations and
ability to swallow can certainly result in choking and the ever-important
aspiration risk, which can be critically important and, certainly for many of
our residents, can ultimately end up leading to certainly morbidity and
mortality. We -- it can increase the resident's risk for malnutrition,
dehydration and certainly the aspiration and pneumonia, and I think we would all
agree on that.
So, what we're going to answer K0100, we're starting to do the assessment. We
want to ask, first and foremost -- if you learn one thing about MDS 3.0, it
should be: please don't ignore the resident. Right? So what should we do first?
We should talk to the resident. "Tell me, how's things going? You know, are you
having any trouble swallowing? Are you having any issues chewing? Do you have
any pain? Does it hurt when you chew? Does it hurt when you swallow? Do you find
it difficult? Are you coughing?" There's all kinds of general questions that we
can ask our residents. So, make sure, first and foremost, that we're actually
asking our residents; and, we're going to be doing this with an eye to, what? A
look-back period. And what's the look-back period for this? It is seven days.
Okay, remember with MDS 3.0, it's seven days unless otherwise stated. So, when
we are looking at these items, we are going to be looking at the resident if
they're losing the loss of liquid or solid food from their mouth. When they're
eating or drinking, are they holding food or pocketing food in their mouth, in
their cheeks? Are they having coughing or choking during meals or when
swallowing medications and are there complaints of difficulty or pain with
So, now we've talked to the resident. We're certainly going to talk to
caregivers, and we should do a casual observation. How is the resident doing?
So, if you get in there, and you can get into the dining room or wherever
they're eating, and take a look and make sure you're talking to staff across all
shifts. Why is that important? Has anyone ever in their career had someone who
presents one way at 7:30, 8 o'clock in the morning and differently at 7:30 in
the afternoon? Right? It's not a rare occasion, right? It happens more often
than not, but our residents can be very different for their evening meal, or
their evening med pass, than they would be after they've had a full night's
sleep, and they're fresh and whatnot. So, make sure that we're not just
capturing what's happening during our little piece of time. We want to make sure
that we're really getting a sense what's happening to this resident over a
24-hour period of time, seven days a week during that look-back period. So, we
can do a variety of things, and some of these slides are kind of similar as we
go through the various sections.
We're going to look at the medical record. Do we have any nursing notes during
this time period that reflected the resident was coughing or having difficulty
with their food? Are there any physician notes? Are there dietician notes that
relate to that? Is the person on speech and language therapy services, and what
does the speech pathologist have to say? What is he or she seeing for this
particular resident? Do they have a dental history or problem? So, we're going
to talk about that. I'm actually going to be teaching that section also, but
when you've done an oral assessment, does this person have -- okay. Here's
another one: have you ever met the person, when you're talking to them, they're
talking and their teeth are going one way? [Laughter] Guess what? That could be
a problem, right? I mean, that happens fairly frequently, right? For people who
have dentures, just a 10 pound weight loss in itself can, not ultimately will,
but can affect the fit of their dentures. So, if you're talking to someone and
they're saying, "No, I don't have any problems," and all you can concentrate
[on] is the teeth going up and down, then we probably want to get a dental
consult and see whether we can, you know -- do we use any kind of a poligrip, or
whatever they want to use. But, do they need those dentures realigned or
whatnot? But, if we're looking at them, if they have dental problems -- so, poor
fitting dentures. Do they have dental caries? Do they have a cavity? Do they
have a fractured tooth that cold or hot bothers them? Do they have an abscess or
the starting of an irritation? So, we need to be in tune to this. Especially the
person who's cognitively impaired and who may not be clearly able to say to us,
"Hey, I have a toothache." Often what happens is we don't find out that there's
an issue until, what? Their jaw is like this, right? They have, you know, they
have a huge abscess, and if you've ever had a toothache you know how hard it is
to eat or chew or do anything on that side.
Looking for mouth sores: So, if someone has oral thrush, it's amazing how many
times when we talk about critical thinking, and we're looking at assessing our
residents - well, if they had a decrease in PO intake, and when you're looking
at them and you can't figure out anything else that's going on, what else should
you do? Make sure you look in their mouth. Could they have an oral thrush? Could
they have multiple, you know, canker sores going on? Have you ever had a canker
sore? Yeah and if you've got a bunch of them, the sores in the mouth, what's
going on? If they, you know, just went through a major, you know, issue and they
had fever, and they really weren't taking in as much PO as they should have, and
their mucus membranes get all dried out, this can be an issue for the person,
too. Certainly, we want to look for -- if there's any obvious tumors or growths
going on in the mouth and do they have pain with food consumption or any issues
like that. And then the person who is dentureless - meaning they have no teeth.
