Inaccurate MDS Coding for Non-Invasive Ventilation Therapy
Penalty
Summary
The deficiency involves the facility’s failure to ensure that Minimum Data Set (MDS) assessments accurately reflected the use of non-invasive mechanical ventilation (BiPAP/CPAP) for two residents. For the first resident, an older male with obstructive sleep apnea, diabetes mellitus type II, dementia, hypertension, and hyperlipidemia, the Annual MDS documented severe cognitive impairment, mobility limitations, and extensive ADL assistance needs. However, the MDS did not indicate that the resident utilized a non-invasive mechanical ventilator, despite existing documentation elsewhere in the record. Record review for this resident showed a care plan focus area initiated and revised over time that identified the need for BiPAP use related to sleep apnea, and a Treatment Administration Record (TAR) order for BiPAP at bedtime for obstructive sleep apnea. During observation, the resident’s BiPAP machine was seen on the nightstand, and the resident stated he used the BiPAP every night. Interviews with MDS staff confirmed that the Annual MDS was incorrect because the resident had been receiving non-invasive ventilation therapy for an extended period according to the care plan. For the second resident, an older male with sleep apnea, diabetes mellitus type II, end stage renal disease, atrial fibrillation, hypertension, congestive heart failure, and hyperlipidemia, the Annual MDS documented intact cognition, lower extremity range of motion impairment, wheelchair use, and extensive assistance needs with ADLs. As with the first resident, the MDS did not indicate use of a non-invasive mechanical ventilator. The care plan documented a focus area for BiPAP use related to sleep apnea, and the TAR contained an order for BiPAP every night shift. Observation showed the BiPAP on the nightstand, and the resident reported staff applied it every night. MDS staff and the Regional Reimbursement Nurse acknowledged that the non-invasive ventilator item on the MDS had not been correctly coded, despite the residents’ ongoing BiPAP therapy, and the DON and Administrator stated that the MDS is expected to accurately reflect resident needs and that inaccurate coding could result in improper treatment plans and billing.
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