Nursing Home News

CMS ICD-10 Interim Final Rule and 2015 Files Available – HHS expects to release an interm final rule in the near future that will include a new compliance date that would require the use of ICD-10 beginning October 1, 2015. The rule will also require HIPAA covered entities to continue to use ICD-9-CM through September 30, 2015. Providers, suppliers, billing companies and clearinghouses are welcome to submit acknowledgement test claims anytime up to the anticipated October 1, 2015 implementation date. Submitters should contact their local Medicare Administrative Contractor (MAC) for more information about acknowledgement testing. However, those who submit claims may want to delay acknowledgement testing utnil after October 6, 2014, when Medicare updates its systems.

The 2015 ICD-10-CM and ICD-10-PCS files are now posted on the 2015 ICD-10-CM and GEMs web page and 2015 ICD-10-PCS and GEMs webpage. There are no new, revised or deleted ICD-10-CM or ICD-10-PCS codes. The 2015 General Equivalence Mappings (GEMs) and Reimbrusement Mappings are also available on these web pages.

The 2015 ICD-9-CM files are now available on the ICD-9-CM Diagnosis and Procedure Codes: Abbreviated and Full Code Titles web page. Since there will be no ICD-9-CM updates, there is no FY2015 addendum. There are no new, revised or deleted ICD-9-CM codes.

MDS Expert Provides Guidance on Pain Medication Interventions (This article from LeadingAge's MDS expert consultant, Judy Wilhide-Brant, RN, provides guidance on how to code pain management medication as part of section J0110A&B of the MDS. She offers a step-by-step guide to coding, and highlights a few relevant excerpts to assist with answering the necessary questions within the section.) – In Section J0110A&B, we are asked some seemingly straightforward questions about pain management in a 5-day look-back period.

At any time in the last 5 days, has the resident:

• Been on a scheduled pain management regimen?
• Received PRN pain medication?
• Received non-medication intervention for pain?

The instructions for completion of this section are below:

Steps for Assessment

1. Review medical record to determine if a pain regimen exists.
2. Review the medical record and interview staff and direct caregivers to determine what, if any, pain management interventions the resident received during the 5-day look-back period. Include information from all disciplines

Coding Instructions for J0100A & B

Determine all interventions for pain provided to the resident during the 5-day look-back period. Answer these items even if the resident currently denies pain.

Coding Instructions for J0100A, Been on a Scheduled Pain Medication Regimen

Code 0, no: if the medical record does not contain documentation that a scheduled pain medication was received.
Code 1, yes: if the medical record contains documentation that a scheduled pain medication was received.

Coding Instructions for J0100B, Received PRN Pain Medication

Code 0, no: if the medical record does not contain documentation that a PRN medication was received or offered.
Code 1, yes: if the medical record contains documentation that a PRN medication was either received OR was offered but declined.

The definition of a pain medication regimen is:

"Pharmacological agent(s) prescribed to relieve or prevent the recurrence of pain. Include all medications used for pain management by any route and any frequency during the lookback period. Include oral, transcutaneous, subcutaneous, intramuscular, rectal, intravenous injections or intraspinal delivery. This item does not include medications that primarily target treatment of the underlying condition, such as chemotherapy or steroids, although such treatment may lead to pain reduction."

Many MDS coders see this definition as troubling and contradictory. There are a host of medications approved and widely used for pain in long term care that primarily target treatment of the underlying condition, such as gabapentin, approved for post-herpetic pain only, but used successfully for many other types of pain in the elderly population. Some CMS or State officials have said to code gabapentin (and others not specifically classified as analgesics) as pain medication because of the first sentence in the definition above. Some have said not to code it, because of the last sentence.

While deciding whether a medication used as part of a pain management regimen may be baffling, we do have very clear guidance in Appendix PP of the State Operations Manual for a pain management program. The following excerpts are from the guidance to surveyors in investigating pain management under F-309:

"'Adjuvant Analgesics' describes any medication with a primary indication other than pain management but with analgesic properties in some painful conditions."

This section goes on to state the importance of addressing underlying causes of pain:

"The resident's needs and goals as well as the etiology, type, and severity of pain are relevant to developing a plan for pain management. It should be noted that while analgesics can reduce pain and enhance the quality of life, they do not necessarily address the underlying cause of pain. It is important to consider treating the underlying cause, where possible. Addressing underlying causes may permit pain management with fewer analgesics, lower doses, or medications with a lower risk of serious adverse consequences."

