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30 LTC NF Online Portal User Manual 03242014

1. 9 S To Date 4 30 2013 Ba 12 v 2013 1127 LTC Nursing Facility Hospice User Guide LTC Online Portal Basics Blue Navigational Bar Links All portal features based on your security level will be found in the blue navigational bar located at the top of the portal screen Options found in the blue navigational bar may include Home Submit Form Form Status Inquiry Current Activity Drafts Alerts Vendors Printable Forms or Help a TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR Home Submit Form Form Status Inquiry Current Activity Drafts Vendors Printable Forms Alerts Help Home When the blue navigational bar above is displayed the Home feature at the far left will take you to My Account From the My Account page providers can perform various maintenance activities for an account such as setting up user accounts changing passwords and other administrative tasks Providers may click the TMHP com link located on the far left side of the My Account page to go back to the www tmhp com home page V TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR Home Submit Form Form Status Inquiry Current Activity Drafts Vendors Printable Forms Alerts Help Using the TMHP home page providers may e Access the LTC Online Portal e Access TexMedConnect e Submit a prior authorization e Access provider manuals and guides
2. v 2013 1127 81 LTC Nursing Facility Hospice User Guide e The facility may submit an LTCMI on an MDS assessment for a resident who will be transitioning from Medicare to Medicaid However the LTCMI cannot be submitted prior to the 3619 Admission The provider has the option to submit the LTCMI either prior to the resident discharging off of Medicare or waiting until the resident is considered Full Medicaid Current Resident Admitted to Hospice e Submit a Form 3618 or 3619 as appropriate discharging the recipient to Hospice Care e CMS states a SCSA should be submitted on a resident who admits to Hospice The MDS 3 0 LTCMI should include the Hospice contract number and Hospice Care should be indicated in O0100K2 e Indicate Hospice Care in 3 0 O0100K2 e Hospice contract number must be entered on the LTCMI Hospice provider submits Forms 3071 and 3074 Form 3618 or 3619 Discharge must be signed and electronically submitted within 72 hours of Hospice election date Submit an MDS with A0310A 04 Significant Change in Status Assessment with a check in O0100K2 indicating Hospice Care Complete Long Term Care Medicaid Information LTCMI S1d Hospice contract number Form 3071 and 3074 submitted by Hospice provider 82 v 2013 1127 LTC Nursing Facility Hospice User Guide Current Hospice Residents Once an MDS SCSA is submitted nursing facilities should continue the MDS cycle for Hospice residents In addi
3. Enter Code 0 No resident was able to complete interview Skip to C1300 Signs and Symptoms of Delirium 1 Yes resident was unable to complete interview Continue to C0700 Short term Memory OK Staff Assessment for Mental Status Do not conduct if Brief Interview for Mental Status C0200 C0500 was completed C0700 Short term Memory OK Enter Code Seems or appears to recall after 5 minutes 0 Memory OK 1 Memory problem C0800 Long term Memory OK Enter Code Seems or appears to recall long past 0 Memory OK 1 Memory problem C0900 Memory Recall Ability i Check all that the resident was normally able to recall A Current season B Location of own room C Staff names and faces D Thathe or she is in a nursing home Z None of the above were recalled C1000 Cognitive Skills for Daily Decision Making Made decisions regarding tasks of daily life 0 Independent decisions consistent reasonable 1 Modified independence some difficulty in new situations only 2 Moderately impaired decisions poor cues supervision required 3 Severely impaired never rarely made decisions Enter Code C1300 Signs and Symptoms of Delirium from CAM Code after completing Brief Interview for Mental Status or Staff Assessment and reviewing medical record J Enter Codes in Boxes A Inattention Did the resident have difficulty focusing attention easily distracted out of touch or Coding difficulty following what wa
4. J9 o 9 c oo ta Vendor Number m Contract Number NPI Number Recipient Information 1 Medicaid Recipient No 4 e Recipient s Last 5 Address Address 2 Social Security No Name ss City 3 Medicare or RR o Reaplent RES State Retirement Claim No Recipient s Middle fe ZIP Initial Recipient Name Suffix Transaction Information e Service Group e Transaction 26 v 2013 1127 LTC Nursing Facility Hospice User Guide 3 Click the Print button located in the yellow Form Actions bar to print the document in progress if you want a hard copy for your records From here you have two choices a Click the Submit Form button located at the bottom right of the screen if you are ready to submit for processing A2300 Assessment Date Observation end date iv unire ubmit Form or b Click the Save as Draft button located in the yellow Form Actions bar to save the document until you are ready to submit Form Actions ET save as Draft D The Save as Draft button will only display in the yellow Form Actions bar in the following circumstances Ifthe provider is entering a PL1 or a Form 3618 3619 3071 or 3074 from the Submit Form link If the provider is creating a new form or screening from a template of a previously submitted form or screening using the Use as template
5. Modified M0210 field text to 1 Yes Continue to M0300 Current Number of Unhealed Pressure Ulcers at Each Stage Deleted M0610 non epithelialized from the field instructions Modified M0700 Most Severe Tissue Type for Any Pressure Ulcer field to change Option 4 from Necrotic tissue Eschar to Eschar Modified Q0100B Option 9 to Resident has no family or significant other v 2013 1002 1 LTC Nursing Facility Hospice User Guide Addendum e Modified Q0100C Option 9 to Resident has no guardian or legally authorized representative e Modified Q500B Changed phrase from or family or significant other to or family or significant other or guardian or legally authorized representative e Modified Q0550A to Does the resident or family or significant other or guardian or legally authorized repre sentative if resident is unable to understand or respond want to be asked about returning to the community on all assessments Rather than only on comprehensive assessments e On MDS NC only Modified O0400F1 instructions must read Total minutes record the total number of minutes this therapy was administered to the individual in the last 7 days If zero skip to O0420 Distinct Calendar Days of Therapy MN LOC 3 0 Changes e Modified C1600 Acute Onset Mental Status Change field to enable providers to select the No information Not assessed option e Modi
6. B Verbal behavioral symptoms directed toward others e g threatening Behavi f thi d 1 PSVIe er MS IRE DOSHTHEHUI IOS others screaming at others cursing at others days Other behavioral symptoms not directed toward others e g physical symptoms such as hitting or scratching self pacing rummaging public sexual acts disrobing in public throwing or smearing food or bodily wastes Behavior of this type occurred daily or verbal vocal symptoms like screaming disruptive sounds Behavior of this type occurred 4 to 6 days but less than daily E0300 Overall Presence of Behavioral Symptoms Enter Code Were any behavioral symptoms in questions E0200 coded 1 2 or 3 0 Noo Skip to E0800 Rejection of Care 1 Yes Considering all of E0200 Behavioral Symptoms answer E0500 and E0600 below E0500 Impact on Individual Did any of the identified symptom s Enter Code A Put the individual at significant risk for physical illness or injury L 0 No 1 Yes Significantly interfere with the individual s care 0 No 1 Yes Significantly interfere with the individual s participation in activities or social interactions 0 No 1 Yes E0600 Impact on Others Did any of the identified symptom s A Putothers at significant risk for physical injury 0 No 1 Yes Significantly intrude on the privacy or activity of others L 0 No 1 Yes Enter Code Significantly disrupt care or living environme
7. 7 4 e Recipient s Last Name 5 Address Address 2 Social Security No Name Recipient s First Name _ 4 City 3 Medicare or RR Retirement 1 Recipient s Middle 1 State wj Claim No Initial ZIP j Recipient Name Suffix Transaction Information e Service Group Nursing Facility e Transaction 1 Admission From v Discharge Type sj Location 2 Nursing Facility v Date of Physical Admission to Private bal Pay If Newly Admitted From Discharged To Hospital Enter Date e Date of Above Transaction Administrator Information I certify that to the best of my knowledge the date in Item 11 Date of Above Transaction is for services provided and the date is not included in the 100 Medicare Part A reimbursement time frame Administrator e State Board License No EE Administrator Last Name a lt Administrator First Name e Is Administrator Signature on Form e Date Siged v 8 Click the Submit Form button Note f the form is successfully submitted a DLN will be assigned and the LTC Online Portal will show Your form was submitted successfully If there are errors they will be displayed in a box at the top of the screen These errors will 132 v 2013 1127 LTC Nursing Facility Hospice User Guide 9 need to be resolved before the form will be successfully submitted Once all errors are resolved cli
8. 5 Therapy start date record the date the most recent 6 Therapy end date record the date the most recent therapy regimen since the most recent entry started therapy regimen since the most recent entry ended enter dashes if therapy is ongoing D Respiratory IY Enter Number of Days L 2 Days record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days E Psychological Therapy by any licensed mental health professional Enter Number of Days 2 Days record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days 00420 Distinct Calendar Days of Therapy si ee Record the number of calendar days that the resident received Speech Language Pathology and Audiology Services Occupational Therapy or Physical Therapy for at least 15 minutes in the past 7 days 00450 Resumption of Therapy Complete only if A0310C 2 or 3 and A0310F 99 Enter Code Hasa previous rehabilitation therapy regimen speech occupational and or physical therapy ended as reported on this End of Therapy OMRA and has this regimen now resumed at exactly the same level for each discipline 0 No gt Skip to 00500 Restorative Nursing Programs 1 Yes Date on which therapy regimen resumed Month Day MDS 3 0 Nursing Home Quarterly NQ Version 1 11 2 Effective 10 01 2013 Page 27 of 35 Resident Identifier Date SectionO Special Treatments
9. K0200 Height and Weight While measuring if the number is X 1 X 4 round down X 5 or greater round up A Height in inches Record most recent height measure inches B Weight in pounds Base weight on most recent measure in last 30 days measure weight consistently according to standard facility practice e g in a m after voiding before meal with shoes off etc Enter Dash if unable to assess K0300 Weight Loss Loss of 5 or more in the last month or loss of 10 or more in last 6 months 0 Noorunknown 1 Yes on physician prescribed weight loss regimen 2 Yes not on physician prescribed weight loss regimen MN and LOC 3 0 V 15 18 of 32 Individual Identifier Date NIIS nEWE Swallowing Nutritional Status K0310 Weight Gain Gain of 5 or more in the last month or gain of 10 or more in last 6 months 0 Noorunknown 1 Yes on physician prescribed weight gain regimen 2 Yes not on physician prescribed weight gain regimen K0510 Nutritional Approaches Y Check all of the following nutritional approaches that were performed during the last 7 days A Parenteral IV feeding Feeding tube nasogastric or abdominal PEG Mechanically altered diet require change in texture of food or liquids e g pureed food thickened liquids Therapeutic diet e g low salt diabetic low cholesterol None of the above K0710 Percent Intake by Artificial Route Comple
10. LTC Nursing Facility Hospice User Guide LTCMI Fields e S3f MD DO License State Required Choose the license state in which the MD DO is licensed from the drop down box S3g MD DO Military Spec Code Conditional This field is required if S3e MD DO License is not populated Enter the Military Spec Code number of the MD DO Fields S3h through S3l MD DO information are required if MD DO is not licensed in Texas S3h MD DO First Name Conditional This field is required if S3f License State is NOT Texas Enter the first name of the resident s MD DO This information is used to mail MN determination letters S3i MD DO Address Conditional This field is required if S3f License State is NOT Texas Enter the street address of the resident s MD DO This information is used to mail MN determination letters S3j MD DO City Conditional This field is required if S3f License State is NOT Texas Enter the city of the resident s MD DO mailing address This information is used to mail MN determination letters S3k MD DO State Conditional This field is required if S3f License State is NOT Texas Enter the state of the resident s MD DO mailing address This information is used to mail MN determination letters S3l MD DO ZIP Code Conditional This field is required if S3f License State is NOT Texas Enter the ZIP co
11. Musculoskeletal Arthritis e g degenerative joint disease DJD osteoarthritis and rheumatoid arthritis RA Osteoporosis Hip Fracture any hip fracture that has a relationship to current status treatments monitoring e g sub capital fractures and fractures of the trochanter and femoral neck Other Fracture Neurological Alzheimer s Disease Aphasia Cerebral Palsy Cerebrovascular Accident CVA Transient Ischemic Attack TIA or Stroke Non Alzheimer s Dementia e g Lewy body dementia vascular or multi infarct dementia mixed dementia frontotemporal dementia such as Pick s disease and dementia related to stroke Parkinson s or Creutzfeldt Jakob diseases Neurological Diagnoses continued on next page MDS 3 0 Nursing Home Comprehensive NC Version 1 11 2 Effective 10 01 2013 Page 18 of 41 Resident Identifier Date Section __ Active Diagnoses Active Diagnoses in the last 7 days Check all that apply Diagnoses listed in parentheses are provided as examples and should not be considered as all inclusive lists Neurological Continued Hemiplegia or Hemiparesis Paraplegia Quadriplegia Multiple Sclerosis MS Huntington s Disease Parkinson s Disease Tourette s Syndrome Seizure Disorder or Epilepsy Traumatic Brain Injury TBI 15600 Ma
12. To register for the RUG training or for more information visit www txstate edu continuinged professional development PD Online RUG Training html RUG training is valid for two years then it must be renewed by completing the online RUG training via Texas State University RUG training is required for RNs who sign assessments as complete RUG training can take two to seven working days M F 8 5 to process and report completions of RUG training to TMHB depending on current volume of enrollments and completions Note RUG training is valid for a period of two years The implementation of the MDS 3 0 assessment did not impact the expiration date of your RUG training certificate 150 v 2013 1127 LTC Nursing Facility Hospice User Guide Reminders LTC Online Portal has 24 7 availability to submit and track forms and assessments A PL1 must be submitted on all individuals prior to admission into a Nursing Facility Monitor document statuses regularly on the LTC Online Portal Ensure all MDS assessment submissions include an accurate Medicaid ID to assist with eligibility validation A current Admission 3618 or 3619 form must be available on the LTC Online Portal with TMHP to complete the MDS LTCMI Submit a 3618 3619 Admission on the LTC Online Portal prior to completing the LTCMI The LTC Online Portal validates that an active admission is on the LTC Online Portal to allow the provider to complete the MDS LTCMI information o
13. e Access bulletins and banner messages v 2013 1127 n LTC Nursing Facility Hospice User Guide Submit Form The Submit Form feature allows providers to submit forms and PASRR Level 1 PL1 Screenings v TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR Home Submit Form Form Status Inquiry Current Activity Drafts Vendors Printable Forms Alerts Help Submit Form Form Select Type of Form e v vendor Number v Recipient To prepopulate recipient information please provide one of the following combinations of information Medicaid CSHCN ID or Social Security Number AND Last Name or Social Security Number AND Date of Birth or Date of Birth AND Last Name AND First Name Medicaid Number SSN L Date of Birth First Name Last Name error Note Hospice providers will have the 3071 and 3074 form types available for submission 3071 Recipient Election Cancellation Discharge Notice 3074 Physician Certification of Terminal Illness To submit a form or screening 1 Log in to the LTC Online Portal 2 Click the Submit Form link located in the blue navigational bar 3 Type of Form Choose from the drop down box 4 If desired enter additional information about an existing recipient This will auto populate the form or screen ing with the recipients demographical information except gend
14. expired as of day 123 LMHA Local Mental Health Authority LTC Long Term Care v 2013 1127 161 LTC Nursing Facility Hospice User Guide e LTCMI Long Term Care Medicaid Information Is the replacement for the federal MDS Section S and contains items for Medicaid state payment Once your MDS assessments have been transmitted to CMS TMHP will retrieve all assessments that meet the retrieval criteria and assign a DLN The assessment will be set to Awaiting LTC Medicaid Information status e MDS Minimum Data Set e MEPD Medicaid for the Elderly and People with Disabilities e MESAV Medicaid Eligibility Service Authorization Verifications e Missed Assessment Missed assessment is an assessment not submitted within the Anticipated Quarter or within 92 days of the dates that the assessment covers The Anticipated Quarter is defined as the 92 day antici pated MDS assessment quarter following the 92 day span of the current MDS assessment MN Medical Necessity e NPI National Provider Identifier e OES Office of Eligibility Services e OIG HHSC Office of Inspector General PAN Prior Authorization Number e PC Purpose Code e PDF Portable Document Format e PE PASRR Evaluation Level ID PLI PASRR Level 1 Screening e Preadmission Screening and Resident Review PASRR PASRR is a federal mandate that requires the State of Texas to screen all persons suspected of having Mental Illness MI Intellectual Disab
15. Consider all of the symptoms assessed in items E0100 through E1000 0 1 2 3 How does individual s current behavior status care rejection or wandering compare to prior assessment Same Improved Worse N A because no prior assessment MN and LOC 3 0 V 15 9 of 32 Individual Identifier Date Section G Functional Status G0110 Activities of Daily Living ADL Assistance Instructions for Rule of 3 m When an activity occurs three times at any one given level code that level m When an activity occurs three times at multiple levels code the most dependent exceptions are total dependence 4 activity must require full assist every time and activity did not occur 8 activity must not have occurred at all Example three times extensive assistance 3 and three times limited assistance 2 code extensive assistance 3 m When an activity occurs at various levels but not three times at any given level apply the following o When there is a combination of full caregiver performance and extensive assistance code extensive assistance o When there is a combination of full caregiver performance weight bearing assistance and or non weight bearing assistance code limited assistance 2 If none of the above are met code supervision ADL Self Performance 2 ADL Support Provided Code for individual s performance not including setup If the ADL activity Code for most support provided occurred 3 or more
16. G Snacks between meals H Staying up past 8 00 p m I Family or significant other involvement in care discussions J Useofphonein private K Place to lock personal belongings L Reading books newspapers or magazines M Listening to music N Being around animals such as pets O Keeping up with the news P Doing things with groups of people Q Participating in favorite activities R Spending time away from the nursing home S Spending time outdoors T Participating in religious activities or practices Z None of the above MDS 3 0 Nursing Home Comprehensive NC Version 1 11 2 Effective 10 01 2013 Page 14 of 41 Resident Identifier Date SectionG _ Functional Status G0110 Activities of Daily Living ADL Assistance Refer to the ADL flow chart in the RAI manual to facilitate accurate coding Instructions for Rule of 3 m When an activity occurs three times at any one given level code that level m When an activity occurs three times at multiple levels code the most dependent exceptions are total dependence 4 activity must require full assist every time and activity did not occur 8 activity must not have occurred at all Example three times extensive assistance 3 and three times limited assistance 2 code extensive assistance 3 m When an activity occurs at various levels but not three times at
17. If the prior 3618 discharge was Return Not Anticipated validate that Return Not Anticipated was correctly marked on the discharge form If it was not correct the discharge and submit Once the correction to Return Not Anticipated is processed ending the Levels per that discharge the rejected MDS can be resubmitted If the discharge was Return Not Anticipated and the form was marked correctly verify that the MDS Entry Date corresponds to the admission following that discharge If the MDS Entry Date corresponds to an earlier admission submit a modifi cation to the federal CMS database to correct the Entry Date If this MDS was only submitted because a current resident admitted from the hospital as Medicare and a dually coded MDS was being submitted there are three options Inactivate the MDS at the federal CMS database and resubmit it as a dually coded form using an appropriate Medicaid Reason for Assessment typically a Quarterly Annual or SCSA This will allow Medicaid to use the MDS for payment Inactivate the MDS at the federal CMS database and resubmit it as Medicare only no Medicaid Reason for Assessment The resubmitted form will not appear on the LTC Online Portal Contact DADS Provider Claims Services at 512 438 2200 Option 1 and request that the MDS be moved to Invalid Complete status because an admission assessment was not appropriate If neither situation above applies contact DADS Provider Claims Serv
18. Location 130 v 2013 1127 LTC Nursing Facility Hospice User Guide e Recipient Address e Recipient First Name e Recipient Middle Initial e Dates of Qualifying Stay Form 3619 The correctable fields can be changed even if the form has processed into the system For example if a Medicare resident transfers to Medicaid on the fifth of the month and then it is discovered that the transfer was actually on the eighth of the month instead two corrections should be submitted The original Form 3619 discharge and Form 3618 admission must be corrected to the eighth rather than submitting new forms Even if the original forms are processed corrections can be submitted TMHP places the original form in a corrected status and gives the new form a DLN creating a Parent Child DLN relationship If a form contains incorrect information in a field that is not correctable and the form is set to the status Processed Complete a counteracting form will need to be submitted If the form is not set to a Processed Complete status inactivate the form and resubmit with the correct information Please refer to the Counteracting Forms section of this User Guide for additional information Correction to Forms 3618 or 3619 1 Login to the LTC Online Portal 2 Click the Form Status Inquiry link in the blue navigational bar 3 Search for Form 3618 or 3619 using the recipients SSN Medicaid recipient number First and Last Name or DLN 4 Clic
19. enter a dash in each box M0700 Most Severe Tissue Type for Any Pressure Ulcer Select the best description of the most severe type of tissue present in any pressure ulcer bed Enter Code 1 Epithelial tissue new skin growing in superficial ulcer It can be light pink and shiny even in persons with darkly pigmented skin Granulation tissue pink or red tissue with shiny moist granular appearance 2 3 Slough yellow or white tissue that adheres to the ulcer bed in strings or thick clumps or is mucinous 4 Eschar black brown or tan tissue that adheres firmly to the wound bed or ulcer edges may be softer or harder than surrounding skin None of the Above M0800 Worsening in Pressure Ulcer Status Since Prior Assessment OBRA or Scheduled PPS or Last Admission Entry or Reentry Complete only if A0310E 0 Indicate the number of current pressure ulcers that were not present or were at a lesser stage on prior assessment OBRA or scheduled PPS or last entry If no current pressure ulcer at a given stage enter 0 Enter Number E A Stage 2 Enter Number B Stage 3 Enter Number C Stage 4 MDS 3 0 Nursing Home Comprehensive NC Version 1 11 2 Effective 10 01 2013 Page 26 of 41 Resident Identifier Date SectionM _ Skin Conditions M0900 Healed Pressure Ulcers Complete only if A0310E 0 Enter Code Enter Number Enter Number Enter Number A Were pressure ulcers present on the prior ass
20. how resident moves between surfaces including to or from bed chair wheelchair standing position excludes to from bath toilet C Walk in room how resident walks between locations in his her room D Walk in corridor how resident walks in corridor on unit ZH LI EJ ELE EJ EJEILILILI L LI UO ELE EJ EJEILILILI E Locomotion on unit how resident moves between locations in his her room and adjacent corridor on same floor If in wheelchair self sufficiency once in chair F Locomotion off unit how resident moves to and returns from off unit locations e g areas set aside for dining activities or treatments If facility has only one floor how resident moves to and from distant areas on the floor If in wheelchair self sufficiency once in chair G Dressing how resident puts on fastens and takes off all items of clothing including donning removing a prosthesis or TED hose Dressing includes putting on and changing pajamas and housedresses H Eating how resident eats and drinks regardless of skill Do not include eating drinking during medication pass Includes intake of nourishment by other means e g tube feeding total parenteral nutrition IV fluids administered for nutrition or hydration I Toilet use how resident uses the toilet room commode bedpan or urinal transfers on off toilet cleanses self after elimination changes pad manages ostomy or catheter and adjusts clothes Do not include emptying of bedpan
21. to length e cm C Pressure ulcer depth Depth of the same pressure ulcer from the visible surface to the deepest area if depth is e em unknown enter a dash M0700 Most Severe Tissue Type for Any Pressure Ulcer Select the best description of the most severe type of tissue present in any pressure ulcer bed 1 Epithelial tissue new skin growing in superficial ulcer It can be light pink and shiny even in persons with Enter Code darkly pigmented skin L 2 Granulation tissue pink or red tissue with shiny moist granular appearance 3 Slough yellow or white tissue that adheres to the ulcer bed in strings or thick clumps or is mucinous 4 Eschar black brown or tan tissue that adheres firmly to the wound bed or ulcer edges may be softer or harder than surrounding skin 9 None of the Above M1030 Number of Venous and Arterial Ulcers Enter Number Enter the total number of venous and arterial ulcers present M1040 Other Ulcers Wounds and Skin Problems Check all that apply Foot Problems A Infection of the foot e g cellulitis purulent drainage B Diabetic foot ulcer s C Other open lesion s on the foot Other Problems Open lesion s other than ulcers rashes cuts e g cancer lesion Surgical wound s Burn s second or third degree Skin tear s Moisture Associated Skin Damage MASD i e incontinence