Now, I knew a lady who had no teeth, and she had no teeth 30 years prior to
coming to a nursing home. She could chew a steak better than I could. So, the
fact that she had no teeth, for her, was not an issue. She didn't want dentures.
She said if she wanted them she would have gotten them. She's happy. She has no
pain, and she can eat just fine. So, we need to certainly look at our residents
and see. So, we don't want to run to any -- make any assumptions. We certainly
need to look at the resident as an individual.
When we're coding K0100, code a symptom even if it occurred only once in a
look-back period. So, it doesn't need to be something that's happening on a
daily basis or it needs to happen three or more times or anything like that.
Even if they had one episode during that 7-day look-back period, then you want
to go ahead and code it here. The second major portion, the comment here is, we
do not want to code a swallowing problem even if the intervention has been
successful in treating the problem. So, if someone used to cough with thin
liquids, and now we give them nectar thick liquids, and they're fine. They have
no coughing, no issues, they meet none of the criteria for K0100. We're not
going to code the swallowing problem, and a lot of people are having
difficulties with this. We're getting some questions about this, and it's that
whole idea like pain, where people wanted to on the MDS 2.0 -- they wanted to
code pain because the person's on a really good pain regimen. So, they didn't
have pain during the time - look-back period. So, you're like, listen, if I held
it back from them, they'd have horrible pain. So, they wanted to code that the
person had excruciating pain because, if they hadn't medicated them, they would
have had that.
Well, it's that same kind of theory. Here, if we put intervention in place, we
certainly want a care plan for that intervention, and we want to make sure that
it's communicated to all the staff and whatnot. It's not that it's not
important, but for the MDS, we don't want to code it here because the things
we're looking at for here are, what potential problem identification areas that
may be of concern to us and that we want to go ahead and work forward.
Obviously, for someone where you have an intervention already in place, you've
already identified that problem and put some interventions in place. Now you
want to continue to make sure and monitor what you're -- the interventions that
you've put in place are working well for that particular resident. So in this
item, this is one of these, as they talked a little bit this morning about the
coding matrix, and this is a check-all-that-apply item. So, you can check
multiple items here, and, so you would just go ahead if they were holding food
in their mouth or they had complaints of difficulty swallowing. We would go
ahead and check each one of those items. And, again, please make sure that you
are keeping it to your 7-day look-back period from your assessment reference
All right, K0200 - Height and Weight. Well, you know, there's a lot of slides
here, and this is what I said to the group. I don't know that it's going to take
quite an hour to do this section, although there's a lot of slides here. This
has not changed a lot except for in one particular area, and we're going to go
to that. So, the importance of monitoring height and weight - we can look at
diminished nutritional hydration status, and it can lead to health and safety
issues. It can lead to quality of life issues, and measuring weight, as we know,
is one way of determining how someone is doing. And, significant weight gains is
as important to monitor as weight loss ,and this came up in our April conference
when we taught a similar group and people -- there was a lot of questions, or I
should say comments, where people said, "Why are you only looking at weight loss
when here in the United States weight gain is as big of an issue as weight loss
is?" And it's not that it's not important, but for right now, with the item set
that we have, we are going to be coding weight loss, not weight gain. That does
not mean that you should ignore someone who has a major weight issue and
continues to gain weight. You should still assess them, work with the team, and
care plan for them. So this is not everything, the end-all and be-all. What is
it? It's the minimum, right? It's a minimum assessment. So, please, people want
us to, like, answer every question possible and every situation possible. And we
can't do this unless you want to spend, you know, a week on every single
resident, and even then there'd be something that would be unique to one
resident not to another. So, we're looking at a minimal amount of data that
we're collecting on these particular residents, but that does not relieve us of
the responsibility to go ahead and care plan.
