CMS Releases Clarification on ADL Coding

The Centers for Medicare & Medicaid Services (CMS) has released a clarification to State RAI Coordinators on correct Activities of Daily Living (ADL) coding.  Since this clarification will change the way many providers in Virginia code their assessments, Cil Bullard, Virginia RAI/OASIS Coordinator is preparing a webinar to be available once CMS releases additional information.  The clarification will be included in the new RAI Manual expected to be released early May.  Because CMS considers this announcement as a clarification of current guidance, it is effective now.  The clarification has been released due to questions sent to CMS from providers and state coordinators due to inconsistencies and apparent conflicts in the RAI Manual, especially between the ADL graph and the text of Section G.

CMS clarified the following:

  • If an ADL occurs at the same level three or more times, assign that code.  For example, the resident received total assist x1, extensive assist x2, limited assist x2, and supervision x3.  Therefore, the MDS would be coded ‘1- Supervision’.
  • If an ADL occurs three or more times at multiple levels, code the most dependent. For example, limited assist x3, supervision x3, and independent x3 would be coded as ‘2-Limited Assist’.
  • If an ADL does not occur at the same level for three or more times, follow the guidance on G-4(at the bottom) and G-5(at the top).

This information will also be posted on the Virginia MDS Community webpage.  If providers identify a need for additional training besides the initial webinar, please notify Cil Bullard if your facility could volunteer to host training.

VHCA acknowledges the following additional information on the MDS changes provided by Mary Chiles, Chiles Healthcare Consulting, and Judy Wilhide-Brandt, Judy Wilhide MDS Consulting, Inc, “AANAC has received clarification from CMS on scoring ADLs.  It is anticipated that these instructions will be detailed in the upcoming MDS manual update to be posted in early May. The significant clarification will reinvent the rule of three, although CMS says this is not a new interpretation. Preliminary analysis of this clarification indicates there may be significant impact on your RUGs scores [lowers ADL total score] and on QMs.  Consider the following example from AANAC: Supervision occurred five times in the look back period while Limited Assistance occurred twice and Extensive Assistance and Total Assistance each occurred once. The correct code for G01101 would, in this scenario, be “1” indicating Supervision.”

According to Ms. Chiles and Ms. Wilhide-Brandt, nursing facilities should use this opportunity to be “proactive and instill mechanisms that promote frequent charting of ADLs by your CNAs and mechanisms to ensure documentation of bedside assessment and documentation by the person responsible for completing Section G.”  Additional updates and clarification are expected to be released by CMS.