Under the Patient Driven Payment Model (PDPM), resident characteristics are used to classify Medicare residents into payment groups. One of these characteristics is isolation due to an active infection. Being coded for infection isolation can have a significant impact on the Medicare payment rate for a resident’s SNF stay. The increase in a SNF resident’s payment rate as a result of being coded under infection isolation is driven by the increase in the relative costliness of treating a resident who must be isolated due to an infection. Isolation coding is a qualifier for the Extensive Services 1 (ES1) Nursing case-mix group (CMG), one of the highest-paying case-mix groups, and will account for 1 point in the non-therapy ancillary (NTA) CMG.
For a resident to qualify to be coded as being isolated for an active infectious disease, the following criteria outlined in the MDS 3.0 RAI User’s Manual must be met:
- The resident has active infection with highly transmissible or epidemiologically significant pathogens that have been acquired by physical contact or airborne or droplet transmission.
- Precautions are over and above standard precautions. That is, transmission-based precautions (contact, droplet, and/or airborne) must be in effect.
- The resident is in a room alone because of active infection and cannot have a roommate. This means that the resident must be in the room alone and not cohorted with a roommate regardless of whether the roommate has a similar active infection that requires isolation.
- The resident must remain in his or her room. This requires that all services be brought to the resident (for example, rehabilitation, activities, dining, etc.).
Specific exclusions apply to isolation coding for the following conditions: wound infections, urinary tract infections, encapsulated pneumonia, and history of infectious disease, such as MRSA and/or c-diff without active symptoms.
Supportive Documentation: Given the significant payment implications associated with the coding of isolation under PDPM, it is imperative that the medical record clearly support the above criteria are met.
- Given active infection is a medical diagnosis, it should be documented by a physician, NP, or PA in the last 60 days and have a direct relationship to the resident’s current functional status, cognitive status, mood or behavior, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period. In addition to being documented in the medical record by the physician, this active infection should be coded in Section I of MDS and on the Medicare claim (UB04)
The resident must be symptomatic and/or have a positive test and be in the contagious stage. The medical record must support the determination that the resident is either:
- Symptomatic AND in the contagious stage, or
- Has a positive test AND is in the contagious stage.
The documentation should include the initial identification of symptoms and/or the date of the positive test. Skilled documentation should address any ongoing symptoms identified.
- The Care Plan should be updated to address the need for and duration of the transmission-based precautions and single room isolation, using the Centers for Disease Control and Prevention (CDC) guidelines. The use of isolation should be medically necessary and align with standards of care for the resident’s condition. The care plan should also address how the resident’s physical and psychosocial needs and risks are to be met while on strict single room isolation.
- The documentation should support:
- The resident was alone in the room, and
- Did not leave their room unless they required a service that could not be provided within the facility, and
- All services were brought to the resident (ie rehabilitation therapy, activities, meals, etc.)
Isolation and COVID 19: Since the identification of the Public Health Emergency (PHE) related to COVID-19, CMS has implemented several waivers and flexibilities to elevate the burden of care during the pandemic. None of these apply to the coding of isolation on the MDS. As a result, to code isolation for known or under investigation for COVID all the above criteria must be met. Placing two residents with an active COVID infection on isolation in the same room (cohorting) does not meet the criteria for coding isolation for either resident nor does placing a new admission whose COVID status is unknown in single room isolation while monitoring for symptoms or awaiting a negative test result.
CMS is aware of stakeholder concerns about the increased cost of care associated with the pandemic but maintain that the definition of “infection isolation” is appropriate and should not be changed in response to the circumstances of the COVID-19 PHE. CMS addressed these concerns in the FY 2022 SNF PPS Proposed Rule by inviting public comment about this topic. Specifically, CMS is seeking comments on how the staff time resources for treating residents with an active infection is affected by the PHE whether the resident in a cohorted room or single room.
Comments must be received no later than 5 pm on Friday, June 10th and may be submitted electronically or by mail. When submitting electronically use the following link: https://www.regulations.gov. Follow the “Submit a comment” instructions.
By regular mail. Comments may be sent to the following address ONLY: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1765-P, P.O. Box 8016, Baltimore, MD 21244-8016.
Contact Proactive for assistance in ensuring quality skilled nursing documentation and MDS coding accuracy to support the care and services your facility provides.