22. 1 Yes M0210 Unhealed Pressure Ulcer s Enter Code Does this resident have one or more unhealed pressure ulcer s at Stage 1 or higher 0 No gt Skip to M0900 Healed Pressure Ulcers 1 Yes Continue to M0300 Current Number of Unhealed Pressure Ulcers at Each Stage M0300 Current Number of Unhealed Pressure Ulcers at Each Stage Number of Stage 1 pressure ulcers Stage 1 Intact skin with non blanchable redness of a localized area usually over a bony prominence Darkly pigmented skin may not have a visible blanching in dark skin tones only it may appear with persistent blue or purple hues Enter Number Stage 2 Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed without slough May also present as an intact or open ruptured blister Enter Number 1 Number of Stage 2 pressure ulcers If 0 Skip to M0300C Stage 3 Enter Number Number of these Stage 2 pressure ulcers that were present upon admission entry or reentry enter how many were noted at the time of admission entry or reentry Date of oldest Stage 2 pressure ulcer Enter dashes if date is unknown Month Day Stage 3 Full thickness tissue loss Subcutaneous fat may be visible but bone tendon or muscle is not exposed Slough may be present but does not obscure the depth of tissue loss May include undermining and tunneling Enter Number 1 Number of Stage 3 pressure ulcers If 0 Skip to M0300D Stage
23. 2 Behavior of this type occurred 4 to 6 days but less than daily 3 Behavior of this type occurred daily E1000 Wandering Impact Does the wandering place the resident at significant risk of getting to a potentially dangerous place e 9 stairs outside of the facility 0 No 1 Yes Enter Code Enter Code B Does the wandering significantly intrude on the privacy or activities of others 0 No 1 Yes E1100 Change in Behavior or Other Symptoms Consider all of the symptoms assessed in items E0100 through E1000 How does resident s current behavior status care rejection or wandering compare to prior assessment OBRA or Scheduled PPS 0 Same 1 Improved 2 Worse 3 N A because no prior MDS assessment Enter Code MDS 3 0 Nursing Home Comprehensive NC Version 1 11 2 Effective 10 01 2013 Page 12 of 41 Resident Identifier Date SectionF Preferences for Customary Routine and Activities F0300 Should Interview for Daily and Activity Preferences be Conducted Attempt to interview all residents able to communicate If resident is unable to complete attempt to complete interview with family member or significant other Enter Code 0 No resident is rarely never understood and family significant other not available Skip to and complete F0800 Staff Assessment of Daily and Activity Preferences 1 Yes Continue to F0400 Interview for Daily Preferences F0400 Interview for Daily Preferences S
24. A Ask individual Over the past 5 days has pain made it hard for you to sleep at night 0 No 1 Yes 9 Unable to answer B Ask individual Over the past 5 days have you limited your day to day activities because of pain 0 No 1 Yes 9 Unable to answer J0600 Pain Intensity Administer ONLY ONE of the following pain intensity questions A or B Enter A Numeric Rating Scale 00 10 Ask individual Please rate your worst pain over the last 5 days on a zero to ten scale with zero being no pain and ten as the worst pain you can imagine Show individual 00 10 pain scale Rating Enter two digit response Enter 99 if unable to answer Verbal Descriptor Scale E Ask individual Please rate the intensity of your worst pain over the last 5 days Show individual verbal scale 1 Mild Moderate Code Severe 2 3 4 Very severe horrible 9 Unable to answer MN and LOC 3 0 V 15 16 of 32 Individual Identifier Date Section J Health Conditions J0700 Should the Caregiver Assessment for Pain be Conducted Enter Code No J0400 1 thru 4 Skip to J1100 Shortness of Breath dyspnea Yes J0400 9 Continue to J0800 Indicators of Pain or Possible Pain Caregiver Assessment for Pain J0800 Indicators of Pain or Possible Pain in the last 5 days Check all that apply Non verbal sounds e g crying whining gasping moaning or groaning Vocal complaints
25. A0310F are used by CMS but are not retrieved and loaded onto the LTC Online Portal The 3618 and 3619 are used by the state for Medicaid processing of recipient movement 62 v 2013 1127 LTC Nursing Facility Hospice User Guide If the resident expires on the day the MDS Quarterly is due and there is no level of service for the date of death the MDS Quarterly must be submitted in order to receive payment for the date of death To receive a RUG payment when a resident expires prior to completion of an Admission assessment the Admis sion assessment must be completed and submitted to CMS with the information that is available If CMS cannot calculate a RUG because the Admission assessment is incomplete or has errors CMS will still assign a RUG value of BC1 which is the default rate If the Admission assessment meets medical necessity and the resident has Medicaid eligibility for the days of services payment can be made for the RUG value calculated by CMS Submission and Retrieval of MDS Assessment Providers should use their current method for submission to CMS either through jRAVEN or another third party software package Validate the acceptance of the MDS 3 0 assessment using the validation report process from federal CMS TMHP receives assessments nightly Only assessments that meet the following criteria will be loaded onto the LTC Online Portal e Reason for Assessment Admission assessment A0310A 01 Quarterly rev
26. Admit Provider Message Displayed in History NF 0026 This admission cannot be processed because the client is admitted to Full Medicaid as of the submitted admission date Verify the Medicaid dates and submit the needed 3618s Resubmit the reject ed Medicare Coinsurance admission once the client is discharged from Medicaid NF 0028 This admission cannot be processed because the Qualifying Stay days plus any Full Medicare days already documented add up to more than the 20 days allowed for this Spell of Illness 3619 Admit Admit Mod Suggested Action The recipient has an existing Service Authorization for Full Medicaid e Review the facility s records to determine which discharge is prior to this admission Pull a MESAV and review the Service Authorizations to determine the authorized services If the MDS for the recipient has not processed you will not have services authorized If the recipient has an ongoing Service Authorization with a begin date prior to the rejected admission and the current Service Authorization is for Full Medicaid Code 1 a 3618 discharge must be processed prior to resubmitting the rejected 3619 admission If the recipient has a closed Service Authorization for Code 1 with an end date after the rejected 3619 admission Verify that the 3618 discharge was submitted for the correct date If not correct the discharge If the discharge is now prior to the rejected 3619 admission i
27. After opening a form or assessment scroll to the bottom The History trail will display a list of every processing status that has been held by the document along with any appro priate details Any notes added by the provider or any comments from TMHP or DADS will also be located in the History trail Form 4 7 2013 9 27 48 AM Submitted Individual 4 7 2013 9 27 48 AM Placed in NF Expedited Admission 4 7 2013 TMHP Individual has been admitted to the nursing facility under Expedited Admission Category 6 Respite 9 27 48 AM Very brief and finite stay of up to a fixed number of days to provide respite to in home caregivers to whom the individual with MI or ID is expected to return following the brief NF stay Awaiting PE 4 21 2013 10 00 42 AM 4 21 2013 TMHP PL1 submitted by a Nursing Facility Please contact the nearest local authority to conduct a PASRR 10 00 42 AM Evaluation L H H v 2013 1127 LTC Nursing Facility Hospice User Guide UnLock Form Upon opening the document becomes automatically locked by the viewer and will remain locked for 20 minutes of no activity or until the viewer clicks the UnLock Form button The UnLock Form button will unlock the document so that a different user can make changes If a document is locked others will not be able to make changes or add additional information You may be asked to unlock a document if you are seek
28. B RUG version code TT EET Z0300 Insurance Billing A RUG billing code TTT TTT tty B RUG billing version TT ETT Ty MDS 3 0 Nursing Home Comprehensive NC Version 1 11 2 Effective 10 01 2013 Page 40 of 41 Resident Identifier Date SectionZ Assessment Administration Z0400 Signature of Persons Completing the Assessment or Entry Death Reporting certify that the accompanying information accurately reflects resident assessment information for this resident and that collected or coordinated collection of this information on the dates specified To the best of my knowledge this information was collected in accordance with applicable Medicare and Medicaid requirements understand that this information is used as a basis for ensuring that residents receive appropriate and quality care and as a basis for payment from federal funds further understand that payment of such federal funds and continued participation in the government funded health care programs is conditioned on the accuracy and truthfulness of this information and that may be personally subject to or may subject my organization to substantial criminal civil and or administrative penalties for submitting false information also certify that am authorized to submit this information by this facility on its behalf Date Section Signature Sections Completed Z0500 Signature of RN Assessment Co
29. C Trouble falling or staying asleep or sleeping too much D Feeling tired or having little energy E Poor appetite or overeating F Indicating that s he feels bad about self is a failure or has let self or family down G Trouble concentrating on things such as reading the newspaper or watching television H Moving or speaking so slowly that other people have noticed Or the opposite being so fidgety or restless that s he has been moving around a lot more than usual I States that life isn t worth living wishes for death or attempts to harm self J Being short tempered easily annoyed a 5 in E a N E a fhm a BEA a eee LN L L E E L L LI LI D0600 Total Severity Score Add scores for all frequency responses in Column 2 Symptom Frequency Total score must be between 00 and 30 Enter Score D0650 Safety Notification Complete only if D050011 1 indicating possibility of resident self harm Enter Code Was responsible staff or provider informed that there is a potential for resident self harm 0 No 1 Yes Copyright Pfizer Inc All rights reserved MDS 3 0 Nursing Home Comprehensive NC Version 1 11 2 Effective 10 01 2013 Page 10 of 41 Resident Identifier Date SectionE Behavior E0100 Potential Indicators of Psychosis i Check all that apply A Hallucinations perceptual experiences in the absence of real external sensory stimuli B Delusions misc
30. Contract No Individual Medicaid No N Social Security No Medicare No PASRR Level 1 Screening 124 v 2013 1127 LTC Nursing Facility Hospice User Guide Creating Alerts Nursing Facility users can create alerts to be sent to the Local Authority 1 Click the Alerts link located on the blue navigational bar The Alerts screen displays 2 Click the Create Alert button d TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR Home Submit Form Form Status Inquiry Current Activity Drafts Vendors Printable Forms Alerts Return To Alerts Page Send Alert Greate Alert Vendor Contract No v Alert Subject v PL1 Screening DLN P PE Screening DLN Send Alert To or Facility Name Street Address Please enter one of the following valid field combinations Medicaid Number and Last Name or Medicare Number and Last Name or Social Security Number AND Last Name Last Name Medicaid No Social Security No Medicare No 3 Choose the Alert Subject from the drop down menu Each alert includes a standard message to the recipient See Appendix C in this User Guide for more information Nursing Facility users can create the following alerts Conduct PL1 Screening Conduct PE First Notification Conduct PE Secon
31. Enter Code Note Once open you may begin entering information into the document and save it to your desktop 22 v 2013 1127 LTC Nursing Facility Hospice User Guide 3 Click the Print Icon To print the entire document a b C To print certain pages instead of the entire document a b Printer Choose the appropriate printer name from drop down box Print Range Click the All radio button Click the OK button Printer Choose the appropriate printer name from drop down box Print Range Click the Pages radio button Enter the pages to print Example 1 5 will print all pages 1 through 5 1 3 7 will print only pages 1 3 and 7 This is useful for printing only the LTCMI instead of the entire MDS assessment Click the OK button Name WAUSPRNTOINPRINTSS x Status Ready Comments and Forms Type HP Laseet 5100 PCL 6 Document and Markups x Print Range Preview Composite OA K 5 34 Q Current view O Current page Pages 1 5 Subset an pages in range v C Reverse pages Copies Y Page Scaling Shrink to Printable Area 7 Auto Rotate and Center C Choose Paper Source by PDF page size Print to file Print color as black vst CoD 2013 1127 23 LTC Nursing Facility Hospice User Guide Alerts The Alerts link al
32. Enter the total number of venous and arterial ulcers present M1040 Other Ulcers Wounds and Skin Problems J Check all that apply Foot Problems A Infection of the foot e g cellulitis purulent drainage B Diabetic foot ulcer s C Other open lesion s on the foot Other Problems D Open lesion s other than ulcers rashes cuts e g cancer lesion E Surgical wound s F Burn s second or third degree H Moisture Associated Skin Damage MASD i e incontinence IAD perspiration drainage None of the Above Z None of the above were present M1200 Skin and Ulcer Treatments J Check all that apply A Pressure reducing device for chair B Pressure reducing device for bed C Turning repositioning program D Nutrition or hydration intervention to manage skin problems E Pressure ulcer care F Surgical wound care G Application of nonsurgical dressings with or without topical medications other than to feet H Applications of ointments medications other than to feet l Application of dressings to feet with or without topical medications Z None of the above were provided MDS 3 0 Nursing Home Quarterly NO Version 1 11 2 Effective 10 01 2013 Page 23 of 35 Resident Identifier Date SetionN JjMediations 2 N0300 Injection
33. Indicate response in column 2 Symptom Frequency 1 Symptom Presence 2 Symptom Frequency 1 2 0 No enter 0 in column 2 0 Never or 1 day Symptom Symptom 1 Yes enter 0 3 in column 2 2 6 days several days Presence Frequency 9 Noresponse leave column 2 blank 7 11 days half or more of the days 12 14 days nearly every day Enter Scores in Boxes Little interest or pleasure in doing things Feeling down depressed or hopeless Trouble falling or staying asleep or sleeping too much Feeling tired or having little energy Poor appetite or overeating Feeling bad about yourself or that you are a failure or have let yourself or your family down Trouble concentrating on things such as reading the newspaper or watching television Moving or speaking so slowly that other people could have noticed Or the opposite being so fidgety or restless that you have been moving around a lot more than usual Thoughts that you would be better off dead or of hurting yourself in some way JEJE ILL LOL LL JL LL EIL LOL UL D0300 Total Severity Score The sum of the scores for all frequency responses in Column 2 Symptom Frequency The sum should be a number 00 27 A score of 99 indicates that the individual was unable to complete interview i e Symptom Frequency is blank for 3 or more cmc items D0350 Safety Notification Complete only if D020011 1 indicating po
34. L LLLI D UO MN and LOC 3 0 V 15 10 of 32 Individual Identifier Date Section G Functional Status G0120 Bathing How individual takes full body bath shower sponge bath and transfers in out of tub shower excludes washing of back and hair Code for most dependent in self performance and support Enter Code A Self performance Independent no help provided Supervision oversight help only Physical help limited to transfer only Physical help in part of bathing activity Total dependence Activity itself did not occur during the entire period Enter Code Support provided Bathing support codes are as defined in Item G0110 column 2 ADL Support Provided above G0300 Balance During Transitions and Walking After observing the individual code the following walking and transition items for most dependent Enter Codes in Boxes Coding A Moving from seated to standing position 0 Steady at all times 1 Not steady but able to stabilize B Walking with assistive device if used without human assistance i a 2 Not steady only able to stabilize with C Turning around and facing the opposite direction while walking human assistance D Movi d off toil 8 Activity did not occur _ oving on andor tolet E Surface to surface transfer transfer between bed and chair or wheelchair G0400 Functional Limitation in Range of Motion Code for limitation th
35. LI 0 No 1 Yes EnterCode C Significantly interfere with the resident s participation in activities or social interactions LI 0 No 1 Yes E0600 Impact on Others Did any of the identified symptom s EnterCode A Put others at significant risk for physical injury 0 No 1 Yes Enter Code B Significantly intrude on the privacy or activity of others LI 0 No 1 Yes Enter Code C Significantly disrupt care or living environment LI No Yes E0800 Rejection of Care Presence amp Frequency Did the resident reject evaluation or care e 9 bloodwork taking medications ADL assistance that is necessary to achieve the resident s goals for health and well being Do not include behaviors that have already been addressed e g by discussion or care planning with the resident or family and determined to be consistent with resident values preferences or goals Enter Code 0 Behavior not exhibited LI 1 Behavior of this type occurred 1 to 3 days 2 Behavior of this type occurred 4 to 6 days but less than daily 3 Behavior of this type occurred daily MDS 3 0 Nursing Home Comprehensive NC Version 1 11 2 Effective 10 01 2013 Page 11 of 41 Resident Identifier Date SectionE Behavior E0900 Wandering Presence amp Frequency Enter Code Has the resident wandered 0 Behavior not exhibited Skip to E1100 Change in Behavioral or Other Symptoms 1 Behavior of this type occurred 1 to 3 days
36. May include undermining and tunneling 1 Number of Stage 3 pressure ulcers D Stage 4 Full thickness tissue loss with exposed bone tendon or muscle Slough or eschar may be present on some parts of the wound bed Often includes undermining and tunneling 1 Number of Stage 4 pressure ulcers E Unstageable Non removable dressing Known but not stageable due to non removable dressing device 1 Number of unstageable pressure ulcers due to non removable dressing device F Unstageable Slough and or eschar Known but not stageable due to coverage of wound bed by slough and or eschar 1 Number of unstageable pressure ulcers due to coverage of wound bed by slough and or eschar G Unstageable Deep tissue Suspected deep tissue injury in evolution 1 Number of unstageable pressure ulcers with suspected deep tissue injury in evolution 20 of 32 Individual Identifier Date Section M Skin Conditions M0610 Dimensions of Unhealed Stage 3 or 4 Pressure Ulcers or Eschar Complete only if M0300C1 M0300D1 or M0300F1 is greater than 0 If the individual has one or more unhealed Stage 3 or 4 pressure ulcers or an unstageable pressure ulcer due to slough or eschar identify the pressure ulcer with the largest surface area length x width and record in centimeters A Pressure ulcer length Longest length from head to toe e cm B Pressure ulcer width Widest width of the same pressure ulcer side to side perpendicular 90 degree angle
37. PASARR not found invalid form Pending Applied Income Pending Denial need more information Pending Medicaid Eligibility Pending More Info Pending Review Pending RN License Verification Processed Complete Provider Action Required SAS Request Pending Submitted to manual workflow Waiting for PASARR verification 3 Form Status Choose Awaiting LTC Medicaid Information from the drop down box Entera date range for the period searching for the system default for the search is within the past month however the date range must include the period in which the assessment was submitted Note 1t may take up to 48 hours after submission to CMS before the MDS 3 0 assessment is accessible on the LTC Online Portal for data entry in Awaiting LTC Medicaid Information status 5 Click the Search button and the search results will display 6 Click the View Detail link to display the details of the assessment If You Cannot Locate Your MDS Using FSI or Current Activity After confirming the requested date range be sure to verify all of the following e MDS was accepted not rejected by CMS via your validation report e A valid Medicaid number or was entered in field A0700 e A0700 does not contain an N e A0310A has a response of 01 02 03 04 05 or 06 e A0310A does not contain a 99 v 2013 1127 95 LTC Nursing Facility Hospice User Guide Name on the MDS is exactly the same as the reside
38. Portal Lm LA submits PE NF certifies able RE faxes PL1 to LA LA submits PL1 LA performs PE on Portal or unable to LA coordinates gt P within 72 hours gt within 7 days of gt gt serve individual 9 placement of 72 hour timer on Portal Brass SENS E A starts of notification notification on PL1 in the individual in NF Payment for PE Portal 1 The Preadmission Process starts with the RE who performs the initial PL1 Screening on paper for the individual seeking Nursing Facility placement 2 Ifthe PLI is negative a The RE sends the PL1 to the admitting NF with the individual b The NF admits the individual and submits the PL1 on the LTC Online Portal 3 Ifthe PL1 is positive a The RE faxes the PL1 to the LA this notification starts the 72 hour timer b The LA submits the PL1 on the LTC Online Portal immediately upon receipt c The LA performs a PE within 72 hours of notification by the Referring Entity d The LA submits the PE on the LTC Online Portal within seven calendar days of notification by the Refer ring Entity Authorization for payment to the LA for completion of the PE is setup as a result of successful submission of the PE on the Portal 4 The NF reviews the PE including recommended services and certifies if they are able or unable to serve the individual on the PL1 Section D 5 The LA coordinates placement of the indiv
39. Procedures and Programs 00500 Restorative Nursing Programs Record the number of days each of the following restorative programs was performed for at least 15 minutes a day in the last 7 calendar days enter 0 if none or less than 15 minutes daily Number of Days A Range of motion passive Technique B Range of motion active C Splint or brace assistance Number of Days Training and Skill Practice In D Bed mobility E Transfer G Dressing and or grooming H Eating and or swallowing Amputation prostheses care J Communication B x i x A J Li ee 0 E LE e LE oc LE coe oo Lg oo ee UM B cement 00600 Physician Examinations Enter Days LII Over the last 14 days on how many days did the physician or authorized assistant or practitioner examine the resident 00700 Physician Orders Enter Days LII Over the last 14 days on how many days did the physician or authorized assistant or practitioner change the resident s orders MDS 3 0 Nursing Home Quarterly NO Version 1 11 2 Effective 10 01 2013 Page 28 of 35 Resident Identifier Date P0100 Physical Restraints Physical restraints are any manual method or physical or mechanical device material or equipment attached or adjacent to the resident s body that the individual cannot remove easily which restricts freedom of movement or normal access to one s body J Enter Codes in Boxes Us
40. S1d Hospice Contract Number Conditional This field is required if O0100K Hospice care column 2 While a Resident is checked Enter the Medicaid Hospice provider contract number assigned by DADS Entering the Hospice provider contract number in this field will allow the Hospice provider to view the assessment submitted on their behalf by the NF This number will be validated and must contain a valid Hospice provider number to be accepted onto the LTC Online Portal If not valid the provider will receive an error message stating Hospice Contract Number is invalid 70 v 2013 1127 LTC Nursing Facility Hospice User Guide LTCMI Fields e S1e Purpose Code Optional E Missed Assessment M Coverage Code must be P Providers should verify that the MESAV Coverage Code is P prior to submitting a Purpose Code M This field is not removable once a Purpose Code has been selected and the assessment successfully submitted on the TMHP LTC Online Portal S1f Missed Assessment or Prior Start Date The first date the facility was not paid Conditional This field is required if S1e Purpose Code E or M This would be the first missed assessment date Check MESAV for gaps Enter the date in mm dd yyyy format of the missed assessment start date Start Date cannot be prior to September 1 2008 Field is correctable S1g Missed Assessment or Prior End Date The last date the facility
41. Sic DADS Vendor Site ID Number S S S S 2h Contract Provider Number Service Group 3 CBA 11 PACE 17 CWP 18 MDCP 19 Star 4 Plus HHA License Expiration Date S3 Primary Diagnosis 3a Primary Diagnosis ICD Code S3b Primary Diagnosis ICD Description S4 For DADS use only S4a MN S4b RUG S4c Effective Date S4d_ Expiration Date S4e County S4f DADS RN Signature S4g_ Signature Date MN and LOC 3 0 V 15 S5 Licenses Certification To the best of my knowledge certify to the accuracy and completeness of this information Last Name HHA RN License License State DADS RN Last Name DADS RN License S5g DADS RN License State DADS RN Signature Date DADS RN Signa ture PACE RN Last Name PACE RN License PACE RN License State HMO RN Last Name License HMO RN License State S6 Additional MN Information Tracheostomy Care 1 Less than once a week 2 1 to 6 times a week 3 Once a day 4 Twice a day 5 3 11 times a day 6 Every 2 hours 7 Hourly continuous Ventilator Respirator 1 Less than once a week 2 1to6times a week 3 Once a day 4 Twice a day 5 3 11 times a day 6 6 23 hours 7 24 hour continuous 29 of 32 Individual Identifier Date LTC Medicaid Information S7 Physician s Eva