So, when we're looking at K0200A, this is specifically looking at calculating
the height, and we're going to measure and record the height in inches on
admission, and then we're going to measure the height consistently over time in
accordance with facility policies and procedures, which should reflect current
standards of practice. So what does that mean? Well, it came out when we were
doing work on MDS 2.0. Jennifer started to say I did some work on the DAVE 2,
and actually, I was part of the team and supervised all the nurses who were out
actually validating the MDS. And so, I was out across the United States and got
a lot of really interesting questions, and people wanted to know, well, you
know, how do we measure someone who's a bilateral amputee or has birth defects,
or has this -- they had all kinds of questions and so this got brought back,
actually got formally put into questions and the CMS team, which Terry Mota and
myself were a part of under another contract, were answering all these
questions, and we went round and round and round. I researched everything. One
of my jobs was to research this whole thing on height. I was like, "Wow. I never
knew there were so many ways to measure someone," but there are. And so instead
of dictating how you measure someone, all that CMS wants is for you, as a
facility or an organization, determine what is going to be your process that
meets the current standards. There's, like, I think five or six different ways
to measure height -- and then apply it consistently within your organization.
So, that if I was going out, let's say this is three years from now, and I'm
going to go out to your facility, I'm going to validate this MDS 3.0, one of the
things I might ask you is, "What is your policy on how you measure," and you
should be able to show me what your policy is and that staff are educated and
consistently applying that same process. So, when you're thinking about how do
you operationalize MDS 3.0 in your facilities here's a tip: go back and look at
that and -- by the way, when we get to weight, it's going to be the same thing.
You know, how do we - how do we accommodate for the weight and how do we make
sure that everyone's doing it consistently? All right.
So, we can -- when we're measuring the height, we should look at it
consistently. We're going to check the medical record for subsequent
assessments. If the last height recorded was more than one year ago, we should
do another height on our resident. So, if you have a height that was done, you
know, 18 months ago, we really need to do another height on the resident. So,
again, how do you operationalize that? How do you make sure that happens for
your long-term residents who are in your facilities greater than a year? All
So, here we go - 0200 A. Record the height in the nearest whole inches. That's
nothing new and now, here is the new part. Finally, we're using mathematical
rounding. Does everyone remember -- you know, the problem is when we were out,
many folks were using mathematical round on 2.0, but that's not what the manual
told us to do, right? Right. What did the manual tell us to do? If we were 61.2
inches, what did we become? 62 inches, right? Which is fine. I don't think
people minded being taller, it's when they added the pound that was the problem.
>> Audience: Laughter. >> So, but that being said, we're going to go back to how
we were all taught in school to do rounding, so it makes more logical sense. So,
if you are doing a calculation -- so, someone is 62.5 inches, they would be
recorded as 63 inches and if they were 62.4, we would record them as 62 inches.
Simple. I don't think it's going to be a major issue for anyone in any facility.
So, now let's talk a little bit about weighing our residents. So, we're going to
weigh the resident and record the results upon admission, and then, for
subsequent assessments -- and we're going to go back -- we can look at the
medical record we're going to enter the weight taken within 30 days from the
assessment reference date. We want to record the weight as close to the
assessment reference date as possible. So, if they had a couple of weights taken
right near that 30 days prior, you want the closest to the 30-day to the ARD to
use; and we can re-weigh the resident if it's greater than 30 days and the
previous weight is not available. Certainly that -- that happens sometimes. I
don't know if it would ever happen in any of your facilities that you would have
a missing weight, but if it ever did, we would have to re-weigh the resident.
So...some facilities, man, have that down pat. Most don't, but okay. All right.
So, record the most recent weight if a resident weight was taken more than once
during the preceding month. We take the most recent one and measure the weight
consistently over time in accordance with facility policy and procedures and
practice. This is probably the biggest thing. Who here has ever seen someone
gain 20 pounds every, like, time they get weighed? They gain 20, lose 20. Yeah,
I'd like to know what their gym routine is, huh? You know? I mean, it's crazy.
If you ever -- some of these great programs now - EMRs and stuff you have - and
you start being able to graph out and someone's weight is like this and, yet,
you look at the person, their clothes fit them exactly the same way that they've
been fitting, they eat the same amount of food, there's nothing else going on
with them, so what's the issue? Okay. Do we have any dietitians in the room? A
couple. A couple. All right. So, I can't even tell you how many dietitians have
come up to me and say, "Can you fix this problem in this facility?" You know,
from out doing some consulting working in facilities. You know, and so it's
figuring out a system and a process to consistently get your residents weighed
the same way. So, using the same scale, the same time of day. If you're weighing
them with their artificial limbs, make sure they get weighed consistently with
their artificial limbs. If, you know, weigh them in a wheelchair and they
normally have leg rests on, make sure they have the leg rests on. I know this
sounds silly, but do you know how much rework and how much time is wasted and
how many people like are put -- I mean, all kinds of stuff happens. For
something as simple as getting someone's weight. And then, god forbid you're
using the person's weight that you're weighing them daily, because this is a
person, you know, with chronic congestive heart failure, and we're basing
treatment on it. Right? What's important? Three pounds is easy one way or
another, if you weigh someone after they've had breakfast, compared to the day
before when they just got up and you had them urinate and you weigh them. I
mean, these are silly things, but these are systems and processes. That's a
little bit above and beyond the MDS, but when we talk about critical thinking,
we talk about caring for our residents and looking for the best outcomes and
without chasing our tail, let's figure out how do we get this done and how do we
get it done well and big thing here is communication and systems and processes.
