The Centers for Medicare & Medicaid Services (CMS) released a free four-course training series on May 7, 2021. The series provides an overview of the general and key clinical considerations important for conducting standardized cognitive and mood assessments for skilled nursing facilities (SNF). The names of the four courses and a brief description of each one are:
- Approaches to Cognitive & Mood Assessments for SNF Providers:
The course provides an overview of the general and key clinical considerations important to conducting standardized cognitive and mood assessments. An overview of principles directly applicable to the Brief Interview for Mental Status (BIMS), the Signs and Symptoms of Delirium from the Confusion Assessment Method (CAM©), and the Resident Mood Interview Patient Health Questionnaire (PHQ-9©) is presented. Resources available to assist SNF providers in understanding and training others in the application of related coding guidance are also reviewed.
- Assessment of Cognitive Function for SNF Providers (BIMS):
This course provides an overview of the general principles and key clinical considerations important when conducting the Brief Interview for Mental Status (BIMS). Item intent and rationale, steps for assessment, and coding instructions is covered. A review of the Staff Assessment for Mental Status is provided. Participants will be able to apply coding principles using interactive exercises and videos to code practice scenarios.
- Assessing Delirium in the SNF Care Setting (CAM©):
This course provides an overview of the general principles and key clinical considerations that are important when coding C1310, Signs and Symptoms of Delirium (from CAM©). Item intent and rationale, steps for assessment, and coding instructions are reviewed. Participants will apply coding principles using videos to code practice scenarios.
- The Resident Mood Interview (PH-Q9©) for SNF Providers:
This course discusses the Resident Mood Interview (PHQ-9©) and Total Severity Score. Item intent, rationale, steps for assessment, and coding instructions are reviewed. An emphasis on interview techniques that promote resident engagement and interview accuracy is examined. Participants will have an opportunity to apply coding principles using interactive exercises and videos to code practice scenarios.
Each web-based course takes from 30-45 minutes to complete. The courses include interactive exercises to test the learners knowledge related to cognitive and mood assessments. The courses are intended to be completed in sequential order, but the learner may jump directly to any topic of interest.
The CMS Cognitive & Mood Assessment courses can be accessed at: Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) Spotlights and Announcements | CMS
Issue:
Accurate coding of the MDS is absolutely crucial to ensure accuracy of quality measures for your facility. Quality Measures (QMs) are available online to your residents, their families, and potential customers, and provide them with information regarding the quality of care being delivered by your staff. These QM’s should guide your facility to determine the level of your quality improvement efforts. Inaccurate coding will lead to inaccurate QM’s, which may be seen as fraud in billing practices, and could lead to a deficiency for F641 – Accuracy of Assessments. Facility leadership, including the MDS coordinators, should be trained and knowledgeable on accurate coding and the importance of quality measures, and should have access to the most current version of the Resident Assessment Instrument (RAI) Manual available at Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual | CMS.
Discussion Points:
- Review your policies and procedures to determine if revisions are needed to ensure accurate coding of the MDS. Revise your policy as needed when updates are published.
- Train all appropriate staff on how to code the MDS accurately and how your quality measures are formulated, and document that the training occurred.
- Periodically audit to ensure that MDS coding is accurate by all individuals who are inputting data for the completion of MDSs at your facility. Determine that staff completing any sections of the MDS have the most current version of the users’ manual to guide them.