42. The recipient has a Service Authorization for the same facility processed admission for the same provider covers the submitted admission date Review the recipient s records to find the discharge date between the begin date of the current Service Authorization and this admission form Pull a MESAV to verify the begin date of the most recent Service Authorization Determine through the LTC Online Portal whether that discharge form has been submitted or not Correct the discharge if it was rejected or submit a discharge if it was missing e Resubmit the rejected admission 104 v 2013 1127 LTC Nursing Facility Hospice User Guide Form Assessment 3618 3619 Admit Provider Message Displayed in History NF 0017 This admission cannot be processed because a later admis sion has already been processed This admission occurs in the past and must be one of a pair which will create a separate Service Authorization If the discharge following this admission is missing or rejected both forms must be submitted on the same day NF 0018 This discharge cannot be processed because the client is currently admitted to Medicare Part A Coinsurance and does not have 3618 Discharge a corresponding Nursing Facility admission missing 3618 Verify that the admission 3618 has been processed NF 0019 This discharge cannot be processed because the client is not admitted into your facility If an admission pr
43. Unscheduled assessment used for PPS OMRA significant or clinical change or significant correction assessment 99 None of the above Enter Code Prior Assessment Reference Date A2300 value from prior assessment LLH LI Month Year Enter Score Prior Assessment Brief Interview for Mental Status BIMS Summary Score C0500 value from prior assessment Enter Score Prior Assessment Resident Mood Interview PHQ 9 Total Severity Score D0300 value from prior assessment Enter Score Prior Assessment Staff Assessment of Resident Mood PHQ 9 OV Total Severity Score D0600 value from prior assessment MDS 3 0 Nursing Home Comprehensive NC Version 1 11 2 Effective 10 01 2013 Page 35 of 41 Resident Identifier Date Care Area Assessment CAA Summar V0200 CAAs and Care Planning Check column A if Care Area is triggered For each triggered Care Area indicate whether a new care plan care plan revision or continuation of current care plan is necessary to address the problem s identified in your assessment of the care area The Care Planning Decision column must be completed within 7 days of completing the RAI MDS and CAA s Check column B if the triggered care area is addressed in the care plan Indicate in the Location and Date of CAA Documentation column where information related to the CAA can be found CAA documentation should include information on the complicating factors risks and any referrals
44. or Type Program 11 in the Medicaid section of the MESAV for the dates requested on the LTCMI If the Prior Coverage P or Type Program 11 verified through the resident s MESAV matches the dates requested on the LTCMI resubmit the rejected assessment If the Prior Coverage P or Type Program 11 dates on the recipi ent s MESAV differ from the dates requested on the LTCMI modify the dates on the LTCMI and resubmit the rejected assessment If the resident s MESAV does not reflect Prior Coverage P or Type Program 11 eligibility for the period requested contact the HHSC Eligibility Worker or SSI office If the resident is ineligible change the purpose code to E if a Level record is needed 102 v 2013 1127 LTC Nursing Facility Hospice User Guide Form Assessment Provider Message Displayed in History NF 0004 This assessment cannot be processed because the client does not have a corresponding Nursing Facility admission miss ing 3618 3619 Verify that the admission 3618 3619 has been processed NF 0008 This assessment cannot be processed because an assess ment with the same effective date but different Reason for Assess ment has already been processed Continue to submit assessments based on the client s MDS assess ment schedule MDS Quarterly NF 0010 This assessment cannot be processed because an assess ment with the same effective date has already been processed and is not a Quarterly
45. positions body while in bed or alternate sleep furniture B Transfer how resident moves between surfaces including to or from bed chair wheelchair standing position excludes to from bath toilet C Walk in room how resident walks between locations in his her room D Walk in corridor how resident walks in corridor on unit ZH LI EJ ELE EJ EJEILILILI L LI EJ ELE EJ EJEILILILI E Locomotion on unit how resident moves between locations in his her room and adjacent corridor on same floor If in wheelchair self sufficiency once in chair F Locomotion off unit how resident moves to and returns from off unit locations e g areas set aside for dining activities or treatments If facility has only one floor how resident moves to and from distant areas on the floor If in wheelchair self sufficiency once in chair G Dressing how resident puts on fastens and takes off all items of clothing including donning removing a prosthesis or TED hose Dressing includes putting on and changing pajamas and housedresses H Eating how resident eats and drinks regardless of skill Do not include eating drinking during medication pass Includes intake of nourishment by other means e g tube feeding total parenteral nutrition IV fluids administered for nutrition or hydration I Toilet use how resident uses the toilet room commode bedpan or urinal transfers on off toilet cleanses self after elimination changes pad manages os
46. processed as submitted In order to reduce the total to 80 days the system would have to cancel a processed admission Review the facility s records to determine the recipient s admission and discharge dates and identify the Spell of Illness Pull a MESAV and review the Service Authorizations to determine the number of Coinsurance days on file plus the number of new days that would be added by the rejected form Verify the begin and end dates of the Service Authorizations on file based on the actual admissions and discharges that have occurred Remember that the discharge date results in a Service Authorization end date one day earlier than the transaction date Submit any corrections needed because of incorrect begin or end dates If these corrections will reduce the total number of Coinsurance days to 80 days or less the rejected form should be resubmitted once the new correction forms have processed If the begin and end dates on file are correct and the recipient has a Medicare Replacement policy that allows more than 80 days state this in the comment section of the 3619 and call 512 438 2200 Option 3 or fax the Medicare Replacement EOBs with a copy for the 3619 to 512 438 3400 attention Medicare Advantage Plan If the Spell of Illness involved another facility and your facility s begin and end dates are right except for the correction review your Medicare Remittance If the Medicare Remittance advice validates that Coinsura
47. the Medicaid Eligibility validation was attempted nightly for six months and failed so the request was canceled If the request is canceled it is because the form was corrected or inactivated and the status changes to those statuses not ME Check Inactive If the resident is certified for Medicaid after six months the form or assessment can be reactivated by the provider by clicking on the Reactivate form button 4 Pending Applied Income validation will result in either Applied Income Confirmed the form or assessment will process to SAS Request Pending Pending Applied Income In this status validation attempts will occur nightly until applied income is found the request is canceled or until six months has expired whichever comes first If Applied Income has already been established the provider may contact TMHP to have the form or assessment restarted After Applied Income has been established the provider must allow 14 days for the systems to interface AFTER 14 days the provider may call TMHP to have the form or assessment restarted Note An Applied Income check will be performed for all 3619 forms submitted on the LTC Online Portal AI Check Inactive In this status the Applied Income validation was attempted nightly for six months and failed so the request was canceled gt Ifthe Applied Income is determined after six months the form or assessment can be reactivated by the provider by clicking on
48. 0 esee entere eene ette netten assent aos 88 MDS Purpose Code M ouod bedient or Loc Do ua Dort del Fou Duda dB bs rl dns ELE i ERE DAS 89 What is a Purpose Code M and How Do You Complete a Purpose Code M ease tnr rtre tta ta tnt po rtt ebd rabi ke 90 PC M Start and End Date Limitations MDS 3 0 cc ccccceccccsssscesscesssecesecesseccsascesseceessecessecusesesaeccseessesseeseess 90 Validations Requiring Provider Monitoring 1d aed Le bu Rorate Lea adu Dua ono nd ade bu n bal 91 Provider Workflow BEOEBSS asinina e Eb tanen GOL era Delpb ced brun uod bru e tpp led 94 Finding Forms and Assessments with Provider Action Required Status 1 tiene besote creer ea peel ege 94 Using FS eiiean aE aE AE tv evseeaceaucetaetudes EE A E AE EE ETEA EAR ANES 94 Ine cea ER 99 Provider Wonca Rejection Myles sa eS ouis petextbbe Dvd cepere Epson abel iud EEEE 100 Specife Dnistkuletlofidcu ecu addict emi chi aid ca EEE da cds cibos uiua pi Ra N QU CH God Htm eames LEUR ULT Cd 101 P T M aaed 122 ACCESSINE PUA ecco Betcha checkups ouam dudo bug bua omi bein 122 Creatine ANCES MOT EP T T e 125 Bouteille A n 126 Corrections and UW pd ate T 127 MU ie c eee en EERO PD OR REISE EEE 127 PASRR Level 1 Screening U
49. 11 2 Effective 10 01 2013 Page 7 of 35 Resident Identifier Date Cognitive Patterns C0600 Should the Staff Assessment for Mental Status C0700 C1000 be Conducted Enter Code 0 No resident was able to complete interview Skip to C1300 Signs and Symptoms of Delirium 1 Yes resident was unable to complete interview Continue to C0700 Short term Memory OK Staff Assessment for Mental Status Do not conduct if Brief Interview for Mental Status C0200 C0500 was completed C0700 Short term Memory OK Enter Code Seems or appears to recall after 5 minutes 0 Memory OK 1 Memory problem C0800 Long term Memory OK Enter Code Seems or appears to recall long past 0 Memory OK 1 Memory problem C0900 Memory Recall Ability i Check all that the resident was normally able to recall A Current season B Location of own room C Staff names and faces D Thathe or she is in a nursing home Z None of the above were recalled C1000 Cognitive Skills for Daily Decision Making Made decisions regarding tasks of daily life 0 Independent decisions consistent reasonable 1 Modified independence some difficulty in new situations only 2 Moderately impaired decisions poor cues supervision required 3 Severely impaired never rarely made decisions Enter Code C1300 Signs and Symptoms of Delirium from CAM Code after completing Brief Interview for Mental Status or Staff Assessment and reviewing med
50. 2013 Page 4 of 41 Resident Identifier Date SectionA Identification Information A2200 Previous Assessment Reference Date for Significant Correction Complete only if A0310A 05 or 06 A2300 Assessment Reference Date Observation end date Month Day A2400 Medicare Stay Enter Code A Has the resident had a Medicare covered stay since the most recent entry 0 No gt Skip to B0100 Comatose 1 Yes Continue to A2400B Start date of most recent Medicare stay B Start date of most recent Medicare stay Month Day Year C End date of most recent Medicare stay Enter dashes if stay is ongoing Day Month MDS 3 0 Nursing Home Comprehensive NC Version 1 11 2 Effective 10 01 2013 Page 5 of 41 Resident Identifier Date Look back period for all items is 7 days unless another time frame is indicated Hearing Speech and Vision B0100 Comatose Enter Code Persistent vegetative state no discernible consciousness 0 No Continue to B0200 Hearing 1 Yes Skip to G0110 Activities of Daily Living ADL Assistance B0200 Hearing Ability to hear with hearing aid or hearing appliances if normally used 0 Adequate no difficulty in normal conversation social interaction listening to TV 1 Minimal difficulty difficulty in some environments e g when person speaks softly or setting is noisy 2 Moderate difficulty speaker has to increase volume and speak distinctly 3 Highly i
51. 3 12 14 days nearly every day J Enter Scores in Boxes J Us 2 A Little interest or pleasure in doing things B Feeling or appearing down depressed or hopeless C Trouble falling or staying asleep or sleeping too much D Feeling tired or having little energy E Poor appetite or overeating F Indicating that s he feels bad about self is a failure or has let self or family down G Trouble concentrating on things such as reading the newspaper or watching television H Moving or speaking so slowly that other people have noticed Or the opposite being so fidgety or restless that s he has been moving around a lot more than usual I States that life isn t worth living wishes for death or attempts to harm self J Being short tempered easily annoyed a 5 in E a N E a fhm a BEA a eee LN L L E E L L LI LI D0600 Total Severity Score Add scores for all frequency responses in Column 2 Symptom Frequency Total score must be between 00 and 30 Enter Score D0650 Safety Notification Complete only if D050011 1 indicating possibility of resident self harm Enter Code Was responsible staff or provider informed that there is a potential for resident self harm 0 No 1 Yes Copyright Pfizer Inc All rights reserved MDS 3 0 Nursing Home Quarterly NQ Version 1 11 2 Effective 10 01 2013 Page 10 of 35 Resident Identifier Date SectionE Behavior E0100 Potential In
52. 4 Enter Number 2 Number of these Stage 3 pressure ulcers that were present upon admission entry or reentry enter how many were noted at the time of admission entry or reentry Stage 4 Full thickness tissue loss with exposed bone tendon or muscle Slough or eschar may be present on some parts of the wound bed Often includes undermining and tunneling Enter Number 1 Number of Stage 4 pressure ulcers If 0 Skip to M0300E Unstageable Non removable dressing Enter Number 2 Number of these Stage 4 pressure ulcers that were present upon admission entry or reentry enter how many were noted at the time of admission entry or reentry M0300 continued on next page MDS 3 0 Nursing Home Comprehensive NC Version 1 11 2 Effective 10 01 2013 Page 25 of 41 Resident Identifier Date SectionM Skin Conditions M0300 Current Number of Unhealed Pressure Ulcers at Each Stage Continued E Unstageable Non removable dressing Known but not stageable due to non removable dressing device enter Number 1 Number of unstageable pressure ulcers due to non removable dressing device If 0 Skip to M0300F Unstageable Slough and or eschar Enter Number Number of these unstageable pressure ulcers that were present upon admission entry or reentry enter how many were noted at the time of admission entry or reentry F Unstageable Slough and or eschar Known but not stageable due to coverage of wound bed by slough and
53. 5 Ifthe TMHP nurse determines that MN has been met the assessment is approved 6 Ifthe TMHP nurse still cannot determine any licensed nursing need after additional information has been provided the assessment is sent to the TMHP physician for MN determination 7 Ifthe TMHP physician determines that MN has been met the assessment is approved 8 If MN is denied by the TMHP physician notification of denied MN is sent to the resident in a letter 9 The resident s physician may submit additional information within 14 business days of the date on the denial letter by faxing additional medical information to the TMHP LTC department 40 TAC 19 2407 Or the DON or other licensed nurse within the facility may provide additional information by calling and speaking with a TMHP nurse The individual s assessment and the additional or new medical information will be reviewed by the TMHP nurse and either approved or sent to the TMHP physician for a second MN determina tion The TMHP physician will either approve the assessment or uphold the original decision to deny 10 If the NF or individual s physician does not provide additional information clarifying nursing medical needs within 21 calendar days of Pending Denial need more information the assessment is sent to the TMHP physician for review and the steps 6 10 will apply 11 The resident may initiate the appeal process when notified by TMHP that medical necessity was denied by the
54. 512 231 5800 INF Administrator Programi sesser E E pe EE EEEE 512 231 5800 NE POGI si sce ltteer ek ed ee AEE Kanoodle 512 438 3161 PASRR Unit Policy Questions vesrsrnanrn ain uq eei Mi eti Gode di op ol i iei uec Ui enne bad 855 435 7180 Iur dela ICES e CEEE EREE 512 438 2625 Provider miscet teet lae ta tea oam be rupti uet n deed 512 438 2200 NF and Hospice Client Service authorizations MESAV updates and unable t determine Rate Key issues cites reti buie eode Hx bn lu pecu EEEE E E ERE iesus gelu Option 1 Personal Needs Allowance Payments DIA dassudsnidpsgba i itt pdt ivo DU ror Eeri Option 2 Deductionsand E EC see dcensatacees Option 3 Third Party Recoyery aca ieres bod E Roda deli ei pei up cl Ra n Fo val qn rU Lu iE tui deb nad Option 4 Home Community Services ai enr te i im Lee RE a RR LIRE ERROR ERE EUREN AT ENRE Option 5 TX SI LAT C Option 5 Rehabilit tive and Specialized See Vi CBE usineiros t sepa Und dicas c uc een oni a E Option 6 NF Dental Rehab Services auexkosetasrrotlse n beth tua DR nro UBL RR RE RR E LE UE RUO ERU U OE Option 6 Health and Human Services HHSC HHSC Ombudsman Office Medicaid Benefits esses eee eene 1 877 787 8999 Medicaid Erauds anie techstusta teet e d tene eed vane dieci duc diee tur e RS 1 800 436 6184 Rate Analysis docete ei EO ER er R EEA ERAT Hi eerta et rr PRAE e 512 491 1376 Resource Utilizatio
55. 7 00 a m 7 00 p m Central Time excluding holidays Conduct training sessions for providers which includes technical assistance on the TexMedConnect online application Texas State Legislature The state legislature allocates budgetary dollars for Texas Medicaid v 2013 1127 LTC Nursing Facility Hospice User Guide National Provider Identifier NPI Atypical Provider Identifier API Requirements The Health Insurance Portability and Accountability Act HIPAA established the National Provider Identifier NPI as the 10 digit standard unique identifier for health care providers and requires covered health care providers clearinghouses and health plans to use this identifier in HIPAA covered transactions NPI is required on all claims submitted electronically through third party software or through TexMedConnect On the LTC Online Portal NPI is used for security purposes and links providers to their assessments so that only those associated with that NPI are viewable Without an NPI providers would not be able to locate their assess ments on the LTC Online Portal Note DADS Medically Dependant Children Program MDCP nurses are not required to apply for an NPI They enter an Atypical Provider Identifier API which is assigned by the appropriate region To view a map of the DADS Commu nity Services regions go to www dads state tx us contact regional facility To obtain an NPI go to https nppes cms hhs gov
56. 80 days of cessed as submitted Medicare Part A Coinsurance for e Review the facility s records to determine the recipient s this Spell of Illness Confirm the 80 admission and discharge dates and identify the Spell of Illness days of Coinsurance and submit Pull a MESAV and review the Service Authorizations to determine any additional modifications the number of Coinsurance days on file plus the number of new days that would be added by the rejected earlier admission date Verify the begin and end dates of the Service Authorizations on file based on the actual admissions and discharges that have occurred Remember that the discharge date results in a Service Authorization end date one day earlier than the transaction date Submit any corrections needed because of incorrect begin or end dates If these corrections will reduce the total number of Coinsur ance days to 80 days or less the rejected admission should be resubmitted once the new correction forms have processed If the begin and end dates on file are correct and the recipient has a Medicare Replacement policy that allows more than 80 days of Coinsurance state this in the comment section of the 3619 and call 512 438 2200 Option 3 or fax the Medicare Replace ment EOBs with a copy for the 3619 to 512 438 3400 attention Medicare Advantage Plan If the Spell of Illness involved another facility and your facility s begin and end dates are right except for the correction review your
57. Account and actifate an existing Texas Medicaid or CSHCN Services Program provider vendor account for online use click New Username and Activate Existing Provider pxas e If you do have a TMHP User Account choose one of the following options o To make changes to an existing enrollment application for Texas Medicaid or the CSHCN Services Program click Open Existing Enrollment o To activate an existing Texas Medicaid or CSHCN Services Program Provider Vendor account under your existing TMHP User Account click Existing Username and Activate Existing Provider If you are not a Texas Medicaid Provider Vendor or you would like to return to the previous page click here Return to TMHP com If you have difficulty with the account activation process contact the TMHP EDI Helpdesk at 1 888 863 3638 between the business hours of 7 00 am to 7 00 pm CST 7 The following page will appear Follow the instructions listed at the top of the page and click the Create a Provider Vendor Administrator Account link at the bottom of the page IMHP amp S TMHP com Account Activation Home TMHP com My amp ccou What happens when I activate a Provider Vendor Account 1 A TMHP User Account is created 2 A Texas Medicaid or CSHCN Services Program Provider Vendor Account is activated for online use 3 The TMHP User Account is given administrative rights to the Provider Vendor Account What is a TMH
58. Address Required if individual caregiver has reported having a legally authorized representative S12a LAR First Name S12b LAR Last Name S12c Address S12d City 512e State S12f ZIP Code S12g Phone MN and LOC 3 0 V 15 32 of 32
59. Blood Sugar Range LLL LLL Hyponatremia Hyperkalemia Hyperlipidemia e g hypercholesterolemia Thyroid Disorder e g hypothyroidism hyperthyroidism and Hashimoto s thyroiditis MN and LOC 3 0 V 15 13 of 32 Individual Identifier Date Section Active Diagnoses Active Diagnoses in the last 7 days Check all that apply Diagnoses listed in parentheses are provided as examples and should not be considered as all inclusive lists Musculoskeletal 13700 Arthritis e g degenerative joint disease DJD osteoarthritis and rheumatoid arthritis RA 13800 Osteoporosis 13900 Hip Fracture any hip fracture that has a relationship to current status treatments monitoring e g sub capital fractures and fractures of the trochanter and femoral neck 13999 Contractures 14000 Other Fracture 14099 Scoliosis Neurological Alzheimer s Disease OOO OO Aphasia Cerebral Palsy Cerebrovascular Accident CVA Transient Ischemic Attack TIA or Stroke Non Alzheimer s Dementia e g Lewy body dementia vascular or multi infarct dementia mixed dementia frontotemporal dementia such as Pick s disease and dementia related to stroke Parkinson s or Creutzfeldt Jakob diseases Hemiplegia or Hemiparesis Paraplegia Quadriplegia Tremors Multiple Sclerosis MS Huntington s Disease Muscular Dystrophy Parkinson s Disease Tourette s Syndrome Hydrocephalus OOOUOOOOOOOUO CIDIETEIL Seizure Disorder o
60. Complete status for client A provider A transaction date 10 1 08 3618 admit exists in Processed Complete status for client A provider A transaction date 10 21 08 3618 admit submitted for client A provider B transaction date 10 1 08 Submit not allowed because date already in Processed Complete for another provider Same contract A discharge has already been received for the Date of Above Transaction OR Different contract A discharge from another provider has already been received for the Date of Above Transaction Rejection of New Discharge for Same Date of Above Transaction New discharge has same Date of Above Transaction as a discharge already received i e 11 1 2008 discharge 11 1 2008 discharge Same contract Possibly attempting to submit a duplicate form OR Different contract A different provider has previously submitted a discharge for the same Date of Above Transaction date One provider is in error Contact other provider Date of Above Transaction is over one year old do you want to continue When submitting a form that is between one and five years old providers will receive this warning message The provider will have an option to select OK or Cancel before the form will continue to process If a provider submits a Date of Above Transaction that is equal to or more than five years old the form will not be accepted onto the LTC Online Portal Additionally
61. Enter Code A Individual participated in assessment L 0 No 1 Yes Enter Code B Family or significant other participated in assessment L 0 No 1 Yes 9 Nofamily or significant other available Enter Code C Guardian or legally authorized representative participated in assessment L 0 No 1 Yes 9 No guardian or legally authorized representative available Q0300 Individual s Overall Expectation Complete only if A0310A 01 Enter Code A Select one for individual s overall goal established during assessment process L 1 Expects to be discharged to the home i e currently in ALF 2 Expects to remain in the home 3 Expects to be transferred to a facility institution 9 Unknown or uncertain Enter Code B Indicate information source for Q0300A L 1 Individual 2 If not individual then family or significant other 3 If not individual family or significant other then guardian or legally authorized representative 9 Unknown or uncertain MN and LOC 3 0 V 15 27 of 32 Individual Identifier Date Sa euF Assessment Administration Z0500 Signature of RN Completing Assessment A Signature B Date Assessment Completed TETE rn MN and LOC 3 0 V 15 28 of 32 Individual Identifier Date LTC Medicaid Information S1 Medicaid Information S1a Medicaid Client Indicator 1 Medicaid a S2 Claims Processing Information Sib Individual Address
62. First Name city 3 Medicare or RR Retirement Claim No 1 Recipient Middle Initial 1 State mum v Recipient Name Suffix ZIP Transaction Information Service Group v Transaction v Location i Date of Above Transaction ial Dates Of Qualifying Stay Enter an explanation in the Comments section if less than 20 days of Qualifying Stay are entered on this form If additional sets of dates are needed a second Form 3619 must be completed using the same Date of Above Transaction in order to supply the additional set s of dates o Stay 1 From iba Stay 1 To e Stay 2 From sty2To Administrator Information I certify that to the best of my knowledge the date in Item 11 Date of Above Transaction is for services provided and the date is not included in the 10096 Medicare Part A reimbursement time frame Administrator State Board License No Administrator Last Name Administrator First Name Is Administrator Signature on Form v Date Signed iia Submit Form Submit Form 3619 for e Medicare Co insurance Admission e Medicare Co insurance Discharge Form 3619 Discharge is needed if the Co insurance is no longer due to the NF e g the recipient discharged from the NE Medicare benefits are exhausted or denied or the recipient is deceased In addition type the following information in th
63. Guide Form Actions Use as template Update Form Add Note Add Note The Add Note feature is available for PL1 PE MDS assessments and Forms 3071 3074 3618 and 3619 Add Note located in the yellow Form Actions bar may be used to add additional information not captured at original submission and is not used in system processing Information is added to the History trail of the document not to the document itself e g not added to Comments in the LTCMI section of the assessment If the status is set to Pending Denial need more information and a note is added the document is set to status Pending Review and the additional information will be reviewed by a TMHP nurse To add a note to a submitted document 1 Locate the submission using FSI or Current Activity 2 Click the Add Note button a text box will open Form Actions Use as template Update Form Add Note 3 Enter additional information up to 500 characters PASRR LEVEL 1 SCREENING Current Status Awaiting PE Name DLN Form Actions Use as template Update Form Add Note Section B Section c Section D Section E Section F 4 Click the Save button to save your note or Cancel button to erase your note located under the text box Note If unsure why an assessment or screening is set to status Pending Denial need more information call the TMHP Help Desk 1 800 626 4117 Option 2 to speak wit