All right.
Use mathematical rounding. The same type of thing here, instead of going 152.1
pounds and all of a sudden you become 153, here if they're 152.5 they go up to
153. If they're 152.4 they go to 152. Use the "No information" code if the
resident cannot be weighed or if the resident's refusing being weighed and that
sometimes happens. Now, I will tell you that it was asked in the April
conference. What the facility should do?
If you'll notice on this item -- I think we have the item set there. There are
three squares. So, one of the questions that came in and was asked is what do we
do if we need a fourth square? That's a problem. If you have someone over a
thousand pounds in your facility, it's a problem. Could it happen? I guess. I'm
here to tell you I hope that doesn't happen that you have someone over a
thousand pounds in your facility. God bless you if you do and that you'll
hopefully be able to take care of them. But for the MDS, you're going to have to
put in 999 - 999 pounds - because we've not put in four squares, and I don't
know that we will put in four squares. But, for right now, you have to max it
out, alright? So, that's the answer to that question.
Okay, K0300. Now, we're talking about weight loss. So, weight loss can result in
debility, it can adversely affect the health; the safety; the quality of life -
and for persons with morbid obesity, a controlled and careful weight loss can
improve mobility and health status. We all know that. And for persons with large
volume fluid overload, controlled and careful diuresis can improve health
status. So, we have people that we've taken care of where they, all of a sudden,
you know, have put on 10 or 11 pounds of water weight on, and man, they're
usually very symptomatic at that point. And, so, controlled use of diuretics to
drop that weight, not from weight weight, but water weight and get that off so
that, hopefully, we'll be relieving symptoms. So, we should ask the residents
and family or significant others about, you know, history of any issues with
weight loss. Compare admission weights to previous weights. We can consult with
the resident's physician. If you have the opportunity to get a hold of their
private practitioner in the community, wouldn't that be wonderful? And if that
person had actually gone to their practitioner in any reasonable time frame
before they came to you, if you could get a weight from them. Review transfer
documents. Some of the hospitals now have -- well, really they'll say, "You
know, we measured them on a bed scale," or whatever scale they used, and they
give you the exact weight. So, hopefully you can have some level of confidence
in that weight that they are providing to you.
We are going to look at calculating percentage of weight loss if admission
weight is less than the previous weight, and we're going to do it at two time
frames. We're looking at the 30-day and the 180-day and that's not different
than we've looked at in 2.0. So, we'll compare the weight 30 days prior, and
then we're going to calculate the percentage of weight loss if the weight is
less. And we're going to compare the current weight to the weight at 180 days,
and then we're going to calculate the percentage of weight loss for the
So, what does K0300 do here? It does not consider weight fluctuations outside of
the two time frames, and that's been a big issue for people because, you know --
we're going to talk a little bit about this 7.5 and three months, and there's
been a real pushback to CMS to say, "Well, why are we looking at that?" And
maybe we will. I'm not going to speak for CMS at this point, but I think it's a
valid thing to look at, but for right now, it's not there. It's not an item set,
but that doesn't mean that you, we, as healthcare providers shouldn't be looking
at it and dealing with it. But for the MDS, again, you know, it's going back to
the whole idea: this is a minimum set. It is not going to cover all scenarios,
even though we want it to cover more scenarios. So, in this situation we're
looking at the 30 days and we're looking at 180 days, but please don't put your
head in the sand and ignore it because the MDS doesn't force you to address the
Code weight loss based on whether it was planned and managed or unplanned and
unmanaged. And we're going to look at the item set as we go on to talk about
those issues. We're going to use mathematical rounding for any of our
calculations. And here we go. If you ever wanted to know how to calculate a
weight loss, here it is. This is self-explanatory. I don't think we need to
spend a lot of time on it, but it walks you through the calculation. Some
facilities have computer systems. They put it in. It calculates it for them.