Many residents have more than one active medical condition and may experience pain from several different causes simultaneously. Many medical conditions may be painful such as pressure ulcers, diabetes with neuropathic pain, immobility, amputation, post- CVA, venous and arterial ulcers, multiple sclerosis, oral health conditions, and infections. In addition, common procedures, such as moving a resident or performing physical or occupational therapies or changing a wound dressing may be painful. Understanding the underlying causes of pain is an important step in determining optimal approaches to prevent, minimize, or manage pain.

Under "pharmacological interventions" we have the following guidance:

"The interdisciplinary team (nurses, practitioner, pharmacists, etc.) is responsible for developing a pain management regimen that is specific to each resident who has pain or who has the potential for pain, such as during a treatment. The regimen considers factors such as the causes, location, and severity of the pain, the potential benefits, risks and adverse consequences of medications; and the resident's desired level of relief and tolerance for adverse consequences. The resident may accept partial pain relief in order to experience fewer significant adverse consequences (e.g., desire to stay alert instead of experiencing drowsiness/confusion). The interdisciplinary team works with the resident to identify the most effective and acceptable route for the administration of analgesics, such as orally, topically, by injection, by infusion pump, and/or transdermally."

It is important to follow a systematic approach for selecting medications and doses to treat pain. Developing an effective pain management regimen may require repeated attempts to identify the right interventions. General guidelines for choosing appropriate categories of medications in various situations are widely available.

Factors influencing the selection and doses of medications include the resident's medical condition, current medication regimen, nature, severity, and cause of the pain and the course of the illness. Analgesics may help manage pain; however, they often do not address the underlying cause of pain. Examples of different approaches may include, but are not limited to:

• Administering lower doses of medication initially and titrating the dose slowly upward.
• Administering medications "around the clock" rather than "on demand" (PRN).
• Combining longer acting medications with PRN medications for breakthrough pain.

Recurrent use of or repeated requests for PRN medications may indicate the need to reevaluate the situation, including the current medication regimen. Some clinical conditions or situations may require using several analgesics and/or adjuvant medications (e.g., antidepressants or anticonvulsants) together. Documentation helps to clarify the rationale for a treatment regimen and to acknowledge associated risks.

In conclusion, it may be helpful to remember that the most important responsibility we have is to assist our residents to be as free of pain as they care to be. Pain management is a very intensive, cooperative venture with the entire interdisciplinary team.

If the regimen your resident is using is working for him or her, but you are not sure how to code this section of the MDS, my recommendation would be to ask the physician if the medication is prescribed primarily to treat pain or to treat the underlying condition, document the response and code accordingly. Another option is to ask your State RAI manager for written guidance.

LeadingAge Insights: Webinars on Using Quality Metrics – LeadingAge Insights is a new suite of market intelligence tools brought to you exclusively by LeadingAge. Each tool is designed to be intuitive and easy to use, but because these tools are brand new, we're offering introductory webinars to get you acquainted with each one and make it as streamlined as possible for you to access the information you need when you need it.

Thanks to the generosity of LeadingAge NY, we've been able to offer several webinars so far. Each webinar includes an overview of the tools available through LeadingAge Insights and a live demonstration of Quality Metrics.

The links below will take you to an event page that includes a registration link, allowing you to sign up for the webinar time that is most convenient for you.

LeadingAge Insights Quality Metrics Webinar Dates

1. June Webinar #1: June 11 from 11 a.m.-noon EST
2. June Webinar #2: June 24 from 11 a.m.-noon EST

For more information on the webinars, please send an email to qualitymetrics@leadingageny.org or call Linda Spokane at 518-867-8857.

AHCA Schedules a Rule Development Workshop – The Agency for Health Care Administration (AHCA) has scheduled a rule development workshop for the purpose of discussing the Certification of Need requirements for Nursing Facility Beds as well as language associated with these facilities in Certificate of Need rules.

The meeting will take place on Tuesday, July 1 at 10 a.m. at the Agency for Health Care Administration, Building 3, Conference Room C at 2727 Mahan Drive in Tallahassee.

For more information or for copies of the agenda, please contact Marisol Fitch via email or by phone at (850) 412-3750.