64. Individual Identifier Date Yale Health Conditions J1700 Fall History Enter A Did the individual have a fall any time in the last month 0 No 1 Yes 9 Unable to determine Bid the individual have a fall any time in the last 2 6 months L 0 No 1 Yes 9 Unable to determine Did the individual have any fracture related to a fall in the last 6 months 0 No 1 Yes 9 Unable to determine 41900 Number of Falls in the last 6 months with or without injury Complete only if J1700A or J1700B 1 Enter Codes in Boxes A No injury no evidence of any pain injury or change in the individual s behavior after the fall as reported by the individual caregiver Coding 0 None B Injury except major skin tears abrasions lacerations superficial bruises hematomas and sprains or 1 One any fall related injury that causes the individual to complain of pain 2 Two or more C Major injury bone fractures joint dislocations closed head injuries with altered consciousness subdural hematoma K0100 Swallowing Disorder Signs and symptoms of possible swallowing disorder Check all that apply A Loss of liquids solids from mouth when eating or drinking B Holding food in mouth cheeks or residual food in mouth after meals Coughing or choking during meals or when swallowing medications Complaints of difficulty or pain with swallowing None of the above
65. Medicare Part A Coinsurance for your facility Either the 3619 admission for your facility has not processed or the discharge date exceeds the client s maximum of 80 days of traditional Coinsurance for all providers for this Spell of Illness NF 0033 This discharge cannot be processed because a later discharge has already been processed If an admission after this discharge is missing resubmit with the submis sion of the matching admission 3619 Discharge NF 0044 This form cannot be processed because the other half of the pair of forms failed to process Validate and submit both forms 3618 3619 Pair Suggested Action The corresponding Medicare Part A Coinsurance admission has not processed on the recipient s file Review the facility records to identify the Coinsurance admission date prior to this discharge and the Spell of Illness for this discharge Pull a MESAV and review the Service Authorizations to determine if the 3619 admission has processed and if the Spell of Illness has been authorized If Coinsurance is not authorized use the LTC Online Portal to determine the status of the 3619 admission If the 3619 admission was rejected correct the 3619 admission and resubmit If the 3619 admission was never entered submit the missing 3619 admission If Coinsurance is authorized compare the end date of the Service Authorization to the transaction date of the rejected discharge If the transaction
66. Medicare Remittance If the Medicare Remittance advice validates that Coinsurance is due for the time period that your 36195 indicate fax them with a copy of the 3619s to 512 438 3400 attention ECF Form Processing or call 512 438 2200 Option 3 If all the begin and end dates on the MESAV are correct except for the admission the rejected form is attempting to correct the last discharge date will need to be adjusted so the total of the new days added plus the adjusted existing dates equal 80 or less days The rejected admission should then be resubmitted 114 v 2013 1127 LTC Nursing Facility Hospice User Guide Provider Message Form Displayed in History Assessment NF 0056 This modification cannot 3619 Mod be processed because the cor responding adjustment based on the 80 day limit would cancel a later admission that has already been processed Verify the Service Authorizations already established and submit any additional modifi cations NF 0057 This discharge modifica tion cannot be processed because Mod the new discharge date would can cel the Medicare Part A Coinsurance record being modified If the new discharge date is incorrect modify and resubmit 3619 Discharge Suggested Action For each Medicare Spell of Illness the state will pay a maximum of 80 days of Medicare Part A Coinsurance to one or more provid ers The recipient will exceed the 80 day limit if this correction is
67. NPPES It is important the NPI or API be included in MN LOC Assessment submissions field S2d NPI or API is required on claims and assessment submissions using the following methods e LTC Online Portal e TexMedConnect e Third party software vendor v 2013 1127 3 LTC Nursing Facility Hospice User Guide The LIC Online Portal Providers must use the LTC Online Portal to submit forms screenings evaluations and the LTCMI section of the MDS Assessment with the exception of the 3071 3074 Hospice forms They may be mailed to Texas Medicaid amp Healthcare Partnership LTC Unit PO Box 200765 Austin TX 78720 0765 Benefits of Using the LTC Online Portal e Web based application e 24 7 system availability e TMHP provides LTC Online Portal technical support by telephone at 1 800 626 4117 Option 3 from 7 00 a m 7 00 p m Central Time Monday through Friday excluding holidays Edits are in place to verify the validity of data entered e Provides error messages that must be resolved before submission e Providers have the ability to monitor the status of forms assessments screenings and evaluations by using Form Status Inquiry FSI or Current Activity e Allows providers to submit additional information LTC Online Portal Security In order to use the LTC Online Portal providers must request access to the LTC Online Portal Your facility may already have an account You may need to contact your facility
68. Nursing Facility Hospice User Guide My Account My Account is used to perform various maintenance activities for your account such as setting up user accounts changing passwords and other administrative tasks To access My Account 1 Go to www tmhp com 2 Click providers in the green bar located at the top of the screen TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR clients providers y wf i PUN A TMHP Home Welcome to Texas Medicaid amp Healthcare Partnership Click here to find out how you can What is TMH Thank you for visiting the Texas Medicaid amp Healthcare Partnership s TMHP Internet website for Texas Medicaid and other state health care programs As of January 1 2004 ACS State Healthcare LLC under contract with the Texas Health and Human Services Commission HHSC assumed administration of claims processing for Texas Medicaid and TM i P other state health care programs ACS a XEROX company meets its new consolidated health care Looking fora TEXAS MEDICAID responsibilities with a tearn of subcontractors under the name Privacy HIPAA and related Reporting Fraud programs Provider Lookup 3 Click the Log in to My Account button in the blue bar located at the top right hand side of the screen Note You may be prompted to enter your LTC Online Portal User ID and password va TEXAS MEDICAID
69. PM Pending Review free M 10 8 2010 9 02 02 AM Processed Complete mue 10 9 201098 42 44 AM Overturned Doctor Review v 2013 1127 m LTC Nursing Facility Hospice User Guide 4 Click the DLN link to display the details of the document Providers are able to sort the Current Activity results in a variety of ways By clicking on the heading of a column the provider can choose to sort results by DLN Received Date SSN Medicaid Number Medicare Number Name or Status When the provider clicks on a column heading for the first time it is sorted in ascending order By clicking on the column heading a second time the sort will change to descending order Sorting will apply only within the form or assessment type where the header being clicked is located MDS 3 0 and MDSQTR 3 0 are separate groups and column headings Drafts v a TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR Home Submit Form Form Status Inquiry Current Activity Drafts Vendors Printable Forms Alerts Help The Drafts feature allows access to all drafts saved under the vendor contract number to which the user is linked To access a saved draft 1 Click the Drafts link in the blue navigational bar 2 Click the appropriate vendor number hyperlink under Vendor Numbers A list of drafts saved for the selected vendor contract number will display TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CO
70. Pending Denial Review Answer the following questions 1 What are the two ways that a provider can get additional information to the TMHP RN when Medical Neces sity is pending denial 1 2 2 Ifthe TMHP RN is unable to determine a reason for medical necessity or the assessment is set to status Pending Denial need more information how many days will it remain in this status 3 What happens to the assessment if additional information is not provided within 21 calendar days of being set to status Pending Denial need more information v 2013 1127 179 LTC Nursing Facility Hospice User Guide Review Answers 1 What are the two ways that a provider can get additional information to the TMHP RN when Medical Neces sity is pending denial 1 Calling and speaking with a TMHP nurse 2 Adding information through the Add Note feature 2 Ifthe TMHP RN is unable to determine a reason for medical necessity or the assessment is set to status Pending Denial need more information how many days will it remain in this status For up to 21 calendar days or the TMHP RN has been notified whichever is sooner 3 What happens to the assessment if additional information is not provided within 21 calendar days of being set to status Pending Denial need more information It is sent to the TMHP physician for review LTC Nursing Facility Hospice User Guide Appendix G LTC Jumble Long Term Care Nursing Facil
71. Procedures and Programs 00500 Restorative Nursing Programs Record the number of days each of the following restorative programs was performed for at least 15 minutes a day in the last 7 calendar days enter 0 if none or less than 15 minutes daily Number of Days A Range of motion passive Technique B Range of motion active C Splint or brace assistance Number of Days Training and Skill Practice In D Bed mobility E Transfer G Dressing and or grooming H Eating and or swallowing Amputation prostheses care J Communication B x i x A J Li ee 0 E LE e LE oc LE coe oo Lg oo ee UM B cement 00600 Physician Examinations Enter Days LII Over the last 14 days on how many days did the physician or authorized assistant or practitioner examine the resident 00700 Physician Orders Enter Days LII Over the last 14 days on how many days did the physician or authorized assistant or practitioner change the resident s orders MDS 3 0 Nursing Home Comprehensive NC Version 1 11 2 Effective 10 01 2013 Page 32 of 41 Resident Identifier Date P0100 Physical Restraints Physical restraints are any manual method or physical or mechanical device material or equipment attached or adjacent to the resident s body that the individual cannot remove easily which restricts freedom of movement or normal access to one s body J Enter Codes in Boxes
72. Provider Monitoring Documents process through several validations before reaching status SAS Request Pending The following will outline the various statuses which require close monitoring by the provider to ensure timely processing 1 Awaiting PE results in an alert being sent by the LTC Online Portal to the LA notifying the LA to complete the PE Until the LA submits the PE an NF cannot certify Able to Serve Individual or Unable to Serve Individual If the PE is successfully submitted it continues to the next validation Pending Placement in NF PE Confirmed An NF should view the PL1 and PE and certify Able to Serve Individual or Unable to Serve The admitting NF should also enter the Admitted To date on the PL1 2 Medicaid ID Pending validation results in either ID Confirmed If confirmed it continues to next validation Medicaid ID Pending In this status validation attempts will occur nightly until eligibility is found the request is canceled or until six months has expired whichever comes first ID Invalid If the form or assessment is in this status the provider must verify Medicaid number SSN Medicare number and the first four letters of the last name for accuracy They must match what is on the residents Medicaid card if they have one However the last name cannot contain spaces or special charac ters e g hyphen If this information is accurate the provider may contact TMHP to have th
73. Review Assessment Continue to submit assessments based on the client s MDS assess ment schedule MDS Signifi cant Correction to a Prior Quarterly NF 0011 This admission cannot be processed because you have reached the limit of Swing Bed days for this client for a 12 month period Submit an admission if the client becomes eligible to receive additional Swing Bed services 3618 Admit Suggested Action There is no 3618 3619 admission for the resident that covers one or more days of the assessment period If the resident is a Hospice resi dent a Hospice provider number should be entered on the LTCMI Review the facility s records to determine whether the resident is considered Medicare or Medicaid and what is the admission date to your facility Review the LTC Online Portal to determine the status of the admission 3618 3619 If the 3618 3619 is not processed determine why the form rejected Correct the current 3618 3619 admission or inactivate the rejected form and submit a new 3618 3619 admission If the 3618 3619 is processed compare the processed date to the rejection date of the MDS If the admission was processed after the MDS rejected resubmit the rejected MDS If a 3618 3619 admission has not been submitted because the resident is Hospice review the LTCMI to verify that a Hospice contract number has been entered If not modify the LTCMI on the LTC Online Portal to include the Hospice contract number If th
74. Save BE GV m O X 29 Populate Le MI daos rust ient EEEE l EEE Qe dilate ned dice Uoc bus acd A E on E Clio Eli oL plu De d GER 30 Oiher Basie Infotmatioi o iine eii ee e Ge e reru Er eae e ed iU E RUE e e EE Eee MEE er bodega 31 v 2013 1127 i LTC Nursing Facility Hospice User Guide Required M 31 lta M RE 31 Pe diam T UU LL UR 32 lusodS LII M 33 Entering Dates C assy setesns austia ss udtessn uctlusangvaesveceyeey vccecnsy NEEN 33 ior EE 34 iB 34 Preadmission Screening and Resident Review PASRR eese 35 Overview of PASRR DrOGSSSBE fi enact o dr SR wae ica Nob Dodo Es EEEE 35 Admission Process for Exempted Hospital Discharge rst tenus ee interi kos ac Eo a pen ennemi Fund 36 Expedited Admission Process Bios ccsascucccnaies Sewarentar netaa aKa EAE EEEE easiness untied iva oue ddp Uu Debut lu 37 Pre adinissiob PrOCESS 226r eno eenaa EEE Ee EEE OEE E EE EE ET AEN EEEE EA 39 Alternate Placement Processies imnari ne a A E E T ss eo ea ee 40 Resident Review Process M TT 41 Howto Vettori PASRR Level T Sete rata one iese arere EEE epe e pani E pelos du 42 How t Submit PASRR Level T S
75. Stage 4 pressure ulcers that were present upon admission entry or reentry enter how many were noted at the time of admission entry or reentry M0300 continued on next page MDS 3 0 Nursing Home Quarterly NO Version 1 11 2 Effective 10 01 2013 Page 21 of 35 Resident Identifier Date SectionM Skin Conditions M0300 Current Number of Unhealed Pressure Ulcers at Each Stage Continued E Unstageable Non removable dressing Known but not stageable due to non removable dressing device enter Number 1 Number of unstageable pressure ulcers due to non removable dressing device If 0 Skip to M0300F Unstageable Slough and or eschar Enter Number Number of these unstageable pressure ulcers that were present upon admission entry or reentry enter how many were noted at the time of admission entry or reentry F Unstageable Slough and or eschar Known but not stageable due to coverage of wound bed by slough and or eschar EntenNumpen 1 Number of unstageable pressure ulcers due to coverage of wound bed by slough and or eschar If 0 Skip to M0300G Unstageable Deep tissue Enter Number L Number of these unstageable pressure ulcers that were present upon admission entry or reentry enter how many were noted at the time of admission entry or reentry G Unstageable Deep tissue Suspected deep tissue injury in evolution enter Number 1 Number of unstageable pressure ulcers with suspected deep tissue
76. TMHP physician If a hearing is requested additional information may be submitted at any time by the Nursing Facility or by the individual s physician either via telephone call to the TMHP nurses or via fax Note The submitter is responsible for checking the status of their submitted forms assessments screenings and evaluations using FSI or Current Activity and supplying additional information if needed Upcoming Changes to the MN Determination Process for PASRR Individuals During the first release of PASRR the MDS assessment will continue to be the assessment used for MN Determina tion of a PASRR Positive individual during the Preadmission process see the Overview of PASRR Preadmission Process With full PASRR Implementation the PE will be used for MN Determination of a PASRR Positive individual during the Preadmission process Request for Fair Hearing A fair hearing is an informal orderly and readily available proceeding held before an impartial health and human services enterprise hearing officer At the hearing a individual applicant appellant or their representa tive including legal counsel may present the case as they wish to show that any action inaction or agency policy affecting the case should be reviewed The individual the individual s responsible party or in the case of no responsible party the LA DON or the NF administrator may request a fair hearing on behalf of the individual within 90 days from the e
77. Used in Bed A Bed rail B Trunk restraint C Limb restraint Coding 0 Not used 1 Used less than daily 2 Used daily Used in Chair or Out of Bed E Trunk restraint F Limb restraint G Chair prevents rising EEEE HEE SectionQ Participation in Assessment and Goal Setting Q0100 Participation in Assessment Enter Code A Resident participated in assessment 0 No 1 Yes B Family or significant other participated in assessment Enter Code 0 No 1 Yes 9 Resident has no family or significant other C Guardian or legally authorized representative participated in assessment Enter Code 0 No 1 Yes 9 Resident has no guardian or legally authorized representative Q0300 Resident s Overall Expectation Complete only if A0310E 1 A Select one for resident s overall goal established during assessment process Expects to be discharged to the community Expects to remain in this facility Expects to be discharged to another facility institution Unknown or uncertain Enter Code B Indicate information source for Q0300A 1 Resident 2 If not resident then family or significant other 3 If not resident family or significant other then guardian or legally authorized representative 9 Unknown or uncertain Q0400 Discharge Plan Enter Code Enter Code A Is active discharge planning already occurring for the resident to return to the community 0 No 1 Yes Skip to Q0600 Referral MDS 3 0 Nu
78. active diagnoses Enter diagnosis description and ICD code MN and LOC 3 0 V 15 15 of 32 Individual Identifier Date Yale mm Health Conditions J0100 Pain Management Complete for the individual regardless of current pain level At any time in the last 5 days has the individual Enter A Received scheduled pain medication regimen 0 No Code 1 Yes Enter Received PRN pain medications OR was offered and declined 0 No Code 1 Yes Enter Received non medication intervention for pain 0 No Code 1 Yes J0200 Should Pain Assessment Interview be Conducted Attempt to conduct interview with the individual If individual is comatose skip to J1100 Shortness of Breath dyspnea 0 No individual is rarely never understood OR individual is less than 3 years of age Skip to J0800 Indicators of Pain or Possible Pain 1 Yes Continue to J0300 Pain Presence Pain Assessment Interview J0300 Pain Presence Enter Ask individual Have you had pain or hurting at any time in the last 5 days 0 No 5 Skip to J1100 Shortness of Breath 1 Yes Continue to J0400 Pain Frequency 9 Unable to answer Skip to J0800 Indicators of Pain or Possible Pain Code Pain Frequency Ask individual How much of the time have you experienced pain or hurting over the last 5 days 1 Almost constantly 2 Frequently 3 Occasionally 4 Rarely 9 Unable to answer Pain Effect on Function
79. admission Scenarios 3618 admit exists in Processed Complete status for client A provider A transaction date 10 20 08 3618 admit submitted for client A provider A transaction date 10 21 08 Submission is not allowed without a prior discharge 3618 admit exists in Corrected status for client A provider A transaction date 10 20 08 3618 admit submitted for client A provider A transaction date 10 21 08 Submit allowed Previous admit in corrected status so not considered 3618 admit exists in ME Check Inactive status for client A provider A transaction date 10 20 08 3618 admit submitted for client A provider A transaction date 10 21 08 Submit allowed Previous admit in ME Check Inactive status so not considered 3618 discharge exists in Processed Complete status for client A provider A transaction date 10 19 08 3618 admit exists in Processed Complete status for client A provider A transaction date 10 19 08 3618 admit submitted for client A provider A transaction date 10 21 08 Submission is allowed because of multiple matching date of above transaction on prior form 140 v 2013 1127 LTC Nursing Facility Hospice User Guide Edit Description System Message displayed at time of submission System Message Clarification System Message Resolution assistance for resolving error Last form submitted was a discharge Please supply admission form pri
80. amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR All Sites v P Advanced Search Log In 4 The My Account page will appear Welcome to My Account This section allows a user to perform various maintenance activities for their TMHP account amp ft TMHP com i ACCOUI Click the appropriate link for access to the maintenance options My Account LTC Online Portal Submit Form Inquire about a form status Manage Provider Accounts Administer a Provider Identifier Become a Provider Administrator for a Provider Identifier authorization required Administer a Provider Enrollment Transaction Open the provider enrollment application Account Settings My Profile Modify your profile information 10 v 2013 1127 LTC Nursing Facility Hospice User Guide Log In to the LTC Online Portal 1 Go to www tmhp com 2 Click providers in the green bar located at the top of the screen ix TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR clients providers H PTVNY A S TMHP Home Welcome to Texas Medicaid amp Healthcare Partnership m Jt ick here to find What is TMHP out how you can become a provider for Texas Medicaid and related programs Thank you for visiting the Texas Medicaid amp Healthcare Partnership s TMHP Internet website for Texas Medicaid and other stat
81. anata br E once eden 11 LIC Online Portal B sics neret ne ecd i po eus ee Fh ee Ae p de tesa cer en da sed ode daca 13 Bl e Navigational Bar LInlSunudenosuini cinere tu OM LE bd PE lex Leader uM M tipa Kin t e Dn E CN RUNE eta nsu E a 13 glo e 13 Submit Foti cuni Den rxartuotetin ibd dme i bre EET a orbe i a i Rr ee E oo EU o iets 14 Form Status Inguiry EST wt 16 GurtentAGUVI arseen en eE Gs EEA EEEE EAEEREN E RAEE EE E EERS 19 Drafts ssis e Debet ERE E E EE EE E E EE E EEEE 20 Printable Forms nato retenti re ROI tb bene de vert ede 21 LR 24 lo RN HI Metre EA 25 Yellow Fortin Actions Bat uestis estes eerie bete td entre tegeret utei tempe aset sse vede dd eoe edente pee reste event 25 jc P PER 26 TU oir c 26 Correct this fOr aom tti Uer eed eost three dates Wh nd unen E E Ee mer eer deer ia Per He D HERE tg nd 27 Update Forni MT aw EE EEEE TEER RR E 28 Add Noteer ineeie aeaa ein edi i n eR d E re dre eine Pia pu Ea e ER ian EN eE 28 Inactivate FOC sido pretii ir I S erae Eee EUER COE Ras eR seen d RE RUE EUR SU ALTUS EE NE send FER UE E EEE 28 Form Actions Available When Assessment is Set to Status Awaiting LTC Medicaid Information 29
82. authorization for nonemergency ambulance transport Understand Resource Utilization Group RUG training requirements Recognize how to prevent Medicaid waste abuse and fraud Understand Health Insurance Portability and Accountability Act HIPAA guidelines and provider responsibilities Identify additional resources v 2013 1127 1 LTC Nursing Facility Hospice User Guide Medicaid Team The following groups and individuals make up the Medicaid Team Together they make it possible to deliver Medicaid services to Texans Centers for Medicare amp Medicaid Services CMS The agency in the Department of Health and Human Services that is responsible for federal administration of the Medicare Medicaid and State Children s Health Insurance Program CHIP Individuals A person enrolled in a program Individuals are those served by Texas Medicaid Managed Care Organization MCO State contracted entity that has been given delegated authority to provide acute and long term services to support enrolled managed care members Program Provider An entity that provides services under a contract with the Department of Aging and Dis ability Services DADS Program provider is the preferred term for provider agency Program providers are the crucial players in a quality health care program The focus is on providing the best care possible while being reimbursed for allowed services rendered Texas Department of Ag
83. be saved to Drafts Successful submission will display the DLN and a message Your form was submitted successfully a TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR Home Submit Form Form Status Inquiry Current Activity Drafts Vendors Printable Forms Alerts Help Your form was submitted successfully You can track this form using the DLN ubmit another form nquiry on a forms Status Unsuccessful submission will result in error messages being displayed at the top of the page you will need to scroll to the top of the page to see the errors TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR Home Submit Form Form Status Inquiry Current Activity Drafts Vendors Printable Forms Alerts Help r ae eee The following errors must be fixed before the form will submit MD DO Last Name is a required field MD DO License State is a required field MD DO First Name is a required field MD DO Address is a required field MD DO City is a required field MD DO State is a required field MD DO ZIP Code is a required field RN Coordinator Last Name field is a required field RN Coordinator License Number is a required field RN Coordinator License State field is a required field Primary Diagnosis ICD Code is a required field Enter the number of times this resident has fallen in the last 90 days is a required field In how many of the falls listed ab