There are grids that can tell you calculating your weight loss. There's these
nice little grids. So, if you leave it on as a reference material right on your
units, the nursing staff can look at it and the dietitians are expert at doing
these calculations for us, but you want to go ahead and say, "Do they meet the
So, here's how we do these calculations -- and you can do this. This is one way,
you know, example: 160 pounds times 0.90 equals 144. So, a resident whose weight
drops from 160 to 144, or less, had experienced a 10% or more weight loss.
Depending on how you learned math, you may do it differently. I wouldn't do it
this way. I would do it differently. So, it depends. This is not the only way.
This happens to be an example of one way to calculate it.
So, here's a little bit of a practice run for calculations. So, Mrs. J. has been
on a physician-ordered, calorie-restricted diet for the past year. So, there's
some important words in this example. For this particular example, it is on a
physician-ordered. So, where would we find that information? In the order sheet
somewhere, right? Physician-ordered, calorie-restricted diet for the past year
with the idea of weight loss. I'm going to restrict the person's calories in
hope that they will drop some weight. Her current weight is 169 pounds, and then
her weight 30 days ago was 172 pounds and her weight 180 days ago was 192
pounds. So, just quickly looking at that, has she been successful? Yeah. It's
great. Big difference.
Okay. Does Mrs. J. have a weight loss of 5% or more over the last 30 days? I'll
give you a second. Do the calculations in your head. Do you want me to go back
again? Okay, so here's the numbers. Okay, so stretching your brain now. Right?
We got up and stretched our legs. Stretch your brains a little bit. Okay. Well,
okay. We went back. Here's her numbers, right? So, she weighs 169 now. Thirty
days ago she was 172. So, we look at the difference between. Okay? And then at
180 days ago, she was 192 pounds. So, the question here is we're looking at the
30-day. So, did she have a 5% weight loss or not? Okay. >> Audience: No. >>
>>Ann: Okay. So, let's see here. Let's see. So, she didn't have that. So, let's
look at the next thing here. Alright. So, and then, what this next slide does is
walks you through the calculation. Her current weight is 169. Her weight 30 days
ago was 172. The 30-day 5% calculation equals 172 times .95 and her 5% weight
loss point is 163.4. She does not weigh less than 163.4, so she doesn't have a
5% weight loss in the last 30 days. Does she have a 10% weight loss in 180 days?
>> Audience: Yes. >>
>>Ann: Okay, so she does have a 10% or weight loss over the last 180 days. That
makes sense, right? Alright, but again remember if you're going back from the
idea you may understand how to do this very clearly or it may always be your
dietician's job, but if you're going back and you're working with your nurses on
the units, your LPNs, and whoever else is helping to fill out the MDS, maybe
they never knew quite how to do this calculation. So, you may have to teach
this. So, just to make sure that you don't -- I'm running over a little bit here
because, again, we're at the train-the-trainer level here and you guys, doing
this probably for as many years as you've been doing it, you know these
calculations. But, think about if you're teaching someone about the new to MDS,
because I'm hearing facilities taking on brand new staff who never did MDS 2.0,
and figure well, we'll just teach them 3.0, and they're going to be our MDS
Coordinators. Okay, we need to support them, don't we? So, hopefully you know
you may be a mentor for someone who has this opportunity because it's becoming
harder and harder. I don't know. Depending on where you are in the United
States, it's become harder and harder to get a really good MDS Coordinator.
Okay? You're becoming a premium commodity out there. So, we're going to have to
teach other people how to do this, nevermind just the general staff. All right.
So, coding K0300. We're going to determine by the percentage. So, it's asking us
the question, and it says, "Loss of 5% or more in the last 30 days or 10% in the
last 180 days." So, one of the questions that we got in the -- whatever method
that came in to us, people were saying, "Do you need to have both a 5% and a 10%
weight loss to code this?" No, it's an either/or.
So, once you -- if you're looking at the 30-day timeframe, you know, once you
hit the 30-day, technically you don't have to do a 180-day calculation because
it's a yes answer at the 30-day. Don't even bother doing the math for the
180-day, because it doesn't matter for this. It doesn't matter for coding the
MDS because it's a mutually exclusive question. It's not asking you to answer
both, and they do not have to meet the criteria in both areas. So, you would
code 0 or "No or unknown," if the resident did not experience a defined weight
loss or the prior weight is not available. Code 1, "Yes." Here's where we're
going to say - we have two yes answers: so, yes they have a weight loss, but
they're on a physician-prescribed weight loss regime or code "Yes not on a
physician prescribed weight loss regime." So, all we're asking here, and what
they've kind of done in this part of the MDS is say we acknowledge certain
people will lose weight because it's therapeutic. It's a good thing, and then
there'll be these others who lose weight - sort of an unplanned weight loss. We
think about it that way. We really weren't planning it. We weren't expecting it,
and hey, they lost the weight. So that's how this item is coded.
