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Questions & answers from the American Association of Nurse Assessment Coordinators (AANAC)

December 1, 2007
by The American Association of Nurse Assessment Coordinators
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Q: Regarding coding of assistance with bathing: According to the RAI User's Manual, you code the highest level of assist given in the past seven days. In theory, therefore, if someone received a total assist to bathe, with the CNA performing all of the care on one day in the past seven days, even if the resident performed all of her own bathing with set up only on the other days, how can you code this as 4/2 (total dependant/one assist)? As this gives the incorrect description of the resident, I would be hesitant to code this way. I would code the above situation as extensive assist (code 3).

A: You code 4/2. There are many places on the MDS that do not ask for an accurate picture of the resident, but a description of resources used for the snapshot, based on coding rules. The care plan should be the place where we paint a picture of our resident. The MDS is where we follow the coding rules.

Q: Some folks at my workplace say that any resident who goes on hospice must automatically have a Significant Change in Status Assessment completed. Is that correct?

A: No, it isn't. The criteria for completing a Significant Change Assessment for a resident opting for hospice are no different than they are for any other resident. The RAI User's Manual, page 2-11, states:

If a resident elects the Medicare hospice program, it is important that the two separate entities (nursing facility and hospice program staff) coordinate their responsibilities and develop a care plan reflecting the interventions required by both entities. The need to complete an SCSA will depend upon the resident's status at the time of election of hospice care, and whether or not the resident's condition requires a new assessment. Because a Medicare-certified hospice must also conduct an assessment at the initiation of its services, this is an appropriate time for the nursing facility to evaluate the MDS information to determine if it reflects the current condition of the resident. The nursing facility and the hospice's plans of care should be reflective of the current status of the resident.

In addition, on the same page, it says that a Significant Change Assessment is not required for individuals with a terminal condition if the change in condition is an expected, well-defined part of the disease course. So, if your resident has been on a decline due to his terminal condition and has now decided to elect hospice care, that action alone (going on hospice) is not a trigger for a Significant Change Assessment. In these situations, as always, the care plan must reflect the resident's current status.

Q: I have a patient scheduled to go for chemotherapy, and the billing department where the chemo will be administered said they will be billing Medicare but that there are some charges that will be the responsibility of theSNF. Please explain Medicare A coverage for chemotherapy.

A: Some chemotherapy drugs fall under consolidated billing, meaning they are excluded and not the SNF's responsibility. In addition, some chemotherapy administration charges are also excluded if the drug is excluded. Some things that may not be excluded are the anti-nausea drugs administered. I would verify which chemotherapy she is getting to make sure it is not going to be the SNF's responsibility. For a general explanation of the exclusions under consolidated billing, go to See Major Category III regarding chemother-apy.

To verify if the drug is on the list of exclusions, you need to check the HCPC file that can be found at the following web site:

With thanks to Diane Carter, RN, MSN, CS, President and CEO of the American Association of Nurse Assessment Coordinators (AANAC).



Q: What is AANAC and how do I get my questions answered on the Resident Assessment Instrument/Minimum Data Set (RAI/MDS)?

A: The American Association of Nurse Assessment Coordinators is a nonprofit association of your peers including all members of the interdisciplinary team dedicated to networking, education and advocacy on behalf of all clinicians involved in the RAI/MDS process. From our online discussion group each week, we select the best questions and answers our members have raised. The questions and answers are reviewed by a national advisory board of experts in this field and they are subsequently published in NAC News, our weekly online newsletter. In addition to our weekly questions and answers, the newsletter contains all sorts of timely and accurate information on this process. AANAC also offers certification and other educational information services for clinicians committed to accurate and timely completion of the MDS. For further information on AANAC, visit or call us at (800) 768-1880.



One critical thing to remember for the bathing ADL is that in G0120A, Self-Performance, you are not coding Self-Performance in the same way you code it for G0110, Column 1. Bathing has it's own set of Self-Performance codes. I think that is why the assessor was struggling with how to code this item. If bathing was part of G0110, this scenario would be coded a 7, as the activity only happened once in the 7-day look-back period, but since G0120A has it's own codes, you must follow them in order to code this item, so 4/2 is the correct answer.

The answer given above regarding SCSA and Hospice is incorrect. When a resident elects or revokes the hospice benefit, an SCSA must be performed. This information is found in Chapter 2, Comprehensive Assessments, #03. Significant Change In Status Assessment (SCSA) (A0310A=04)on page 2-21:

"A SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare Hospice or other structured hospice) and remains a resident at the nursing home. The ARD must be within 14 days from the effective date of the hospice election (which can be the same or later than the date of the hospice election statement, but not earlier than). A SCSA must be performed regardless of whether an assessment was recently conducted on the resident. This is to ensure a coordinated plan of care between the hospice and nursing home is in place. A Medicare-certified hospice must conduct an assessment at the initiation of its services. This is an appropriate time for the nursing home to evaluate the MDS information to determine if it reflects the current condition of the resident, since the nursing home remains responsible for providing necessary care and services to assist the resident in achieving his/her highest practicable well-being at whatever stage of the disease process the resident is experiencing.

•If a resident is admitted on the hospice benefit (i.e. the resident is coming into the facility having already elected hospice), the facility should complete the Admission assessment, checking the Hospice Care item, O0100K. Completing an Admission assessment followed by a SCSA is not required.

•A SCSA is required to be performed when a resident is receiving hospice services and then decides to discontinue those services (known as revoking of hospice care). The ARD must be within 14 days from one of the following: 1) the effective date of the hospice election revocation (which can be the same or later than the date of the hospice election revocation statement, but not earlier than); 2) the expiration date of the certification of terminal illness; or 3) the date of the physician’s or medical director’s order stating the resident is no longer terminally ill."

The comments just sent in regarding Bathing and SCSA Hospice were submitted by Teresa M. Mota, BSN, RN, Healthcentric Advisors, Providence, RI. Sorry...I forgot to add that at the bottom of my responses.