84. c aoi dedo a NE ate iade nube Ceteri a ioa 52 Howto Submit Potuit 3519 ope re ae meee EEUU qu elt ME DX uc E Oc pl Rin Roc Te Mareen DUE RE 52 Hospice Form 3071 Election Cancellation Discharge Notice secssrstiaccnnianccepsriaacriauatenistiauivercamateceasbecsnceatunints 55 Howto Submit Form 3 7 T cde Seed ects E REE E EE E EENE E ci E E cbe 56 Hospice Form 3074 Medicaid Medicare Physician Certification of Terminal Illness sss 58 Howto submit Forn 2078 geen Seem ey ne eE Meats ae anny me Dd Dod eT nN ee Auer eae PRT MeCN nts oe er Tee 59 MDS Assessments E 61 Validating the Appropriateness of an Admission Assessment yoaccaidhissinchisssacecistectiesadegasiecedeassan UR e Fa aiederdeedarrnnnes 62 Subimissdan and Retrieval of MIJS Assessment ode p PED ence om sb Rb Bde a oO cielo 63 INS Dually C ded PGS tT oxen sat uad dnte eniti spite ani Dad dat t Gc EEEE ANEKERE EEEa EEEE EEEREN a ERE 64 Long Term Care Medicaid Infarmation ETCMD ieosseddqaespesDtepens Dept uo hebucko oe Bde E epu busde bot used EE 64 v 2013 1127 LTC Nursing Facility Hospice User Guide sued trigo MEOS U rc L 64 Finding Assessments Using Form Status Dyguityseeexedeccetnr re teetb tee e iiia 64 If You Cannot Locate Your MDS Using FSI or Current Activity nort bert e anb eA ev AERE DR bx e E oaa Fel o eae 65 How to Submit Long Term Care Medicaid Information LI CMI
85. date 10 21 08 Submit not allowed Form 3619 Medicare SNF Patient Transaction Notice Edits Edit Description System Message displayed at time of submission System Message Clarification System Message Resolution assistance for resolving error Last form submitted was an admission Please supply discharge form prior to this new admission Last form submitted was a discharge Please supply admission form prior to this new discharge Rejection of New Admission for missing Previous Discharge New admission follows an admission for same contract i e 11 1 2008 admission no discharge 12 1 2008 admission submitted Rejection of New Discharge for missing Previous Admission New discharge follows a discharge for same contract i e 11 1 2008 discharge no admission 12 1 2008 discharge submitted Submit a discharge form prior to this admission Attempting to submit two 3619 admissions in a row missing a 3619 discharge Submit the missing discharge then submit the 3619 admission Submit an admission form prior to this discharge Attempting to submit two 3619 discharges in a row missing a 3619 admission Submit the missing admission then submit the 3619 discharge 142 v 2013 1127 LTC Nursing Facility Hospice User Guide Edit Description System Message displayed at time of submission System Message Clarification System Message Resolution assistance for r
86. denied The following information assists TMHP in determining the appropriateness of the transport e An explanation of the residents physical condition that establishes the medical necessity for transport The explanation must clearly state the resident s conditions requiring transport by ambulance e The necessary equipment treatment or personnel used during the transport e The origination and destination points of the resident s transport Nonemergency Prior Authorization Process Medicaid providers may request prior authorization using one of the following methods The resident s physician NF ICF IID health care provider or other responsible party completes the online prior authorization request on the TMHP website at www tmhp com e Providers may fax the Nonemergency Ambulance Prior Authorization Request form to the TMHP Ambulance Unit at 512 514 4205 The completed forms and any supporting documentation must be sent with the request before the resident is transported to the medical appointment This form is available on the TMHP website at www tmhp com Documentation requirements for a request are outlined in the Supporting Docu mentation section e To request prior authorization providers may call TMHP at 1 800 540 0694 between the hours of 7 00 a m and 7 00 p m Central Time Monday through Friday Prior authorization request periods are as follows Refer to Prior Authorization Requests Through the TMHP
87. facility and within the last 14 days Only check column 1 if 1 2 resident entered admission or reentry IN THE LAST 14 DAYS If resident last entered 14 or more days While NOT a Whilea ago leave column 1 blank Resident Resident 2 While a Resident Performed while a resident of this facility and within the last 14 days J Check all that apply J Cancer Treatments A Chemotherapy LR LE B Radiation Respiratory Treatments C Oxygen therapy D Suctioning E Tracheostomy care LS E NM F Ventilator or respirator H IV medications l Transfusions J Dialysis LE M K Hospice care M Isolation or quarantine for active infectious disease does not include standard body fluid precautions La UN ggg 00250 Influenza Vaccine Refer to current version of RAI manual for current flu season and reporting period Enter Code A Did the resident receive the Influenza vaccine in this facility for this year s Influenza season 0 No gt Skip to 00250C If Influenza vaccine not received state reason 1 Yes Continue to O0250B Date vaccine received B Date vaccine received gt Complete date and skip to 00300A Is the resident s Pneumococcal vaccination up to date Month Day C If Influenza vaccine not received state reason 1 Resident not in facility during this year s flu season Received outside of this facility Noteligible medical contraindication Offered and declined Not of
88. field if S6h indicates the resident has fallen Valid range includes 0 zero with a maximum being the number entered in S6h S6j In the falls listed in S6h above how many had the following contributory factors More than one factor may apply to a fall Indicate the number of falls for each contributory factor Conditional S6j1 through S6j6 are required only if S6h indicates the resident has fallen Valid range includes 1 one with a maximum being the number entered in S6h S6j1 Environmental debris slick or wet floors lighting etc S6j2 Medication s S6j3 Major Change in Medical Condition Myocardial Infarction MI Heart Attack Cerebrovascular Accident CVA Stroke Syncope Fainting etc S6j4 Poor Balance Weakness S6j5 Confusion Disorientation S6j6 Assault by Resident or Staff S7 For DADS Only RUG S7b For DADS Only RUG When the LTCMI is printed S7b will show the calculated RUG value S8 Resident s Current Address S8a Resident s Address Required Enter the street address where the resident is presently living This information is used to mail MN determination letters S8b City Required Enter the city where the resident is presently living This information is used to mail MN determination letters 76 v 2013 1127 LTC Nursing Facility Hospice User Guide LTCMI Fields S8c State Required Enter the state where of the r
89. in the last 7 days Enter Number of Minutes Concurrent minutes record the total number of minutes this therapy was administered to the individual concurrently with one other individual in the last 7 days Enter Number of Minutes Group minutes record the total number of minutes this therapy was administered to the individual as part of a group of individuals in the last 7 days If the sum of individual concurrent and group minutes is zero skip to O0400D Respiratory Therapy Enter Number of Minutes 3A Co treatment minutes record the total number of minutes this therapy was administered to the individual in co treatment sessions in the last 7 days Enter Number of Days 4 Days record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days 5 Therapy start date record the date the most recent 6 Therapy end date record the date the most recent therapy regimen since the last assessment started therapy regimen since the last assessment ended CLI CL enter dashes if therapy is ongoing Month Day Month D Respiratory Therapy Enter Number of Minutes 1 Total minutes record the total number of minutes this therapy was administered to the individual in the last 7 days If zero skip to O0400E Psychological Therapy Enter Number of Days 2 Days record the number of days this therapy was administered for at least 15 min
90. interpreter to communicate with a doctor or health care staff 0 No 1 Yes Specify in A1100B Preferred language 9 Unable to determine Enter Code B Preferred language TTP TTT ETT TET ty A1200 Marital Status Never married Married Widowed Separated Divorced Enter Code A1300 Optional Resident Items A Medical record number LIE ET pr B Room number TTT ETT tt C Name by which resident prefers to be addressed LILITEILITXIIDITLDLDELLDEELETI D Lifetime occupation s put between two occupations ITIITI A1500 Preadmission Screening and Resident Review PASRR Complete only if A0310A 01 03 04 or 05 Is the resident currently considered by the state level II PASRR process to have serious mental illness and or intellectual disability mental retardation in federal regulation or a related condition 0 No Skip to A1550 Conditions Related to ID DD Status 1 Yes gt Continue to A1510 Level Il Preadmission Screening and Resident Review PASRR Conditions 9 Nota Medicaid certified unit gt Skip to A1550 Conditions Related to ID DD Status A1510 Level Il Preadmission Screening and Resident Review PASRR Conditions Complete only if A0310A 01 03 04 or 05 J Check all that apply A Serious mental illness B Intellectual Disability mental retardation in federal regulation C Other related conditions Enter Code MDS 3 0 Nursing Hom
91. last 7 days Enter Number of Minutes 3 Group minutes record the total number of minutes this therapy was administered to the resident as part of a group of residents in the last 7 days If the sum of individual concurrent and group minutes is zero skip to O0400C5 Therapy start date Enter Number of Minutes 3A Co treatment minutes record the total number of minutes this therapy was administered to the resident in co treatment sessions in the last 7 days Enter Number of Days x E i 4 Days record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days 5 Therapy start date record the date the most recent 6 Therapy end date record the date the most recent therapy regimen since the most recent entry started therapy regimen since the most recent entry ended enter dashes if therapy is ongoing Month D Respiratory Therapy Enter Number of Minutes 1 Total minutes record the total number of minutes this therapy was administered to the resident in the last 7 days IL LLLI If zero skip to O0400E Psychological Therapy Enter Number of Days L 2 Days record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days E Psychological Therapy by any licensed mental health professional Enter Number of Minutes 1 Total minutes record the total number of minutes this therapy was administered to the resident in the last 7 days
92. missing one of a pair Review the facility s records to determine which discharge is prior to this admission Pull a MESAV and review the Service Authorizations to determine the authorized services If the recipient has a closed Service Authorization for Code 3 with an end date after the rejected 3619 admission the rejected 3619 is part of a retroactive pair Determine the discharge prior to this admission and submit that discharge and the rejected admission as a pair to create a gap in the Service Authorization on file If the recipient has a closed Service Authorization for Code 1 with an end date after the rejected 3619 admission determine if the end date is correct If the end date is wrong submit a correcting 3618 discharge to change the end date to be prior to the rejected 3619 admission Once the Service Authorization ends prior to the 3619 Admission resubmit the rejected 3619 admission If the end date is correct there is a 3618 retroactive pair that needs to be processed to create a gap for the rejected 3619 admission and corresponding discharge Identify the 3618 discharge prior to the rejected 3619 admission and the 3618 admission prior to the current end date and submit as a retroactive pair Once the gap has been created within the Code 1 resubmit the rejected 3619 admission with the corresponding 3619 discharge v 2013 1127 107 LTC Nursing Facility Hospice User Guide Form Assessment 3619
93. must have already spent 20 days of Full Medicare Coverage in a Skilled Nursing Bed though the stay does not have to be in the same facility The administrator must sign and submit the form within 72 hours of the resident s Admission to or Dis charge from Medicare Co insurance to be considered timely In hospitals acting as temporary Texas Medicaid nursing homes the person responsible such as the DON may sign as the administrator the 72 hour deadline will still apply A facility administrator may authorize a person to sign the form in their absence The authorization must be in writing and on file at the facility The administrator date signed check box is required for Forms 3618 and 3619 If the facility is temporarily without an administrator a signature is still required Note in the comment section of Form 3619 that the facility is without an administrator at this time and enter 999999 for the State Board License No When Medicaid provides the rest of the payment this is called Medicare Co insurance In order for Medicare Co insurance to begin the recipient must meet the following requirements e Medicaid financial eligibility e Have an Admission Form 3619 on file e Have a qualifying stay of 20 days of full Medicare coverage not the three day acute care hospitalization stay The Dates of Qualifying Stay fields allow for two separate time frames However the dates may be broken up into multiple stays but will need to total 20 da
94. on the new screening the new screening will continue to process and the old screening will be inactivated A PLI and a PE are required prior to submission of an MDS Admission 3 0 A0310A 01 if the assessment indicates Mental Illness Developmental Disability or Intellectual Disability If the Referring Entity information is unknown at the time of screening the facilitys Medical Director may be entered onto the PL1 The Medical Directors name and license number is required The Nursing Facility must check the LTC Online Portal for completed PL1s to determine if their facility can provide the services the individual will require When a PL1 is set to status of Pending Placement in NF PE Confirmed the Nursing Facility will indicate that it is either willing and able to serve an individual or unable to serve an individual A Nursing Facility must convene an Interdisciplinary Team IDT meeting that includes collaboration with the LA or LMHA to develop the individual s comprehensive care plan if the PE indicates that the individual requires specialized services that are provided by the LA or LMHA 42 v 2013 1127 LTC Nursing Facility Hospice User Guide Medical Necessity and the MN Determination Process TMHP is responsible for reviewing submitted MDS assessments to determine MN Definition of Medical Necessity 40 TAC 19 101 73 states Medical Necessity is the determination that a recipient requires the services of licen
95. or Quarterly assessment There typically are two situations when MDS PC E should be submitted 1 RUG Gap Once the resident has been established as a RUG recipient a PC E will be needed if the next MDS assessment submission completely misses the anticipated assessment quarter Each Z0500B MDS 3 0 estab lishes a 92 day period Z0500B 91 days so the next assessment should be completed and submitted within the 92 day anticipated MDS assessment quarter following the 92 day span of the current MDS assessment The RUG of the current assessment will expire 31 days after the covering quarter Z0500B 91 days unless the next MDS assessment has been successfully completed DADS cannot pay for services on days when a RUG has expired The next MDS assessment will not be considered missed if it has a Z0500B date within the anticipated MDS assessment quarter and the LTCMI is completed on the LTC Online Portal within 91 days of the new MDS assessment Z0500B date Ifthe new MDS assessment is submitted after the expiration of the RUG on file but within the anticipated quarter the gap following the 31 days and prior to the new Z0500B date will automatically be filled with the new calculated RUG Ifthe new MDS is not submitted within the anticipated quarter or the LTCMI is not completed within 91 days of the Z0500B date a gap will be created following the 31 days until the Z0500B date of the new assessment Payment for this gap will be
96. or eschar EntenNumpen 1 Number of unstageable pressure ulcers due to coverage of wound bed by slough and or eschar If 0 Skip to M0300G Unstageable Deep tissue Enter Number L Number of these unstageable pressure ulcers that were present upon admission entry or reentry enter how many were noted at the time of admission entry or reentry G Unstageable Deep tissue Suspected deep tissue injury in evolution enter Number 1 Number of unstageable pressure ulcers with suspected deep tissue injury in evolution f O Skip to M0610 Dimension of Unhealed Stage 3 or 4 Pressure Ulcers or Eschar Enter Number Number of these unstageable pressure ulcers that were present upon admission entry or reentry enter how many were noted at the time of admission entry or reentry M0610 Dimensions of Unhealed Stage 3 or 4 Pressure Ulcers or Eschar Complete only if M0300C1 M0300D1 or M0300F1 is greater than 0 If the resident has one or more unhealed Stage 3 or 4 pressure ulcers or an unstageable pressure ulcer due to slough or eschar identify the pressure ulcer with the largest surface area length x width and record in centimeters A Pressure ulcer length Longest length from head to toe B Pressure ulcer width Widest width of the same pressure ulcer side to side perpendicular 90 degree angle to length C Pressure ulcer depth Depth of the same pressure ulcer from the visible surface to the deepest area if depth is unknown
97. or near death Sometimes when people are in an accident or have an illness that will cause them to die they are not able to talk or to let others know how they feel S11a Does the resident report having a legally authorized representative Required Choose from the drop down box 0 No 1 Yes ALegally Authorized Representative LAR is a person authorized by law to act on behalf of a person with regard to a matter and may include a parent guardian or managing conservator of a minor or the guardian of an adult S11b Doesthe resident report having a Directive to Physicians and Family or Surrogates Required Choose from the drop down box 0 No 1 Yes Instates other than Texas this document may be referred to as a Living Will gt Directive to Physician Living Will is a document that communicates a resident s wishes about medical treatment at some time in the future when he or she is unable to make their wishes known because of illness or injury S11c Does the resident report having a Medical Power of Attorney Required Choose from the drop down box 0 No 1 Yes S11d Doesthe resident report having an Out of Hospital Do Not Resuscitate Order Required Choose from the drop down box 0 No 1 Yes gt This form is for use when a resident is not in the hospital It lets the person tell health care workers including Emergency Medical Services EMS workers NOT to do some things if the person stops breat
98. perform a PE as follows a Ifthe Expedited Admission category is 1 2 or 3 then the Portal alerts the Local Authority to perform the PE as soon as the PL1 is submitted b Ifthe Expedited Admission category is 4 or 5 then the Portal alerts the Local Authority to perform the PE seven calendar days after the admission c Ifthe Expedited Admission category is 6 then the Portal alerts the Local Authority to perform the PE 14 days after the admission d Ifthe Expedited Admission category is 7 then the state alerts the Local Authority to perform a PE when the MDS indicates the individual is no longer comatose Once notified the Local Authority performs the PE within 72 hours of notification The Local Authority submits the PE on the LTC Online Portal within seven calendar days of notification Authorization for payment to the LA for completion of the PE is setup as a result of successful submission of the PE on the Portal The NF reviews the PE including recommended specialized services and certifies if they are able or unable to serve the individual If the NF is unable to serve the individual the LA coordinates placement into another NF or an alternate setting 38 v 2013 1127 LTC Nursing Facility Hospice User Guide Preadmission Process Is PL1 PASRR RE sends PL1 to Ree enna RE Performs PL1 Positive or Negative gt NF with oA submits PL1 on Negative individual
99. processed because the client is cur rently authorized for Full Medicaid A prior 3618 discharge and a 3619 admission need to be processed prior to this discharge If the Full Medicaid authorization is for this provider submit the 3618 dis charge prior to the Medicare stay A 3619 admission must be processed prior to this discharge NF 0063 This discharge cannot be processed because the client is admitted to Medicare Part A Coin surance for a different provider If an admission prior to this discharge is missing or rejected that admis sion must be processed prior to this discharge NF 0064 This discharge cannot be processed because an admission to Medicare Part A Coinsurance for a different provider has already been processed for the same day This discharge appears to be one of a retroactive pair If an admission prior to this discharge is missing or rejected resubmit the admission and this discharge on the same day Form Assessment 3618 3619 Admit 3619 Discharge 3619 Discharge 3619 Discharge Suggested Action The recipient has a Service Authorization for PACE the Program for All Inclusive Care for the Elderly as of the admission date Review the facility s records to verify that the transaction date on the rejected admission is correct If the submitted admission date is wrong correct the rejected admission and resubmit If the admission date is correct contact the recipient s PACE organi
100. provided as examples and should not be considered as all inclusive lists ml 10100 Cancer with or without metastasis Heart Circulation Anemia e g aplastic iron deficiency pernicious and sickle cell Atrial Fibrillation or Other Dysrhythmias e g bradycardias and tachycardias Coronary Artery Disease CAD e g angina myocardial infarction and atherosclerotic heart disease ASHD Deep Venous Thrombosis DVT Pulmonary Embolus PE or Pulmonary Thrombo Embolism PTE Heart Failure e g congestive heart failure CHF and pulmonary edema Hypertension 10799a Blood Pressure 10800 Orthostatic Hypotension 10900 Peripheral Vascular Disease PVD or Peripheral Arterial Disease PAD 10999 Peripheral Edema OOU OOOO 11100 Cirrhosis 11200 Gastroesophageal Reflux Disease GERD or Ulcer e g esophageal gastric and peptic ulcers 11300 Ulcerative Colitis Crohn s Disease or Inflammatory Bowel Disease EE ac CC 11400 Benign Prostatic Hyperplasia BPH 11500 Renal Insufficiency Renal Failure or End Stage Renal Disease ESRD 11550 Neurogenic Bladder 11650 Obstructive Uropathy Infections Multidrug Resistant Organism MDRO Pneumonia Septicemia Tuberculosis Urinary Tract Infection UTI LAST 30 DAYS Viral Hepatitis e g Hepatitis A B C D and E Wound Infection other than foot 12900 Diabetes Mellitus DM e g diabetic retinopathy nephropathy and neuropathy 12999
101. provider does not complete an OBRA Admission assessment as completely as possible even if the resident is in the providers building for only one day the provider will not have an MDS assessment for billing purposes If the Form 3618 or MDS discharge type is marked incorrectly the discharge type can be corrected 3 Ifthe resident is physically discharged from the facility for over 30 days regardless of reason or location CMS requires an Admission assessment For example if the discharge to the hospital was marked Return Antici pated and the resident is in the hospital over 30 days a new MDS 3 0 Admission assessment is due The Entry Date should be the new admission to the facility after the discharge that was over 30 days If the Entry Date is submitted with a date prior to the discharge a modification will be required to adjust the date so the assessment is valid for the dates after read mission Validating the Appropriateness of an Admission Assessment If the Entry Date of an MDS assessment overlaps with an established MDS for the same NF the coding of Admis sion assessment is most likely in error One of the considerations in validating an Admission assessment is the relationship between the Entry Date and the completion dates An Admission assessment should be completed within 14 days of the Entry Date CMS and DADS will accept the assessment if the timeframe is longer but the provider must validate whether an Admission asses
102. received the following medications during the last 7 days Enter O if medication was not received by the individual during the last 7 days Enter Days A Antipsychotic En B Antianxiety E o E lt o Antidepressant LJ m E 1 g Iw 2 o Hypnotic L m o e Ey lt o E Anticoagulant warfarin heparin or low molecular weight heparin F Antibiotic G Diuretic MN and LOC 3 0 V 15 22 of 32 Individual Identifier Date Section O Special Treatments Procedures and Programs 00100 Special Treatments Procedures and Programs Check all of the following treatments procedures and programs that were performed during the last 14 days Check all that apply 4 Cancer Treatments A Chemotherapy B Radiation OL Respiratory Treatments C Oxygen therapy D Suctioning E Tracheostomy care F Ventilator or respirator G BiPAP CPAP DODUL IV medications Transfusions Dialysis Hospice care Respite care lsolation or quarantine for active infectious disease does not include standard body fluid precautions N99 Psychiatric care LI LI LI m LI E L None of the Above Z None of the above MN and LOC 3 0 V 15 23 of 32 Individual Identifier Date Section O Special Treatments Procedures and Programs 0400 Therapies A Speech Language Pathology and
103. require the provider to enter additional information depending upon the message received Sequencing validation edits are based on three levels Form Type Transaction and Date of Above Transaction e Form type admission 3618 must be discharged with a 3618 before submitting a 3619 and the reverse e Transactions must alternate between admission and discharge e Date of above transaction should be chronological unless submitting a form effective retroactive e Retroactive forms should be submitted in pairs creating or filling a gap of time Forms set to the following statuses are excluded from consideration in meeting form sequencing requirements Cor rected Invalid Complete Invalid Form Sequence ID Invalid Form Inactivated Med ID Check Inactive ME Check Inactive or AI Check Inactive The errors will display at the time of a 3618 or 3619 form submission There are different errors dependent upon the form type therefore the error messages below have been categorized by form type 1 System Message This is the specific error message that will be displayed in the LTC Online Portal at time of submission 2 System Message Clarification Further clarification of the LTC Online Portal error message including basic example of the situation 3 System Message Resolution Assistance with resolving the error For those situations where a form is missing providers will need to submit the missing form in order for the erroring form