K0500 - Nutritional Approaches. Let me just catch up on my slides here. All
right. So, here we're looking at items for mechanically-altered food and
parenteral IVs and feeding tubes and, certainly, these can diminish the
individual's sense of dignity and self-worth, as well as the ultimate diminish
of pleasure if they're on two feet and they can't eat. That can be heartbreaking
for some people.
There's this one resident in a nursing home I go in and do some work in, and
they've tried and failed so many times to allow her to be able to eat - even
just pleasure foods. And she's from down south. She goes, "Miss Ann, I just want
to eat. I'm hungry. I want some corn bread," and all you want to do is give the
woman something to eat. I mean and, you know, she's maintaining her weight and
all of those other things. So, there's no weight loss, but that loss - because
she's got enough cognitive ability - that this is just a terrible loss for her
not to be able to eat, and she truly aspirates every single time that she eats,
and they've tried everything and they can't get her off the tube feed. And the
family has decided with her that this is the best thing that she have the tube
feed. So, the resident's clinical condition may potentially benefit from various
nutritional approaches, and it's important for the facility to work with the
resident and the family members to establish what are those goals and to support
them and then integrate the resident's preferences with the overall clinical
goals. So, what is it that we want for this particular person? Do we know that
they're going to aspirate, excuse me, a certain percentage of their food or they
have a really high risk. We're going to do everything that we can, but one meal
a day we're going to give them some pleasure foods, and we negotiate with
everyone, and we decide that that's the best plan of care for this particular
resident; and, that's fine. So, we go ahead, and we provide that care.
So, getting back to coding this particular item, we're going to review the
medical record. We're going to determine if any of the listed nutritional
approaches were received by the resident during the look-back period, and so, we
can say K0500A is parenteral and IV feedings - and we're going to talk a little
about more about those. We are going to talk feeding tubes. We're going to talk
about mechanically altered diet, therapeutic diets and then Z, which is, "None
of the above."
So, nutritional approaches - any and all nutritional hydrations received by the
nursing home residents are included in this at the nursing home or at the
hospital, as an outpatient or as an inpatient. So, here we're talking about -- I
think we're missing a slide here. Let me -- let me kind of preface this. This
particular item we're talking about, K0500A -- and we are talking about the
parenteral and IV feedings. So please note, this is where we're seeing someone
received IV fluids, and we're going to code them here if they were provided for
nutritional and hydration needs, and it could be provided anywhere in this
particular situation, as long as the resident -- so, in any of the settings, but
you need to know that the resident who had it administered for the nutritional
hydration - they shouldn't be coded as -- when we're looking at enteral
feedings, they shouldn't be coded as mechanically-altered diets and they should
be coded as therapeutic diets only if you're managing a problem. So, if
someone's getting a, you know, a high nitrogen formula, enteral feeding or
they're getting a low sugar type of feeding, they could be considered a
therapeutic diet, even though it's an enteral feeding. So, I'm sorry those were
a little mixed up, those slides, as far as the flow of ideas.
So let's kind of talk a little bit about the parenteral IVs. So, IV fluids can
include the following when there's supporting documentation that reflects the
need for additional fluid intake specifically addressing nutritional or
hydration needs. That which is underlined and bolded is the most important
message that you can take home from this particular item today. So, this is
going to take some clinical judgment, and we're going to give some examples of
that, and then your job is to make sure that the clinical record supports this
So, tell me if I was the validator and I was going out to your facility and I
wanted to say, "Well, I don't know, you know? Show me why you coded this
particular item for nutrition and hydration." You, in your record, you should be
able to show me where it's documented. Why this person needed this for
additional nutrition and hydration reasons. So, IV fluids or hyperalimentation,
including total parenteral nutrition, administered continuously or
intermittently. So, if someone's getting TPN in your facility, no questions
asked. I mean, that's what it's for. The harder thing is if they're getting half
normal saline, they're getting a D5W or things like that. IV fluids running at a
KVO, or keep vein open rate; IV fluids contained in IV piggybacks - that's the
biggest question. That's the one that everyone is struggling with. So, when do I
count someone who is getting 100cc of, let's say, normal saline in an IV
piggyback every six hours? When would I count that under this? Not the IV meds,
but for nutrition and hydration. Well, I can count it if I can show that they
need this additional fluid for nutrition and hydration and, again, we're going
to go through a couple of examples. And then hypodermoclysis and subcutaneous
ports in hydration therapy. Any one of these, you can count them as long as you
have the supporting documentation in your chart.
