Inaccurate MDS Coding Due to Lack of Physician Documentation
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for one resident who was admitted with diagnoses including dysphasia following a stroke. During the assessment process, the MDS nurse marked malnutrition on the MDS form without having the required physician documentation to support this diagnosis. Although the nurse had provided a query form for the physician to sign as supporting documentation, it had not been signed at the time the MDS was coded and submitted. Interviews with the MDS nurse and the Director of Nursing confirmed that physician documentation was necessary to accurately code malnutrition in the MDS, as this information is submitted to CMS for billing purposes. Review of facility policy and the CMS RAI MDS 3.0 Manual further supported the requirement for accurate and documented assessments. The deficiency resulted in the submission of inaccurate information to the federal database.