104. siessisvierisscessnucneapssnsunssseensuncthansepsbiaceeesusetbes 66 Circumstances for L CMI Subpilseloma ge enspiven eret tba IAE ean EE FEL CR eU ELEME EAM OR KE o CHEQUE 68 Upcoming Changes to the MDS Process Loeoess eerte etee torrent ento etes Festes tubae i 68 INEST I Fields M T 69 Seg u ncing of Documents 2 nnd cni rore cence an Poo HER e Edel oru ERR RE EEEE REAR neni 80 Zicisusstom asa Full Medicaid BaciDIelit Lunes caca guup eli uaria dra En HL ORE LEUR eet o RE mT MPG Dna 80 Recipient Transitioning to Fall Medicaid sarrasina naass euer nM AERE Epi lu pd Sete Linsen ad din 81 F ll Medicare Transitioning to Medicaid osea Loses it babeat nuance Late RR Mule 81 Current Resident Admitted fo HOSDIB nyni seniii onen aeee EREE Eia ea boues into oc semi o xil E SEE 82 Cunsnt Hospice TUS iier o asd Rb cu eI e a cmd Gu a onu Rund ace tu Cu de DU DL MERO a 83 Resident Returns Prior Discharge Return Not Anticipated 11as cenis tatrir sea etta bua ev rai Dea estkRPPaE Ero pA Rave ehe 84 Resident Returns Prior Discharge Return Anticipated usus ixstivebeikls atutbproivepepesebLaebeeskiin supe spit bri ande 85 MDS Purpose Code E Missed Assessment i t D sapendo kon exp sais babes Ld bs uda eu epa du RSEN DAE ba 86 INE Hospice Provider Tips for When to Submit an MDS PC E iuicetetannic pta st REE IRR EIE P DRM UK EH Lau E re PR E ERN PE RN 87 PC E Start and End Date Limitations MDS 3
105. take Setup an administrator account or a user account if an administrator account is already available to the facility 3 Under what condition would you see the yellow Form Actions bar When an individual form or assessment is being viewed in detail 4 How can you tell if a field is required When it is marked with a red dot on the screen When an error message is returned after you have submit ted the form 170 v 2013 1127 LTC Nursing Facility Hospice User Guide Appendix E PASRR Level 1 Screening The PASRR Level 1 Screening is divided into six sections labeled A through E Below are images of each section v 2013 1127 171 LTC Nursing Facility Hospice User Guide PASRR Level 1 Screening Section A va TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR Home Submit Form Form Status Inquiry Section A Submitter Information Current Status Name DLN 0 Current Activity Gave as Draft J Drafts Vendors Letters Printable Forms Alerts Help PASRR LEVEL 1 SCREENING Section B Section C Section D A0100 Name i A0200 Address A Street Address B City C State D ZIP Code Texas TX v A0300 NPI API A0400 Contract No A0500 Vendor No A0510 9 County v Referring Entity Information A0600 9 Date of Asse
106. the Reactivate form button Note The six month time frame is a cumulative time period meaning the form or assessment has a TOTAL of six months to pass through the Med ID Check ME Check and AI Check validations NOT six months to pass each validation Note Detailed diagrams illustrating the Medicaid Eligibility Verification Workflows can be found in Appendix A and B of this User Guide 92 v 2013 1127 LTC Nursing Facility Hospice User Guide The example below shows an assessment that flows successfully Awaiting LTC 5 20 2010 12 00 00 AM Medicaid Information Form 5 28 2010 3 54 13 PM Submitted Pending 5 28 2010 3 54 15 PM Review 5 28 2010 3 54 15 PM TMHP The Form has failed Auto MN Approval Approved 6 1 2010 1 40 19 PM Medicaid ID 6 1 2010 1 40 20 PM Pending 6 1 2010 1 40 20 PM ID Confirmed 6 2 2010 9 58 18 AM TMHP Medicaid ID request submitted 6 2 2010 9 58 18 AM TMHP Medicaid ID ss confirmed for this client Pending 6 2 2010 9 58 18 AM Medicaid Eligibility 6 2 2010 9 58 18 AM TMHP Medicaid Eligibility request sent Medicaid 6 2 2010 9 58 26 AM Eligibility Confirmed 6 2 2010 9 58 26 AM TMHP Medicaid eligibility confirmed for this client Pending 6 2 2010 9 58 26 AM Applied Income 6 2 2010 9 58 26 AM TMHP Applied Income requested Applied 6 2 2010 9 58 38 AM Income Confirmed 6 2 2010 9 58 38 AM SAS Request Pending 6 2 2010 9 58 39 AM TMHP The request is being proces
107. the provider due to the form or assess ment being rejected by SAS Refer to the form or assessment History trail for specific error message SAS Request Pending Form or assessment has passed all validations Medicaid ID Medicaid Eligibility Applied Income etc and will be sent from TMHP to DADS for processing Please allow two to four business days for the next status change Submitted Form or assessment has been submitted Submitted to manual workflow Form or assessment needs to be reviewed by DADS Provider Claims Services due to the form or assessment being rejected by SAS Refer to the form or assessment History trail for additional information v 2013 1127 145 LTC Nursing Facility Hospice User Guide Nonemergency Ambulance If you need to transport a Medicaid recipient by ambulance for a doctor appointment or other nonemergency reason here are some important things to know Prior Authorization Requirements The NF is responsible for providing routine nonemergency transportation for services not provided in the NF The cost of such transportation is included in the NF vendor rate Transports of NF residents for rehabilitative treatment e g physical therapy to outpatient departments or physicians offices for recertification examinations for NF care are not reimbursable ambulance services Nonemergency ambulance services are a benefit for the transport of a Texas Medicaid resident whose medical condi tion is such t
108. then set to status SAS Request Pending 16 Once one of the actions have been completed Correct this form Inactivate form or Resubmit Form the status of the form or assessment will no longer be set to status Provider Action Required Processing will continue based upon action chosen 17 The provider should repeat all the steps for each particular Type of Form until there are no more results found Our example was using Form 3618 Note Dont forget there are 6 Type of Forms that can end up in the provider workflow Form 3618 or 3619 MDS 3 0 Minimum Data Set Comprehensive and MDSQTR 3 0 Minimum Data Set Quarterly Once one Type of Form is chosen with No Results Found continue with the next Type of Form repeating all the steps to clear those set to status Provider Action Required Using Current Activity An alternate method for working forms or assessments recently set to status Provider Action Required is to use Current Activity Current Activity will show all forms and assessments that have been set to a different status in the last 14 calendar days Once the form or assessment has been set to status Provider Action Required for over 14 calendar days it must be located using Form Status Inquiry Once a form or assessment is being considered for Provider Action Required you may want to perform a resident search to see if the resident has any other forms or assessments are set to status Provider Acti
109. times at various levels of assistance code the most dependent except for code regardless of individual s self total dependence which requires full caregiver performance every time performance classification Coding Coding Activity Occurred 3 or More Times 0 No setup or physical help from caregiver Independent no help or caregiver oversight at any time Setup help only Supervision oversight encouragement or cueing One person physical assist Limited assistance individual highly involved in activity caregiver provide guided maneuvering Two persons physical assist of limbs or other non weight bearing assistance Extensive assistance individual involved in activity caregiver provide weight bearing support Total dependence full caregiver performance every time during entire 7 day period ADL activity itself did not occur during entire period Activity Occurred 2 or Fewer Times Activity occurred only once or twice activity did occur but only once or twice 1 2 Activity did not occur activity or any part of the ADL was not performed by individual or Self Performance Support caregiver at all over the entire 7 day period i Enter Codes in Boxes A Bed mobility how individual moves to and from lying position turns side to side and positions body while in bed or alternate sleep furniture B Transfer how individual moves between surfaces including to or from bed chair wheelchair standing positi
110. tmhp com 1 Login to the LTC Online Portal 2 Click the Submit Form link located in the blue navigational bar 3 Type of Form Choose 3618 Resident Transaction Notice from the drop down box 4 Click the Enter Form button 5 Enter all required information as indicated by the red dots Enter at least one of the following Medicaid Recipient No Social Security No or Medicare of RR Retire ment Claim No Ifan Admission from hospital enter the hospital admission date in the field provided between location and Date of Above Transaction Ifan Admission from private pay enter the physical admission date in the field provided next to Private pay Deceased indicates that the client was pronounced in the facility Location indicates where the client is admitting from or discharging to Date of Above transaction will be the actual admission or discharge date The Last Name must match exactly what is shown on the Medicaid card Note The discharge type Return Anticipated or Return Not Anticipated bas an effect on the recipients MDS RUG cycle Return not Anticipated ends the recipients current RUG records This should match the MDS Tracking Form v 2013 1127 49 LTC Nursing Facility Hospice User Guide 6 From here you have two choices a Click the Submit Form button to submit the form Or b Click the Save as Draft button to store the form for future use but n
111. urinal bedside commode catheter bag or ostomy bag J Personal hygiene how resident maintains personal hygiene including combing hair brushing teeth shaving applying makeup washing drying face and hands excludes baths and showers MDS 3 0 Nursing Home Quarterly NO Version 1 11 2 Effective 10 01 2013 2 ADL Support Provided Code for most support provided over all shifts code regardless of resident s self performance classification Coding 0 No setup or physical help from staff Setup help only One person physical assist Two persons physical assist ADL activity itself did not occur or family and or non facility staff provided care 100 of the time for that activity over the entire 7 day period 1 TUTO UNE J Enter Codes in Boxes Page 12 of 35 Resident Identifier Date SectionG _ Functional Status G0120 Bathing How resident takes full body bath shower sponge bath and transfers in out of tub shower excludes washing of back and hair Code for most dependent in self performance and support Enter Code A Self performance 0 Independent no help provided Supervision oversight help only Physical help limited to transfer only Physical help in part of bathing activity Total dependence Activity itself did not occur or family and or non facility staff provided care 10096 of the time for that activity over the entire 7 day period Enter Code g Support provided B
112. was sent to the LA to perform and submit a PE for a Resident Review e To invite the LA to participate in the Interdisciplinary Team IDT Meeting Helpful Contact Information Texas Medicaid amp Healthcare Partnership TMHD General Customer DST VCS T LSR RNEER 1 800 925 9126 Long Term Care ETC Department veces nuts ssanateceonsereeansaveotoiareatneenerontigorneenats 1 800 727 5436 1 800 626 4117 General Inquiries MDS not in the LTC Online Portal LTCMI questions Claim Forms Claim Submission RS Repore PLU Serseniligea ua ecw live koala otc EEE ERE Option 1 Medical Necessity MR PCP nc aAA Option 2 Technical SUD POE asi eic cta tecta ori rb ID Peg Ro AN nuca erede abu adu sid be KEE EER UR GP dec omen ERRER Et Option 3 Audio Message fot Paper Subiuissl hs rese versses irei A AREE UE ek Hd reru cU EO RE Option 4 Pau EL CA LING iade conn tete toa dne OU RU a er eb het tret reete OP LO Option 5 LIC Deparment D assistente iden e dud uiu kasd inea bocca dou ad ecd pane UG doen Dd 512 514 4223 hod coni M 1 800 252 8263 Department of Aging and Disability Services DADS see 512 438 3011 Consumer Rights amp Services Hotlines casses rerr cube urea ci ELEME RAE HEX LEE DeL LFU LEER REEL RIEE 1 800 458 9858 Complaint for LTG Facility A BEDS reira aR Ud but uns abest cd E aD ad brat Option 2 Information About a Facility ER Option 4 Provi
113. with the incorrect contract to Invalid Complete Reminder When submitting a counteracting form for an admission that has payment recoupment will occur unless additional processing occurs at the same time Please coordinate with DADS Provider Claims Services to ensure appropri ate payment 134 v 2013 1127 LTC Nursing Facility Hospice User Guide Modifications NF providers submit all MDS Correction requests to CMS in accordance with the RAI Users Manual Corrections that are classified as a Modification are retrieved by TMHP for processing In field X0900 on 3 0 corrections select the reason for modification TMHP sets the original assessment to status Corrected and gives the new assessment a DLN creating a Parent Child DLN relationship set to status Awaiting LTC Medicaid Information The LTCMI must be completed and submitted at this time The MN will then be determined Note Providers are allowed to submit modifications to an on time MDS without requiring a PC for up to one year For Modifications to an MDS assessment that did not originally meet the timeliness rules a PC E will be required upon submission of the LTCMI Providers must access the LTC Online Portal to retrieve the new assessment complete the LTCMI and submit MDS 3 0 For detailed instructions on completing an MDS 3 0 Modification refer to the MDS 3 0 RAI User s Manual Chapter 5 The Users Manual can be found under Downloads on the CMS website at www cm
114. 10 8 2010 meee Detail Required View Mw 10 8 2010 nee ae wameenea oe wes Provider Action we 10 8 2010 meee Detail Required View w e 10 8 0100 e tome meee Provider Action 10 8 2010 Detail B i Required ORT PAAS Mm 7 Click the View Detail link to open the form 8 Scroll to the bottom of the page to view the History trail History Form 10 8 2010 9 04 18 AM Submitted Medicaid 10 8 2010 9 04 21 AM ID Pending 10 8 2010 TMHP Medicaid ID request submitted 9 04 21 AM ID 10 8 2010 9 04 24 AM Confirmed 10 8 2010 TMHP Medicaid ID confirmed for this client 9 04 24 AM Pending 10 8 2010 9 04 24 AM Medicaid Eligibility 10 8 2010 TMHP Medicaid Eligibility request sent 9 04 24 AM Medicaid 10 8 2010 9 04 25 AM Eligibility Confirmed 10 8 2010 TMHP Medicaid eligibility confirmed for this client 9 04 25 AM SAS 10 8 2010 9 04 26 AM Request Pending 10 8 2010 TMHP The request is being processed by DADS Please allow 2 4 business days for the next status change 9 04 26 AM Provider 10 12 2010 5 10 20 AM Action Required 10 12 2010 TMHP NF 0013 The admission cannot be processed because the client is already admitted into a facility If a discharge prior to 5 10 20 AM this admission is rejected the rejected discharge must be processed first This admission can then be resubmitted to SAS If this is the initial admission into your facility please contact the p
115. 3 0 Manual www cms gov NursingHomeQualityInits 25 NHQIMDS30 asp e State MDS Policy www dads state tx us providers mds index cfm State MDS Clinical Web Page The MDS Mentor www dads state tx us providers MDS e NF MDS Coordinator Support Site www dads state tx us providers MDS 160 v 2013 1127 LTC Nursing Facility Hospice User Guide Acronyms A0310A Reason for Assessment MDS 3 0 A1600 Admission or Entry Date MDS 3 0 A2300 Assessment Reference Date ARD Assessment Reference Date BON Texas Board of Nursing CHOW Change of Ownership CMS Centers for Medicare amp Medicaid Services CPR Cardiopulmonary Resuscitation CVC Central Venous Catheter DADS Texas Department of Aging and Disability Services DLN Document Locator Number DON Director of Nurses DSHS Department of State Health Services EDI Electronic Data Interchange EMS Emergency Medical Services ER Emergency Room FSI Form Status Inquiry HHSC Texas Health and Human Services Commission HIPAA The Health Insurance Portability and Accountability Act HMO Health Maintenance Organization HRC Human Resource Code ICF IID Intermediate Care Facility for Individuals with Intellectual Disability IDD Intellectual and Developmental Disabilities LA Local Authority LAR Legally Authorized Representative Late Assessment An assessment received on day 123 is considered late The previous RUG for that resident has
116. 3 0 Quarterly assessments will display in the search results Note You may omit the Type of Form field if you are the original submitter and enter the DLN of the document you need to retrieve If you are not the original submitter you must choose the Type of Form even if you enter a DLN Note Nursing Facilities NF can only view a PLI or PE when they are one of the NF choices on the associated PLI Once the individual is admitted to an NE only the admitting NF will have access to the PLI and PE 3 Enter To and From Dates These are required fields Dates are searched against the TMHP Received Date date of successful submission 4 Narrow results by entering specific criteria in the additional fields DLN Last Name First Name SSN Medicaid Number Form Status Purpose Code and Reason for Assessment Note The narrowing search criteria fields that display when performing a Form Status Inquiry will vary based on the Type of Form chosen Example When performing a Form Status Inquiry on Type of Form 3618 3619 3071 or 3074 or on PLI or PE the Purpose Code and Reason for Assessment fields will not display because they are only applicable when performing a Form Status Inquiry on MDS assessments 5 Click the Search button and the LTC Online Portal will return any matching submissions records Only 50 records will display at a time To view the next set of records you m
117. 6 months prior to admission entry or reentry 0 No 1 Yes 9 Unable to determine J1800 Any Falls Since Admission Entry or Reentry or Prior Assessment OBRA or Scheduled PPS whichever is more recent d any falls since admission entry or reentry or the prior assessment OBR PPS whichever is more Enter Code recent 0 No Skip to K0100 Swallowing Disorder 1 Yes Continue to J1900 Number of Falls Since Admission Entry or Reentry or Prior Assessment OBRA or Scheduled PPS J1900 Number of Falls Since Admission Entry or Reentry or Prior Assessment OBRA or Scheduled PPS whichever is more recent J Enter Codes in Boxes A No injury no evidence of any injury is noted on physical assessment by the nurse or primary care clinician no complaints of pain or injury by the resident no change in the resident s Coding behavior is noted after the fall 0 None i 1 One B Injury except major skin tears abrasions lacerations superficial bruises hematomas and 5 Two or more sprains or any fall related injury that causes the resident to complain of pain C Major injury bone fractures joint dislocations closed head injuries with altered consciousness subdural hematoma SectionK Swallowing Nutritional Status K0100 Swallowing Disorder Signs and symptoms of possible swallowing disorder J Check all that apply A Loss of liquids solids from mouth when eating or drinking B Holding food in mout
118. A Reason for Assessment 01 Admission assessment required by day 14 LII 02 Quarterly review assessment 03 Annual assessment 04 Significant change in status assessment 05 Significant correction to prior comprehensive assessment 06 Significant correction to prior quarterly assessment 99 None of the above PPS Assessment Entereode PPS Scheduled Assessments for a Medicare Part A Stay 01 5 day scheduled assessment 02 14 day scheduled assessment 03 30 day scheduled assessment 04 60 day scheduled assessment 05 90 day scheduled assessment 06 Readmission return assessment PPS Unscheduled Assessments for a Medicare Part A Stay 07 Unscheduled assessment used for PPS OMRA significant or clinical change or significant correction assessment Not PPS Assessment 99 None of the above PPS Other Medicare Required Assessment OMRA No Start of therapy assessment End of therapy assessment Both Start and End of therapy assessment Change of therapy assessment Enter Code Enter Code D Is this a Swing Bed clinical change assessment Complete only if A0200 2 0 No 1 Yes A0310 continued on next page MDS 3 0 Nursing Home Quarterly NQ Version 1 11 2 Effective 10 01 2013 Page 1 of 35 Resident Identifier Date SectionA Identification Information A0310 Type of Assessment Continued Enter Code E Is this assessment the first assessment OBRA Scheduled PPS or Discharge since the most r
119. Appendix C Alerts Alerts are messages sent to the Local Authority via LTC Online Portal pertaining to new PASRR Level 1 Screening or PASRR Evaluations Alerts also appear when a Resident Review is needed It is the responsibility of the Local Authority to check the LTC Online Portal Alerts screen on a daily basis Communication to the Local Authority Conduct PASRR Level 1 The Local Authority should perform and submit a PASRR Level 1 Screening for an individu Screening al within 72 hours of the Alert date Conduct PASRR Evaluation The Local Authority must perform and submit a PASRR Evaluation for the individual within First Notification 7 calendar days of the notification This Alert can also be generated when the individual was admitted to a Nursing Facility as an Expedited Admission Thisisthe first notice to the Local Authority Conduct PASRR Evaluation The Local Authority must perform and submit a PASRR Evaluation within 7 calendar days Second Notification of this notification Thisalert is triggered if it has been more than 7 calendar days since the date of the alert of the first notification e Ifthe Local Authority has already performed the PASRR Evaluation but has not entered it on the LTC Online Portal the Local Authority should submit the PASRR Evaluation immedi ately Complete the IDD Section ThelDD Section of the PASRR Evaluation has not been submitted on the LTC Online Portal on the PASRR Evalua
120. Audiology Services Enter Number of Minutes Individual minutes record the total number of minutes this therapy was administered to the individual individually in the last 7 days Enter Number of Minutes Concurrent minutes record the total number of minutes this therapy was administered to the individual concurrently with one other individual in the last 7 days Enter Number of Minutes Group minutes record the total number of minutes this therapy was administered to the individual as part of a group of individuals in the last 7 days If the sum of individual concurrent and group minutes is zero gt skip to O0400B Occupational Therapy Enter Number of Minutes 3A Co treatment minutes record the total number of minutes this therapy was administered to the individual in co treatment sessions in the last 7 days Enter Number of Days 4 Days record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days 5 Therapy start date record the date the most recent 6 Therapy end date record the date the most recent therapy regimen since the last assessment started therapy regimen since the last assessment ended enter dashes if therapy is ongoing LLL II L H Month Day Month B Occupational Therapy Enter Number of Minutes Individual minutes record the total number of minutes this therapy was administered to the individual individual
121. C Nursing Facility Hospice User Guide TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR Home SubmitForm Form Status Inquiry Current Activity Drafts Vendors Printable Forms Alerts Help 3618 RESIDENT TRANSACTION NOTICE Current Status Name DLN 0 Form Actions Provider Information eres eee Fw Vendor Number set Contract Number Wt qt NPI Number noe rest Recipient Information 1 Medicaid Recipient No 4 Recipient s Last Name 5 Address Address 2 Social Security No Name Recipient s First Name City 3 Medicare or RR Retirement i Recipient s Middle State vj Claim No Initial ziP Recipient Name Suffix Transaction Information e Service Group x e Transaction If Newly Admitted From Discharged To Hospital Enter C e Date of Above Transaction v Administrator Information I certify that to the best of my knowledge the date in Item 11 Date of Above Transaction is for services provided and the date is not included in the 100 Medicare Part A reimbursement time frame Administrator State Board License No Administrator Last Name Administrator First Name e Is Administrator Signature on Form O e Date Signed v i Submit Form _ Note A Form 3618 admitting the recipient to Full Medicaid or
122. Date Indicate what the effective date is of this certification Verbal Verification If completed within two days of Election the physicians have six months to sign the certification submission cannot occur until signatures are obtained If the form is being completed as an initial certification two physician signatures are required unless the Exclusion Statement is signed If no Verbal Verification is given the physician s signatures must be within two days of the Election on an initial certification If no verbal verification is given and not within two days of the Election the effective date is the later of the two physician s signatures A recertification only requires one physician signature A recertification can be signed up to 30 calendar days prior to the recert date or within the six month recertification period The Exclusion Statement is only completed if the client does not have an attending physician for the initial certification From here you have two choices a Click the Submit Form button to submit the form or Click the Save as Draft button to store the form for future use but not submit it The form does not have to be complete to save the draft Note If the form is successfully submitted a DLN will be assigned and the LTC Online Portal will show Your form was submitted successfully If there are errors they will be displayed in a box at the top of the screen These errors will need t
123. F Surgical wound care G Application of nonsurgical dressings with or without topical medications other than to feet H Applications of ointments medications other than to feet l Application of dressings to feet with or without topical medications Z None of the above were provided MDS 3 0 Nursing Home Comprehensive NC Version 1 11 2 Effective 10 01 2013 Page 27 of 41 Resident Identifier Date SetionN JjMediations 2 N0300 Injections Entel ays Record the number of days that injections of any type were received during the last 7 days or since admission entry or reentry if less than 7 days If 0 Skip to N0410 Medications Received Enkar Des Insulin injections Record the number of days that insulin injections were received during the last 7 days or since admission entry or reentry if less than 7 days Enter Days B Orders for insulin Record the number of days the physician or authorized assistant or practitioner changed the resident s insulin orders during the last 7 days or since admission entry or reentry if less than 7 days N0410 Medications Received Indicate the number of DAYS the resident received the following medications during the last 7 days or since admission entry or reentry if less than 7 days Enter 0 if medication was not received by the resident during the last 7 days Enter Days A Antipsychotic L BL Enter Days B Antianxiety C Antidepre
124. GAT APORXABCBQOBDSHJIKNOQC BFWYMIPYBCCEDTTNTMGN QUARTERLY INACTIVATION ADMISSION ANNUAL MODIFICATION NECESSITY ASSESSMENT CORRECTION HOSPICE VALIDATION WORKFLOW 183 2013 1127 V Solution LTC Nursing Facility Hospice User Guide OQOVSIRKHBMI OXYISIYLEA OITACIFIDOM zao N Z O 4 oloz2zz Ujj un gt wajh gt m z iN H O N H Q n mis Aj A H Dp oO R HFYNUWYTT VUZBWWHWSSSR DLGTWEJSEATXAN HSZUCUTXQQCNFXIQMGAT APORXABCBQOBDSHJKNOQC BFWYMIPYBCCEDTTNTMGN 1127 2 2 v 201 184 TMHP TEXAS MEDICAID HEALTHCARE PARTNERSHIP A STATE MEDICAID CONTRACTOR The LTC Nursing Facility Hospice User Guide is produced by TMHP Training and Organizational Development Services Contents are current as of the time of publishing and subject to change Providers should always refer to Provider Manuals Bulletins and the TMHP and DADS websites for current and authoritative information LTC Nursing Facility Hospice User Guide Addendum Addendum MDS 3 0 and MN LOC Changes LTC Online Portal MDS 3 0 and MN LOC Specification Changes Effective October 1 2013 Texas Medicaid amp Healthcare Partnership TMHP has implemented modifications to the Long Term Care LTC Online Portal in support of the federal Centers for Medicare amp Medicaid Services changes to the Minimum Data Set MDS 3 0 and Medical Necessity and Level o