Do not code IV medications here. There's another section to code this. All
right? This is not IV medications. This is not where we're coding that. Do not
code IV fluids administered as a routine part of an operative or a diagnostic
procedure or in a recovery room. So, that routine, you know, they stick an IV in
everyone before you have these procedures. We're not counting those. IV fluids
administered solely as flushes - we're not counting those and parenteral IV in
conjunction with chemotherapy or dialysis. We're not counting those. Do not code
IV fluids administered solely for the purpose of preventing of dehydration. I
want to quantify or clarify this statement and the second bullet we're actually
going to remove. So, there has been a lot of discussion about this particular
If a resident - if, again, your clinical assessment for the resident indicates
that they need that extra, that example, that extra 400cc of fluid if you've
assessed the resident and you say, you know, based off the fact, maybe -- let me
give you an example. They have a fever and they're only taking in 25% of their
diet and they normally take in, you know, 15-, 16-, 1700cc of fluid, but they're
feeling so crappy, we're only getting, you know, them to take in 4- or 500c of
fluid, guess what? Would it make sense that the extra 400cc of fluid, that with
that IV piggyback over the 24-hour period, is helping for nutrition and
hydration? Would you all agree with me on that? So, that makes sense, right?
The second scenario would be someone who comes to your facility who needs six
weeks of IV antibiotics. They're alert. They're oriented. They're eating 100% of
their diet. They're drinking fluids at will. They're easily taking in, you know,
18 or whatever 100cc of fluids a day. They have no fever. They have no
swallowing difficulties. There are no other issues going on with them except for
they have an osteo, and they need to have continued IV fluids. Let's say that
same 400cc over the 24-hour period of time. Would you say that person has a
clinical indication for nutrition and hydration that need for that extra fluids?
No. Okay, so there's a clinical judgment there, right?
So, when talking actually just today, this afternoon, with some folks at CMS, we
had -- there was this one caveat that was left in the manual, and is here in the
slides, that says you need to have an active diagnosis of dehydration before you
can code K0500A. Well, that kind of defeats the purpose, doesn't it? You may
have some people who still are dehydrated and that's going to go in and that's
fine. You go ahead and do that, but do we want to get to the point of
dehydration? No. Okay, so please clearly write on your slides or write yourself
a note. The manual will be updated. We're working on the language. That will
take this requirement of this actual dehydration out, and it will be left to
clinical judgment. We'll give you some good examples.
So, your job as trainers, and your job as folks in the facilities, is you must
figure out a way to make sure that your records reflect when someone really
needs it. Why? Tell the story. Nursing notes are really a great place to do
that. So, just tell us the story and why you would assess these fluids would
help the resident. The one thing that we don't want to have happen, and this
happened in 2.0, where everyone wrote -- there was some states, some
organizations that were putting anyone -- didn't matter who they were -- who
were getting any kind of IV, intermittent IVs, for antibiotics. They were
writing to prevent dehydration and then coding this item, and that is not what
this is intended to do. So, that's the message. CMS will monitor this item.
We'll see how it goes. We're going to see if there's a, you know -- relative to
our history that we have in this particular item if, all of a sudden, a lot more
people are coding it, then there might be some validation, more investigation,
follow-up. Who knows what's going to happen with it. So, but, here CMS is giving
you latitude. So, take that latitude, use your clinical judgment and document
it. So, make sure that information gets back, and we will get that out to
everyone else who is not here today. K0500 is "Check all that apply," so -- and
then you always have the option of Z, which is, "None that apply". So, you can
check the IV fluids and mechanically-altered diet, and it may be therapeutic as
well - just depending on what's going on with your resident.
All right, so let's look at a couple of scenarios here, and I think I kind of
alluded to one of them already, but -- So, Mrs. H. is receiving antibiotics, and
she is receiving 100cc of normal saline, and she has a urinary tract infection.
She has fever. She has abnormal lab results. She has new pyuria. She has greater
than 100,000 colony-forming units in her urine culture. She has documented
inadequate fluid intake, and she has signs and symptoms starting of dehydration.
Again, your clinical assessment for this particular resident - in this
particular situation, the nursing home has placed her on a hydration plan to
ensure adequate hydration. So, we're not just relying on the extra fluids she's
getting from the IVs. We're encouraging. We're offering her favorite fluids.
We're doing it frequently in small-volume, maybe for this particular resident,
and documentation shows that IV fluids being administered as part of the already
identified need for hydration. So, how would we code 0500 here? For this
particular resident, you don't have a whole lot of information on what else
she's doing, but we certainly would code K0500A. Right? It was clear. You had no
question, right? Okay. So, it was good supporting documentation.
Here you have your other scenario, kind of the other side of the spectrum. Mr.
J. is receiving an antibiotic. He has a UTI. Okay? So, we're starting off the
same, but he has no fever. He has documented adequate fluid intake. He is placed
on the nursing home's hydration plan to ensure adequate hydration. What would
you code him? Would you code K0500A for him? No, he really didn't have -- he
wasn't clinically indicated that he really needed those additional fluids. So,
that's how we want you to code this particular item.
All right, let's go to K0700. So, when are we going to code this item? This is
not a whole lot different than what we did in 2.0. So, complete this item only
if K0500A or B is triggered, right? So, only if the person received parenteral
or IV feedings or they got a feeding tube. Otherwise, we're going to ignore this
particular question, or we're going to have to code it as "None of the above," I
should say. So, we're going to review the intake records, and we're going to
look at what they actually took in. We're going to do the calculation of the
total calories in. If the resident took no food or fluids by mouth, or took just
sips of fluids. We need to stop there. And if the resident had more substantial
oral intake than this, consult with your dietician for some help. Here, we're
going -- giving you some examples. Why? Because these are training materials
that you'll hopefully bring back to your facilities or organizations and train.
Again, we want to make sure that all of the staff who are going to be filling
out the MDS or the nursing on the units who need to know this, understand how to
do this calculation.
So, for this particular person, they had 15,000 cc in with a tube feed and 2450
orally, I mean calories. So, we look at total calories here of 17,450, and then
we're going to divide them. Again, you can do the math differently; but, in this
particular situation, they have 85.9% of the calories were taken in. So, select
the best response. We would code 3 if the resident took no food or fluids by
mouth or took just sips of fluids. Here, we're looking at the percentage the
resident took in, and so here we would say that the resident took in 51% or more
of their calories for that particular example.
For K0700B, tube feedings - we're looking at the amount that the resident has
taken in. In this particular situation, again, we're looking at the past seven
days. We're going to add the total amount of fluids received each day by IV or
tube feeding. We're going to divide it by the seven days, and then we're going
to look at what the average is. So code the average number of cc of fluid.
Record what actually was received by the resident. Here's a big thing both for
tube feeding and for IVs. You know, inevitably something happens, and the tube
feed gets stopped. Make sure you're calculating not what was ordered, but what
the resident actually received. So, it's important -- we found that in the DAVE
2, where we went out, an MDS person was sitting in the office filling this out
based off of what was ordered and didn't know actually what the resident - that
something had happened and the resident actually had it stopped for a certain
amount of hours. And then, for that particular timeframe, did not receive what
was ordered. So, we need to calculate actually what was received. Code 1,
500cc/day or less, or 500 in one.
So, a very quick scenario: a resident has swallowing difficulties secondary to
Huntington's disease. She's able to take oral fluids by mouth with supervision,
but not enough to maintain her hydration. She receives daily fluid by
supplemental tube feed, and she gets water plus a nutritional supplement and
juices, and this all happened during the last seven days. Here, we have our
calculation. She had 6300 cc of fluid divided by seven days. Her daily average
is 900 cc per day. So we would code that as 2 - the person got 501cc or more per
day. That makes sense? That's easy, right?
Here's a little bit one that people have struggled a little bit more with. So,
during a seven day period, Mrs. G. received a one liter of IV fluids during the
assessment period. Just a one liter. That's all she had. Okay? And she received
no other intake via an IV or a tube feed during the assessment period, but we
want to capture -- we want to look at that liter. So, how do we do that
calculation? Well, here it shows you how to do the calculation. That Tuesday she
had the 1000 cc. We look at the rest of the days. - none of them tube feed or
IVs. So, the total for the seven day period was 1000. We divide it by seven, and
we get 142.9cc per day. So, we have to code that as 1. 500 cc/day or less. You
see how you can capture even just liter of fluid that someone had? All right.
Alright, that's the end for Section K and I think we are on time.