125. H Form Status From Date e smoso v To Date Coach Pending More Info Coach Review Invalid Form Sequence Invalid Complete ME Check Inactive Med ID Check Inactive Medicaid ID Pending Provider Action Required Received SAS Request Pending Submitted to manual workflow 5 Click the Search button found on the bottom right of the screen to submit the Inquiry v 2013 1127 95 LTC Nursing Facility Hospice User Guide 6 Those 3618 forms with status Provider Action Required will display Note For confidentiality purposes the form details Medicaid etc have been hidden in this document TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP A STATE MEDICAID CONTRACTOR Home Submit Form Form Status Inquiry Current Activity Drafts Vendors Printable Forms Alerts Form Status Inquiry Form Select Type of Form e 3618 Resident Transaction Notice vj Vendor Number HE for Contract Number Way lu v Form Status Inquiry DLN Medicaid Number Last Name First Name SSN HH Form Status Provider Action Required x From Date e 1 20 2009 v To Date 10 8 2010 7i Seach 4 record s returned Received First Last Transaction Contract Yendor Date Medicare Name Name Type Transaction Date Number Number View 10 8 2010 Provider Action ILL 10 8 2010 Detail Required View c 10 8 2010 eme mae o s c Provider Action
126. IAD perspiration drainage None of the Above Z None of the above were present m A L Li Li MN and LOC 3 0 V 15 21 of 32 Individual Identifier Date SectionM Skin Conditions M1200 Skin and Ulcer Treatments Check all that apply A Pressure reducing device for chair Pressure reducing device for bed Turning repositioning program Nutrition or hydration intervention to manage skin problems Pressure ulcer care Surgical wound care Application of nonsurgical dressings with or without topical medications other than to feet B oemmaonsoi m Applications of ointments medications other than to feet Application of dressings to feet with or without topical medications LI LI LI C L G L1 LI LI L Z None of the above were provided SectionN Medications N0300 Injections Enter Days Record the number of days that injections of any type were received during the last 7 days If 0 Skip to N0410 Medications Received 350 Insulin ter Days B A Insulin injections Record the number of days that insulin injections were received during the last 7 days ter Days B Orders for insulin Record the number of days the physician or authorized assistant or practitioner changed the individual s insulin orders during the last 7 days N0410 Medications Received i Indicate the number of DAYS the individual
127. IL LLLI If zero skip to O0400F Recreational Therapy Enter Number of Days L 2 Days record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days F Recreational Therapy includes recreational and music therapy Enter Number of Minutes 1 Total minutes record the total number of minutes this therapy was administered to the resident in the last 7 days IL LLLI If zero skip to O0420 Distinct Calendar Days of Therapy Enter Number of Days L 2 Days record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days 00420 Distinct Calendar Days of Therapy pua Record the number of calendar days that the resident received Speech Language Pathology and Audiology Services Occupational Therapy or Physical Therapy for at least 15 minutes in the past 7 days 00450 Resumption of Therapy Complete only if A0310C 2 or 3 and A0310F 99 Enter Code A Hasa previous rehabilitation therapy regimen speech occupational and or physical therapy ended as reported on this End of Therapy OMRA and has this regimen now resumed at exactly the same level for each discipline 0 No gt Skip to 00500 Restorative Nursing Programs 1 Yes B Date on which therapy regimen resumed Month Year MDS 3 0 Nursing Home Comprehensive NC Version 1 11 2 Effective 10 01 2013 Page 31 of 41 Resident Identifier Date SectionO Special Treatments
128. ITITI A1200 Marital Status Never married Married Widowed Separated Divorced Enter Code A1300 Optional Resident Items A Medical record number LIE ET pr B Room number TTT ETT tt C Name by which resident prefers to be addressed LILITEILITXIIDITLDLDELLDEELETI D Lifetime occupation s put between two occupations ITIITI A1500 Preadmission Screening and Resident Review PASRR Complete only if A0310A 01 03 04 or 05 Is the resident currently considered by the state level II PASRR process to have serious mental illness and or intellectual disability mental retardation in federal regulation or a related condition 0 No Skip to A1550 Conditions Related to ID DD Status 1 Yes gt Continue to A1510 Level Il Preadmission Screening and Resident Review PASRR Conditions 9 Nota Medicaid certified unit gt Skip to A1550 Conditions Related to ID DD Status A1510 Level Il Preadmission Screening and Resident Review PASRR Conditions Complete only if A0310A 01 03 04 or 05 J Check all that apply A Serious mental illness B Intellectual Disability mental retardation in federal regulation C Other related conditions Enter Code MDS 3 0 Nursing Home Comprehensive NC Version 1 11 2 Effective 10 01 2013 Page 3 of 41 Resident Identifier Date SectionA Identification Information A1550 Conditions Related to ID DD Status
129. If the resident is 22 years of age or older complete only if A0310A 01 If the resident is 21 years of age or younger complete only if A0310A 01 03 04 or 05 J Check all conditions that are related to ID DD status that were manifested before age 22 and are likely to continue indefinitely ID DD With Organic Condition A Down syndrome C Epilepsy D Other organic condition related to ID DD ID DD Without Organic Condition E ID DD with no organic condition No ID DD Z None of the above A1600 Entry Date date of this admission entry or reentry into the facility A1700 Type of Entry Enter Code 1 Admission LI 2 Reentry A1800 Entered From EROR Community private home apt board care assisted living group home Another nursing home or swing bed LI Acute hospital Psychiatric hospital Inpatient rehabilitation facility ID DD facility Hospice Long Term Care Hospital LTCH Other A2000 Discharge Date Complete only if A0310F 10 11 or 12 A2100 Discharge Status Complete only if A0310F 10 11 or 12 EET CAE Community private home apt board care assisted living group home Another nursing home or swing bed LII Acute hospital Psychiatric hospital Inpatient rehabilitation facility ID DD facility Hospice Deceased Long Term Care Hospital LTCH Other MDS 3 0 Nursing Home Comprehensive NC Version 1 11 2 Effective 10 01
130. LTCMI Forms 3071 3074 3618 and 3619 Updates can be made to certain fields on the PL1 Screening It is strongly suggested that providers do not make corrections to assessments that are already in status Processed Complete This may result in payment ceasing Note Forms 3618 and 3619 or the LTCMI section of a MDS assessment that have been set to status Form Inactivated at any time in the history will not allow corrections to the form or assessment The Correct this form button or Update Form button will not be displayed in the yellow Form Actions bar on any form that cannot be corrected or updated This includes submission of these forms or assessments by a third party software vendor for your facility PLIs cannot be submit ted by a third party software vendor LTCMI Corrections Corrections to the LTCMI section data can be submitted directly on the LTC Online Portal Note no PC Purpose Code is identified in field S1e it may be corrected to reflect either an E or M A PC M may be corrected to a PC E However a PC E is unable to be corrected to a PC M Once an assessment is classified as a PC E field Sle is not correctable Prior to correcting adding a PC on an LTCMI validate if payment has been made based on the MDS Entering a PC Start and End date cancels any prior services dates the assessment represented If necessary submit an off cycle MDS 3 0 assessment to submit a PC E or M To submit LTCMI corrections 1 Log in to th
131. NTRACTOR Home Submit Form Form Status Inquiry Current Activity Drafts Vendors Printable Forms Alerts Help Drafts Long Term Care Contract Numbers Vendor Numbers for Contract Number for Contract Number for Contract Number v a TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR Home Submit Form Form Status Inquiry Current Activity Drafts Vendors Printable Forms Alerts Drafts UL A 11 7 2013 4 03 22 PM RTN3618 Remove 20 v 2013 1127 LTC Nursing Facility Hospice User Guide 3 From here you have two choices a Click the Open link to open the draft to edit and submit or b Click the Remove link to permanently delete the draft Note The following confirmation prompt message will appear Microsoft Internet Explorer 2 Press OK to confirm that you would like to delete this draft from the portal Press Cancel to keep the draft v Click the OK button to delete the draft Or Click the Cancel button to keep the draft Note Drafts will display for 60 days only Once a draft has been removed it cannot be retrieved Printable Forms The Printable Forms feature allows the provider to view blank forms or assessments print blank forms or assess ments or interactively complete forms or assessments by saving to your desktop Note All of the forms or assessments listed in the Printable Forms page are interactive with the exce
132. Note v 2013 1127 2 LTC Nursing Facility Hospice User Guide Print The Print feature is applicable to all document types Forms 3071 3074 3618 3619 and 3652 Minimum Data Set MDS PL1 and PE Click the Print button to print completed documents When printing the MDS 3 0 assessment the resident s name will appear on the top left corner of each page The name will be populated based on the information entered in fields A0500A B C and D on an MDS 3 0 assessment Use as template The Use as template feature is only available for a PL1 and for Forms 3071 3074 3618 and 3619 It allows a provider to complete a new form or screening by using the information in a completed form or screening as a template Various fields will auto populate be sure to check for accuracy Be careful not to confuse this feature with a similarly named feature in TexMedConnect Once you have found and are displaying the form or screening using FSI or Current Activity L Click the Use as template button the data in the document will be used to create a new document Note Not all fields will be copied over Enter data into remaining fields not auto populated amp 3618 RESIDENT TRANSACTION NOTICE Current Status Provider Action Required Name Oh v Form Actions Workflow Actions Print Use as template Correct this form Add Note Inactivate Form Resubmit Form Provider Information Qm os
133. P User Account A TMHP User Account includes a username and password which are required to log into TMHP Applications A User Account can be linked to one or more Provider Vendor Accounts What do administrative rights allow a User to do When a TMHP User Account is given administrative rights to a Texas Medicaid or CSHCN Services Program Provider Vendor Account the User is allowed to control account activity and access protected data pertaining to a particular Provider Facility or Vendor Within the secure portion of TMHP com Provider vendor administrators have the ability to Submit Claims Appeal Claims Inquire about claim status Verify client eligibility View R amp S Reports View PCCM Panel Reports Submit prior authorization requests This feature is currently unavailable to CSHCN providers but it is coming soon You can administer a Provider Account three to five days after receiving the TMHP enrollment confirmation letter Click the following link activate an Account v 2013 1127 LTC Nursing Facility Hospice User Guide 8 Choose a Provider Type from the drop down box Note The Provider Types listed are the only two choices in the drop down box that are applicable for this guide Use NF Waiver Programs to submit 3618 3619 LTCMI PASRR Level 1 PL1 Screenings and PASRR Evaluations PE Use Long Term Care to access TexMedConnect for submitting claims accessing R amp S R
134. Ports Central Lines PICC CE S6g t what developmental level the resident functioning S6h Enter the number of times this resident has fallen in the last 90 days S6i In how many of the falls listed above was the person physically restrained prior to the fall Sej In the falls listed in S6h above how many had the following contributory factors More than one factor may apply to a fall Indicate the number of falls for each contributory factor S6ji Environmental debris slick or wet floors lighting etc S6j2 Medication s S6j3 Major Change in Medical Condition Myocardial Infarction MI Heart Attack Cerebrovascular Accident CVA Stroke Syncope Fainting etc S6j4 Poor Balance Weakness S6j5 Confusion Disorientation S6j6 Assault by Resident or Staff S8 Resident s Current Address v 2013 1127 69 LTC Nursing Facility Hospice User Guide S8 Resident s Current Address sga Resident s Address S8b City S8c o State L E S8d ZIP Code S8e Phone S9 Medications List all medications that the resident received during the last 30 days Include scheduled medications that are used regularly but less than weekly O Medication Certification I certify this resident is taking no medications OR the medications listed below are correct Add Meds S10 Comments S11 Advance Care Planning S11a Does the resident report having a
135. Sometimes understands responds adequately to simple direct communication only 3 Rarely never understands B1000 Vision Ability to see in adequate light with glasses or other visual appliances Enter 0 Adequate sees fine detail such as regular print in newspapers books 1 Impaired sees large print but not regular print in newspapers books _ 2 Moderately impaired limited vision not able to see newspaper headlines but can identify objects Code 3 Highly impaired object identification in question but eyes appear to follow objects 4 Severely impaired no vision or sees only light colors or shapes eyes do not appear to follow objects B1200 Corrective Lenses Enter Corrective lenses contacts glasses or magnifying glass used in completing B1000 Vision _ 0 No 1 Yes MN and LOC 3 0 V 15 3 of 32 Individual Identifier Date KEITH DTE Cognitive Patterns C0100 Should Brief Interview for Mental Status C0200 C0500 be Conducted Attempt to conduct interview with the individual 0 No individual is rarely never understood OR individual is less than 7 years of age skip to and complete C0700 C1000 Caregiver Assessment for Mental Status 1 Yes Continue to C0200 Repetition of Three Words Brief Interview for Mental Status BIMS C0200 Repetition of Three Words Ask individual am going to say three words for you to remember Please repeat the words after have said
136. TOR Home Submit Form Form Status Inquiry Current Activity Drafts Vendors Printable Forms Alerts Help Form Status Inquiry Form Select Type of Form v vendor Number 9 v Form Status Inquiry DLN Medicaid Number Last Name fo First Name Form Status Lis SSN M CARE ID p From Date e 331203 S To Date e saon PASRR Eligibility Discharged Deceased FL 9 2 Type of Form Choose from the drop down box Type of Form labels will display in the Type of Form drop down box on FSI 8071 Election Cancellation Notice of Hospice services 8074 Medicaid Medicare Physician Certification of Terminal Illness 8618 Resident Transaction Notice 3619 Medicare SNP patient Transaction Notice 8652 Client Assessment Review and Evaluation CARE MDS 2 0 Minimum Data Set Comprehensive MDSQTR 2 0 Minimum Data Set Quarterly MDS 3 0 Minimum Data Set Comprehensive MDSQTR 3 0 Minimum Data Set Quarterly PASARR PASARR Screening PLI PASRR Level 1 Screening PE PASRR Evaluation 16 v 2013 1127 LTC Nursing Facility Hospice User Guide Note This choice will determine the type of document that will display in the FSI results page For example if a provider chooses Type of Form MDS 3 0 Minimum Data Set Comprehensive the results will only display MDS 3 0 Minimum Data Set Comprehensive assessments No MDS
137. User Guide Addendum The information that was included in the LTC Nursing Facility Hospice User Guide in the MDS Assessments section has been updated to reflect a change to the MDS 3 0 criteria The updated information is included in the addendum which immediately follows the User Guide and can be accessed by using the bookmarks Click the link to view the following addendum MDS and MN LOC 3 0 Updates Addendum added 10 01 2013 For more information contact the LTC Help Desk at 1 800 626 4117 Option 1 2013 1002 Long Term Care Nursing Facility Hospice Workshop USER GUIDE LTC Nursing Facility Hospice User Guide Contents Learning Objectives P 1 Medicaid Team Reser er ere PP ee ee eR Re Sy ne A NEM 2 National Provider Identifier NPI Atypical Provider Identifier API Requirements sss 3 The LTC Online Portal nocent or et teen OPERAE EREER E EGER M a e ad ad e ec ERES 4 ror oe Beau LUGO malin oo T RAEN 4 ETC Online Portal Security sec exces teste eiie etre mte re sim wok agen cata vo canes oc pee Er peius abate Rehan ions 4 How to Create an LTC Online Portal Administrator ACCOUNE c ccccesesssssscesceseeseeseeecaecseeeececssecsseasecseseeesaeeaeeaeens 5 My ACCOUHE ioter teta EE e E EEEE eir ed ee Ive e Poo PEE o taxe Era S D Fes DRE PUDE AR RE REED a cree rT 10 Los Io qosbe LIC Online Portal dead water teense ncn petu crude one tebe itt E tad
138. Website in the 2010 7exas Medicaid Provider Procedures Manual in the Ambulance Services Handbook Volume 2 Provider Handbooks section 2 2 2 Nonemergency Ambu lance Services The manual contains additional information including mandatory documentation requirements and retention Providers may also call the TMHP Contact Center at 1 800 925 9126 for additional information TMHP reviews all of the documentation it receives An online prior authorization request submitted on the TMHP website at www tmhp com receives an online approval or denial Alternately a letter of approval or denial is faxed to the requesting provider The resident is notified by mail if the request is denied or downgraded Reasons for denial include documentation that does not meet the criteria of a medical condition that is appropriate for transport by ambulance or that the resident is not Medicaid eligible for the dates of services requested or the request is submit ted after the transport has been provided Residents may appeal prior authorization request denials by contacting TMHP Client Notification at 1 800 414 3406 The requesting NF or other requesting provider contacts the transporting ambulance provider and supplies the ambulance provider with the PAN and the dates of service that were approved Requesting providers are not required to fax medical documentation to TMHP however in certain circumstances TMHP may request supporting documentation Incomplete online
139. a Form 3619 Medicare Co insurance must be submit ted prior to submission of the MDS LTCMI to be discussed later Form 3619 Medicare Skilled Nursing Facility Patient Transaction Notice Purpose of Form 3619 Form 3619 is for recipients who fall under the Medicare Co insurance category and provides information about the status of a Medicaid applicant or recipient It provides information to Medicaid for the Elderly and People with Disabil ities MEPD worker about the status of a Medicare Co insurance applicant or individual Form 3619 provides DADS with information to initiate close or adjust Medicare Skilled Co insurance payments The dates of qualifying stay are tracked by DADS Traditional Medicare will pay for up to 100 days stay in an SNE After the first 20 days the facility must look to private pay third party insurance or Medicaid to pay the deductible portion of the remaining days Occasionally Medicare Medicaid eligible recipients may be discharged and readmitted under the same Medicare authorization These recipients are eligible for 100 days of skilled nursing care per spell of illness and may use their days in several short term stays or in one long stay v 2013 1127 51 LTC Nursing Facility Hospice User Guide Form 3619 establishes the 20 qualifying days of full Medicare coverage Form 3619 Admission must be completed on the 21st day to begin Medicare Co insurance Before submitting Form 3619 Admission the recipient
140. a fall in the 6 months prior to admission entry or reentry 0 No 1 Yes 9 Unable to determine J1800 Any Falls Since Admission Entry or Reentry or Prior Assessment OBRA or Scheduled PPS whichever is more recent d any falls since admission entry or reentry or the prior assessment OBR PPS whichever is more recent 0 No gt Skip to K0100 Swallowing Disorder 1 Yes Continue to J1900 Number of Falls Since Admission Entry or Reentry or Prior Assessment OBRA or Scheduled PPS J1900 Number of Falls Since Admission Entry or Reentry or Prior Assessment OBRA or Scheduled PPS whichever is more recent J Enter Codes in Boxes A No injury no evidence of any injury is noted on physical assessment by the nurse or primary care clinician no complaints of pain or injury by the resident no change in the resident s Coding behavior is noted after the fall 0 None i 1 One B Injury except major skin tears abrasions lacerations superficial bruises hematomas and 5 Two r more sprains or any fall related injury that causes the resident to complain of pain C Major injury bone fractures joint dislocations closed head injuries with altered consciousness subdural hematoma MDS 3 0 Nursing Home Comprehensive NC Version 1 11 2 Effective 10 01 2013 Page 22 of 41 Resident Identifier Date SectionK Swallowing Nutritional Status K0100 Swallowing Disorder Signs and symptoms of possible sw
141. act Last M NF Contact Initial Name Suffix N NF is willing and able to serve O NF Admitted the P NF Date of Entry individual individual v 0 No vj fi Q Comments ww Add NF Choice v 2013 1127 175 LTC Nursing Facility Hospice User Guide PASRR Level 1 Screening Section E gt v TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TM ASTATE MEDICAID CONTRACTOR Home Submit Form Form Status Inquiry Current Activity Drafts Vendors Letters Printable Forms Alerts Help PASRR LEVEL 1 SCREENING Current Status Name DLN O Section A Section B Section C Section E Section F Section D Sect wE Alternate Placement Preferences E0100 Where Check all that apply would this individual like Ito live now Live alone with support A place where there is 24 hour care A B C A Group home D Family Home E Other F Other Location gt G Unknown E0200 Comments about where Ihe individual would like to live F E E0300 Living Check all that apply Arrangement Options By themselves With a roommate With a lot of friends A B O c With family D E Other F Other Individual B O G Unknown E0400 Comments about with S whom the individual would like to e live Alternate Placement Disposition E0500 Admissi
142. acting forms is available in the Counteracting Forms section of this User Guide Once inactivated a form will not be available for further processing but it may be used as template Forms 3071 and 3074 cannot be inactivated and MDS assessments must be inactivated through CMS in accordance with the MDS 3 0 Resident Assessment Instrument RAI Users Manual Additional information will be given on inactivations in the Inactivations section of this User Guide Note fa new PL1 is submitted for a client with an existing PL1 the previous PL1 and any associated PE will be system atically inactivated TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP IMHP ASTATE MEDICAID CONTRACTOR Home Submit Form Form Status Inquiry Current Activity Drafts Vendors Printable Forms Alerts Help 3618 RESIDENT TRANSACTION NOTICE Current Status Processed Complete Name t DLN Add Note Form Actions Print Use as template Correct this form p Inactivate Form Note The steps to inactivate will be covered in the Inactivations section of this User Guide Form Actions Available When Assessment is Set to Status Awaiting LTC Medicaid Information Current Status Awaiting LTC Medicaid Information Name DLN RUG RAA Form Actions Save LTCMI Populate LTCMI Save LTCMI The Save LTCMI feature allows providers to save the LTCMI section so that any entered LTCMI data is not lost until ready to subm
143. aff Assessment of Resident Mood PHQ 9 OV 1 Yes Continue to D0200 Resident Mood Interview PHQ 96 D0200 Resident Mood Interview PHQ 90 Say to resident Over the last 2 weeks have you been bothered by any of the following problems If symptom is present enter 1 yes in column 1 Symptom Presence If yes in column 1 then ask the resident About how often have you been bothered by this Read and show the resident a card with the symptom frequency choices Indicate response in column 2 Symptom Frequency 1 Symptom Presence 2 Symptom Frequency 0 No enter O in column 2 0 Never or 1 day 1 2 1 Yes enter 0 3 in column 2 1 2 6 days several days Symptom Symptom 9 Noresponse leave column 2 2 7 11 days half or more of the days Presence Frequency blank 3 12 14 days nearly every day A Little interest or pleasure in doing things B Feeling down depressed or hopeless C Trouble falling or staying asleep or sleeping too much D Feeling tired or having little energy E Poor appetite or overeating F Feeling bad about yourself or that you are a failure or have let yourself or your family down G Trouble concentrating on things such as reading the newspaper or watching television H Moving or speaking so slowly that other people could have noticed Or the opposite being so fidgety or restless that you have been moving around a lot more than usual OO OOOO O O L Thoughts that you would be better off d
144. ain Assessment Interview be Conducted Attempt to conduct interview with all residents If resident is comatose skip to J1100 Shortness of Breath dyspnea Enter Code 0 No resident is rarely never understood gt Skip to and complete J0800 Indicators of Pain or Possible Pain 1 Yes Continue to J0300 Pain Presence Pain Assessment Interview J0300 Pain Presence Enter Code Ask resident Have you had pain or hurting at any time in the last 5 days 0 No Skip to J1100 Shortness of Breath 1 Yes Continue to J0400 Pain Frequency 9 Unable to answer Skip to J0800 Indicators of Pain or Possible Pain J0400 Pain Frequency Ask resident How much of the time have you experienced pain or hurting over the last 5 days Almost constantly Frequently Occasionally Rarely Unable to answer J0500 Pain Effect on Function Enter Code A Askresident Over the past 5 days has pain made it hard for you to sleep at night Enter Code 0 No 1 Yes 9 Unable to answer B Askresident Over the past 5 days have you limited your day to day activities because of pain Enter Code 0 No 1 Yes 9 Unable to answer J0600 Pain Intensity Administer ONLY ONE of the following pain intensity questions A or B A Numeric Rating Scale 00 10 Ask resident Please rate your worst pain over the last 5 days on a zero to ten scale with zero being no pain and ten as the worst pain you can imagine Show resident 00 10 pain
145. al 2 Click the Submit Form link located in the blue navigational bar 3 Type of Form Choose 3619 Medicare SNF patient Transaction Notice from the drop down box 52 v 2013 1127 LTC Nursing Facility Hospice User Guide 4 Click the Enter Form button 5 Enter all required information as indicated by the red dots Enter at least one of the following Medicaid Recipient No Social Security No or Medicare of RR Retire ment Claim No Indicate either an admission or discharge transaction Medicaid does not pay for Date of Death on Medicare Co insurance clients Location indicates where the client is admitting from or discharging to Date of Above transaction will be the actual admission or discharge date Enter the Qualifying stay dates equal to 20 days If Full Medicare is more than two time periods use multiple forms with the same Date of Above Transaction to submit the 20 days of Full Coverage The Last Name must match exactly what is shown on the Medicaid card 6 From here you have two choices a b Click the Submit Form button to submit the form or Click the Save as Draft button to store the form for future use but not submit it The form does not have to be complete to save the draft Note If the form is successfully submitted a DLN will be assigned and the LTC Online Portal will show Your form was submitted successfully If there are submission errors they will be displayed i
146. all three The words are sock blue and bed Now tell me the three words Enter Dash if unable to assess Number of words repeated after first attempt 0 None 1 One 2 Two 3 Three After the individual s first attempt repeat the words using cues sock something to wear blue a color bed a piece of furniture You may repeat the words up to two more times Temporal Orientation orientation to year month and day Ask individual Please tell me what year it is right now Enter Dash if unable to assess A Able to report correct year 0 Missed by gt 5 years or no answer 1 Missed by 2 5 years 2 Missed by 1 year 3 Correct Ask individual What month are we in right now Enter Dash if unable to assess B Able to report correct month 0 Missed by gt 1 month or no answer 1 Missed by 6 days to 1 month 2 Accurate within 5 days Ask individual What day of the week is today Enter Dash if unable to assess C Able to report correct day of the week 0 Incorrect or no answer 1 Correct Recall Ask individual Let s go back to an earlier question What were those three words that asked you to repeat If unable to remember a word give cue something to wear a color a piece of furniture for that word Enter Dash if unable to assess Enter A Able to recall sock _ 0 No could not recall 1 Yes after cueing something to wear 2 Yes no cue required Able to reca
147. allowing disorder J Check all that apply A Loss of liquids solids from mouth when eating or drinking B Holding food in mouth cheeks or residual food in mouth after meals C Coughing or choking during meals or when swallowing medications D Complaints of difficulty or pain with swallowing Z None of the above K0200 Height and Weight While measuring if the number is X 1 X 4 round down X 5 or greater round up A Height in inches Record most recent height measure since the most recent admission entry or reentry B Weight in pounds Base weight on most recent measure in last 30 days measure weight consistently according to standard facility practice e g in a m after voiding before meal with shoes off etc K0300 Weight Loss Loss of 596 or more in the last month or loss of 1096 or more in last 6 months EntenGode 0 Noor unknown 1 Yes on physician prescribed weight loss regimen 2 Yes not on physician prescribed weight loss regimen K0310 Weight Gain Gain of 5 or more in the last month or gain of 10 or more in last 6 months EntenCode 0 Noor unknown 1 Yes on physician prescribed weight gain regimen 2 Yes not on physician prescribed weight gain regimen K0510 Nutritional Approaches Check all of the following nutritional approaches that were performed during the last 7 days 1 While NOT a Resident Performed while NOT a resident of this facility and within the las
148. and the date is not included in the 10096 Medicare Part A reimbursement time frame Administrator e State Board License No Administrator Last Name Administrator First Name e Is Administrator Signature on Form O e Date Signed bal 7 From here you have two choices a Click the Save as Draft button in the yellow Form Actions bar to save the form or screening until you are ready to submit The form or screening does not have to be complete to save the draft or b Click the Submit Form button located at the bottom of the screen to submit the form or screening v 2013 1127 15 LTC Nursing Facility Hospice User Guide Form Status Inquiry FSI The FSI feature provides a query tool for monitoring the status of documents that have been successfully submitted FSI allows providers to retrieve submissions in order to Access documents to research and review statuses e Provide additional information to an assessment e Retrieve documents to make corrections or perform inactivations e Resolve any forms or assessments set to status Provider Action Required e Export search results to Microsoft Excel Note FSI can retrieve information from the previous seven years The search is based on the TMHP Received Date 1 Click the Form Status Inquiry link in the blue navigational bar TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRAC
149. any given level apply the following o When there is a combination of full staff performance and extensive assistance code extensive ass istance o When there is a combination of full staff performance weight bearing assistance and or non weight bearing assistance code limited assistance 2 If none of the above are met code supervision 1 ADL Self Performance Code for resident s performance over all shifts not including setup If the ADL activity occurred 3 or more times at various levels of assistance code the most dependent except for total dependence which requires full staff performance every time Coding Activity Occurred 3 or More Times Independent no help or staff oversight at any time Supervision oversight encouragement or cueing Limited assistance resident highly involved in activity staff provide guided maneuvering of limbs or other non weight bearing assistance Extensive assistance resident involved in activity staff provide weight bearing support Total dependence full staff performance every time during entire 7 day period Activity Occurred 2 or Fewer Times Activity occurred only once or twice activity did occur but only once or twice Activity did not occur activity did not occur or family and or non facility staff provided care 10096 of the time for that activity over the entire 7 day period A Bed mobility how resident moves to and from lying position turns side to side and
150. appear to follow objects Severely impaired no vision or sees only light colors or shapes eyes do not appear to follow objects Enter Code Enter Code Enter Code Enter Code B1200 Corrective Lenses Enter Code Corrective lenses contacts glasses or magnifying glass used in completing B1000 Vision 0 No 1 Yes MDS 3 0 Nursing Home Comprehensive NC Version 1 11 2 Effective 10 01 2013 Page 6 of 41 Resident Identifier Date Section C Cognitive Patterns C0100 Should Brief Interview for Mental Status C0200 C0500 be Conducted Attempt to conduct interview with all residents 0 No resident is rarely never understood Skip to and complete C0700 C1000 Staff Assessment for Mental Status 1 Yes Continue to C0200 Repetition of Three Words Brief Interview for Mental Status BIMS C0200 Repetition of Three Words Ask resident am going to say three words for you to remember Please repeat the words after I have said all three The words are sock blue and bed Now tell me the three words Number of words repeated after first attempt 0 None 1 One 2 Two 3 Three After the resident s first attempt repeat the words using cues sock something to wear blue a color bed a piece of furniture You may repeat the words up to two more times C0300 Temporal Orientation orientation to year month and day Ask resident Please tell me what year it is right now Enter Code A Able to re
151. assessment return anticipated 12 Death in facility tracking record 99 None of the above Enter Code G Type of discharge Complete only if A0310F 10 or 11 1 Planned 2 Unplanned A0410 Submission Requirement Enter Code 1 Neither federal nor state required submission 2 State but not federal required submission FOR NURSING HOMES ONLY 3 Federal required submission A0500 Legal Name of Resident A First name B Middle initial TT ETT Titty ty C Last name D Suffix ITI A0600 Social Security and Medicare Numbers A Social Security Number B Medicare number or comparable railroad insurance number ITIITI A0700 Medicaid Number Enter if pending N if not a Medicaid recipient A o A0800 Gender Enter Code 1 Male 2 Female A0900 Birth Date A1000 Race Ethnicity Check all that apply A American Indian or Alaska Native B Asian C Black or African American D Hispanic or Latino E Native Hawaiian or Other Pacific Islander MDS 3 0 Nursing Home Comprehensive NC Version 1 11 2 Effective 10 01 2013 Page 2 of 41 Resident Identifier Date SectionA Identification Information A1100 Language A Doesthe resident need or want an interpreter to communicate with a doctor or health care staff 0 No 1 Yes Specify in A1100B Preferred language 9 Unable to determine Enter Code B Preferred language
152. assword TMHP 99 ing a different email account If you do not have a parate email account you may set up one for free with Yahoo To ensure delivery directly to your inbox please add donotreply amp tmhp com to your address box today Retype email address Do not cut and paste Confirm Email L haracters no spaces or special characters New Password Confirm Password GENERAL TERMS AND CONDITIONS You have entered the secure portion ofthe Texas Medicaid amp Healthcare Partnership TMH employees consultants and subcontractors site Throughout the terms herein reference to TMHP means TMHP ACS State Healthcare LLC its parent company affiliates subsidiaries Terms of Use By accepting the terms of use you will be allowed access to programs reports and information protected by federal and state law contained in the secure portion of this website Only authorized persons in lawful possession of a password provided by TMHP to provide such passwords may enter and access the secure portion of this website The use of this website is subject to the terms of use contained herein Once you have accepted the terms of use you will not be asked to accept such terms again when you access the site another time TMHP has the right at any time to change or modify the terms of use which will be posted on this website L Any use ofthe website by you after modified terms have been posted will be deemed t
153. at interfered with daily functions or placed individual at risk of injury Coding 4 Enter Codes in Boxes 0 No impairment A Upper extremity shoulder elbow wrist hand 1 Impairment on one side 2 Impairment on both sides B Lower extremity hip knee ankle foot G0600 Mobility Devices Check all that were normally used L A Cane crutch O B Walker L C Wheelchair manual or electric 1 D Limb prosthesis L Z None of the above were used G0900 Functional Rehabilitation Potential Complete only if A0310A 01 Enter Code A Individual believes he or she is capable of increased independence in at least some ADLs L 0 No 1 Yes 9 Unable to determine Enter Code B Caregiver believes individual is capable of increased independence in at least some ADLs 0 No 1 Yes No information not assessed MN and LOC 3 0 V 15 11 of 32 Individual Identifier Date SY ini u Bladder and Bowel H0100 Appliances Check all that apply A Indwelling catheter including suprapubic catheter and nephrostomy tube B External catheter C Ostomy including urostomy ileostomy and colostomy D Intermittent catheterization Z None of the above H0200 Urinary Toileting Program Enter C Current continence promotion program or trial Is an individualized continence promotion program e g scheduled toileting prompted voiding or b
154. athing support codes are as defined in item G0110 column 2 ADL Support Provided above G0300 Balance During Transitions and Walking After observing the resident code the following walking and transition items for most dependent J Enter Codes in Boxes A Moving from seated to standing position Coding Steady at all times B Walking with assistive device if used Not steady but able to stabilize without staff assistance i Mo ee Not steady only able to stabilize with staff C Turning around and facing the opposite direction while walking assistance Activity did not occur D Moving on and off toilet E Surface to surface transfer transfer between bed and chair or wheelchair G0400 Functional Limitation in Range of Motion Code for limitation that interfered with daily functions or placed resident at risk of injury J Enter Codes in Boxes Coding 0 No impairment A Upper extremity shoulder elbow wrist hand 1 Impairment on one side 2 Impairment on both sides B Lower extremity hip knee ankle foot G0600 Mobility Devices J Check all that were normally used A Cane crutch B Walker C Wheelchair manual or electric D Limb prosthesis Z None of the above were used MDS 3 0 Nursing Home Quarterly NQ Version 1 11 2 Effective 10 01 2013 Page 13 of 35 Resident Identifier Date SectionH Bladder and Bowel H0100 Appliances i Check a
155. ation for your facility processed 3618 or 3619 admission Review the facility s records to determine which discharge is prior to this admission Pull a MESAV and review the Service Authorizations to determine the authorized services If the MDS for the recipient has not processed you will not have services authorized If the recipient has an ongoing Service Authorization with a begin date prior to the rejected admission If the current Service Authorization is for Full Medicaid Code 1 a 3618 discharge must be processed prior to resubmitting the rejected 3619 admission If the current Service Authorization is for Medicare Part A Coin surance Code 3 a 3619 discharge must be processed prior to resubmitting the rejected 3619 admission If the recipient does not have Service Authorizations on the MESAV use the statuses on the LTC Online Portal to determine the forms that have processed Remember authorizations will only display if the MDS has also processed If the most recent processed form is a 3618 admission prior to the rejected 3619 admission a 3618 discharge must be processed prior to resubmitting the rejected 3619 admission v 2013 1127 121 LTC Nursing Facility Hospice User Guide Alerts Alerts are notices to a user to perform some action on a PL1 or PE The LTC Online Portal creates alerts automati cally when some action needs to take place Nursing Facility users can also create alerts t
156. ave noticed Or the opposite being so fidgety or restless that you have been moving around a lot more than usual OO OOOO O O L Thoughts that you would be better off dead or of hurting yourself in some way D0300 Total Severity Score Add scores for all frequency responses in Column 2 Symptom Frequency Total score must be between 00 and 27 Enter Score Enter 99 if unable to complete interview i e Symptom Frequency is blank for 3 or more items D0350 Safety Notification Complete only if D020011 1 indicating possibility of resident self harm Enter Code Was responsible staff or provider informed that there is a potential for resident self harm 0 No 1 Yes Copyright Pfizer Inc All rights reserved Reproduced with permission MDS 3 0 Nursing Home Quarterly NQ Version 1 11 2 Effective 10 01 2013 Page 9 of 35 Resident Identifier Date D0500 Staff Assessment of Resident Mood PHQ 9 OV Do not conduct if Resident Mood Interview D0200 D0300 was completed Over the last 2 weeks did the resident have any of the following problems or behaviors If symptom is present enter 1 yes in column 1 Symptom Presence Then move to column 2 Symptom Frequency and indicate symptom frequency 1 Symptom Presence 2 Symptom Frequency 0 No enter 0 in column 2 0 Never or 1 day Symptom Symptom 1 Yes enter 0 3 in column 2 1 2 6 days several days Presence Frequency 2 7 11 days half or more of the days
157. be Conducted Attempt to conduct interview with all residents Enten ode 0 No resident is rarely never understood Skip to and complete D0500 D0600 Staff Assessment of Resident Mood PHQ 9 OV 1 Yes Continue to D0200 Resident Mood Interview PHQ 96 D0200 Resident Mood Interview PHQ 90 Say to resident Over the last 2 weeks have you been bothered by any of the following problems If symptom is present enter 1 yes in column 1 Symptom Presence If yes in column 1 then ask the resident About how often have you been bothered by this Read and show the resident a card with the symptom frequency choices Indicate response in column 2 Symptom Frequency 1 Symptom Presence 2 Symptom Frequency 0 No enter O in column 2 0 Never or 1 day 1 2 1 Yes enter 0 3 in column 2 1 2 6 days several days Symptom Symptom 9 Noresponse leave column 2 2 7 11 days half or more of the days Presence Frequency blank 3 12 14 days nearly every day A Little interest or pleasure in doing things B Feeling down depressed or hopeless C Trouble falling or staying asleep or sleeping too much D Feeling tired or having little energy E Poor appetite or overeating F Feeling bad about yourself or that you are a failure or have let yourself or your family down G Trouble concentrating on things such as reading the newspaper or watching television H Moving or speaking so slowly that other people could h
158. be available 2 All information will populate into the current LTCMI except for fields Sle Purpose Code S1f Missed Assess ment or Prior Start Date S1g Missed Assessment or Prior End Date and 10 Comments To populate information on a new LTCMI click the Populate LTCMI button located in the yellow Form Actions bar Be sure to review the auto populated information for accuracy and add any new information if needed Once the LTCMI is complete and accurate the provider may choose to save the information by clicking the Save LTCMIT button or the assessment may be submitted to TMHP by clicking the Submit Form button 30 v 2013 1127 LTC Nursing Facility Hospice User Guide Other Basic Information Required Fields Within the LTC Online Portal red dots indicate required fields Fields without the red dot are optional TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR Home Submit Form Form Status Inquiry Current Activity PIEL endors Printable Forms Alerts Help Form Status Inquiry Form Select Type of Form m vendor Numbe e v Form Status Inquiry DLN Medicaid Number Last Name First Name Form Status v SSN L CARE ID From pat bams W To pat e so wr PASRR Eligibility v Discharged Deceased v History Every document will have a History trail of statuses
159. button gt Ifthe provider opens a draft form or assessment from the Drafts link Correct this form The Correct this form feature is available for the LTCMI section of the MDS and for Forms 3071 3074 3618 and 3619 Corrections are not allowed if a document is set to status Form Inactivated Invalid Complete SAS Request Pending or Corrected Click the Correct this form button to correct a previously submitted LTCMI or form Home Submit Form Form Status Inquiry Current Activity Drafts Vendors Printable Forms Alerts Help UnLock Form MINIMUM DATA SET MDS VERSION 3 0 RESIDENT ASSESSMENT AND CARE SCREENING Nursing Home Comprehensive NC Item Set Current Status Processed Complete Name E 6 4 DLN RUG RAA I Correct this form Add Note Section A Section B Section C Section D Section E Section F Section G Section H Section I Section J Section K Section L Section M Section N Section O Section P Section Q Section V Section X Section Z Section LTCMI Note The steps to correct a form or an LI CMI are covered in the Corrections section of this User Guide 2013 1127 27 LTC Nursing Facility Hospice User Guide Update Form The Update Form feature allows users to make corrections to a PL1 Specific information about updating the PL1 can be found in the PASRR Level 1 Screening Updates section of this User
160. cal Avie int e coo ream bM Eb aa rA Re PARE FRAME DER RSEN MERE ous 156 Helplul Contact Informatiounen ena eR EEEE PVC FO EUR NELL E EE OK FUR KR 156 Informational rir RM H 158 Minimum Data Set MDS Quick Reference Guide eesssssesssseseeeeereeenennenn ener 160 MDS Telephone N mi Ders Rn 160 MDS Informational We st 065 asictsiasalsntspsvonsapcedorappendedeel ants E E E R EE Rd Dra ned 160 Cro NS A eee oe oe E E ae mr eee E E NE 161 iv v 2013 1127 LTC Nursing Facility Hospice User Guide Appendix A Medicaid Eligibility Verification Resident with Medical Eligibility 164 Appendix B Medicaid Eligibility Verification Resident with Pending Medicaid Eligibility 166 Append C i PT 1 e 168 Appendix D LTC Online Portal ReyIew ioneascott ncenct eee resins pou van nk Mesue oed rcu EE ERA SEE Fai inda 169 Appendix E PASRR Level 1 Screening aii diee ende bee tise Dacian n pete blond hd tasca dui en npa iE rd sa ER i 171 PASRR Level Screening Section ca ies ctinntcuics cues sR ais cubito eal eas ocala Sac Cn DU URDU UD aes 172 PASRR Level 1 Sercening Section D arrsa eaen ae NEEE ru Undo ERE Ton ere Nett re er X cet cO ir RETENE 173 PASRR Level 1 Screening Section P UI 174 PASRR Level 1 Screening Section D s 175 PASRE Level 1 Sorestun
161. can be sorted by clicking the column header of the Alerts list Alerts can be deleted Once deleted they can not be retrieved The Alert Subject column provides a brief description of the alert Click the Alert Subject link to see the alert detail v 2013 1127 123 LTC Nursing Facility Hospice User Guide V a TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR Home Submit Form Form Status Inquiry Current Activity Drafts Vendors Printable Forms Alerts Alerts Dutgoing Alerts Select BEY GREET ymaa Mit TN B 4 28 2013 MI gt 4 27 2013 IDD The alert detail describes exactly what needs to be done It also provides information about the individual and a link to the current PL1 or PE 7 Click the Return to Alerts Page button at the top of the page to return to the Alerts list V a TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR Home Submit Form Form Status Inquiry Current Activity Drafts Vendors Printable Forms Alerts Help Return To Alerts Page Subject Conduct PASRR Evaluation First Notification Sent 4 16 2013 2 16 13 PM An individual exhibiting signs of MI and or IDD requires a PASRR Evaluation This Face to Face assessment must be completed within 7 calendar days of this notification and the associated PASRR Evaluation must be submitted on the TMHP LTC Online Portal Admitting Nursing Facility NPI S Vendor No
162. cant correction to prior comprehensive assessment 06 Significant correction to prior quarterly assessment 99 None of the above PPS Assessment Entereode PPS Scheduled Assessments for a Medicare Part A Stay 01 5 day scheduled assessment 02 14 day scheduled assessment 03 30 day scheduled assessment 04 60 day scheduled assessment 05 90 day scheduled assessment 06 Readmission return assessment PPS Unscheduled Assessments for a Medicare Part A Stay 07 Unscheduled assessment used for PPS OMRA significant or clinical change or significant correction assessment Not PPS Assessment 99 None of the above PPS Other Medicare Required Assessment OMRA No Start of therapy assessment End of therapy assessment Both Start and End of therapy assessment Change of therapy assessment Enter Code Enter Code D Is this a Swing Bed clinical change assessment Complete only if A0200 2 LI 0 No 1 Yes A0310 continued on next page MDS 3 0 Nursing Home Comprehensive NC Version 1 11 2 Effective 10 01 2013 Page 1 of 41 Resident Identifier Date SecionA Identification Information A0310 Type of Assessment Continued Enter Code E Is this assessment the first assessment OBRA Scheduled PPS or Discharge since the most recent admission entry or reentry 0 No 1 Yes Enter Code F Entry discharge reporting 01 Entry tracking record 10 Discharge assessment return not anticipated 11 Discharge
163. ccessfully but unnecessarily submitted via LTC Online Portal The assess ment will suspend for six months and if the resident never applies for Medicaid the status will be set to Med ID Check Inactive 144 v 2013 1127 LTC Nursing Facility Hospice User Guide MN Approved Medical Necessity met MN Denied Medical Necessity has not been met View the History trail for detailed status and information about the denial of MN Negative PASRR Eligibility The PL1 did not indicate that the individual has a diagnosis of Mental Illness Intellectual Disability or Developmental Disability NF Placement Process Exhausted This is a PL1 status which occurs when an individual has not been placed in an NF or alternate setting within 90 days of submitted PE Out of State RN License Invalid The state issuing the compact license has indicated the compact RN license is invalid Overturned Doctor Review Assessment was denied medical necessity and then provider supplied more infor mation Assessment is pending Pending Applied Income Applied Income validation is pending Validation attempts occur nightly until applied income is found request canceled or until six months has expired whichever comes first Contact the Medicaid Eligibility Worker Pending Denial needs more information TMHP nurse did not find the assessment to qualify for Medical Necessity Provider has 21 calendar days to submit additional information for consideratio
164. ce Hospice Contract Name e TEST PROVIDER CM2 Number 000000000 Phone Number Address H E City State TX v Zip 9 ewe Physician Information Physician First Name 9 Physician Last Name 9 State License Mo 9 Date of Orders 9 7 Signatures HospiceRep First Name 9 HospiceRep Last Name 9 Is Signature on File 9 Date Signed 9 7 Is Client Signature on File Client Date Signed T i Submit Form v 2013 1127 57 LTC Nursing Facility Hospice User Guide Hospice Form 3074 Medicaid Medicare Physician Certification of Terminal Illness Form 3074 is used to certify that the recipient has a diagnosis of six months or less to live if the illness runs its normal course and to complete enrollment for the Medicaid Hospice program This form may also be used for Medicare physician certification The provider must maintain a blank Form 3074 on file for reproduction An original can be obtained by submitting a written request to Medicaid Hospice Program Department of Aging and Disability Services Provider Forms PO Box 149030 Mail Code E205 Austin Texas 787 14 9030 This form is also located on line at www tmhp com Pages LTC Itc_forms aspx or on the TMHP LTC Online Portal under the Printable Forms feature The physician completes Form 3074 when a recipient elect
165. cian First Mame Name 9 Hospice Physician Signature on Oo Date Signed 7 File License Type State of TX Lic Num State License No 9 Exclusion Statement Exclusion Exclusion Statement Last Statement Name First Name Is obi o Date Signed Tl Submit Form 60 v 2013 1127 LTC Nursing Facility Hospice User Guide MDS Assessments The LTC MDS is a standardized primary screening and assessment tool of health status that forms the founda tion of the comprehensive assessment for all recipients in a Medicare or Medicaid certified LTC facility The MDS contains items that measure physical psychological and psychosocial functioning The items in the MDS give a multidimensional view of the resident s functional capacities and helps staff to identify health problems Assessments that providers may submit to CMS and for Medicaid payment include e Admission assessment required by day 14 e Quarterly review assessment e Annual assessment Significant change in status assessment e Significant correction to prior comprehensive assessment e Significant correction to prior quarterly assessment e nactivation e Modification MDS 3 0 assessments that are accepted by federal CMS are retrieved by TMHP nightly loaded onto the LTC Online Portal and set to status Awaiting LTC Medicaid Information Once the LTCMI has been successfully completed and submitted on the LTC Online Portal the MN determination process w
166. ck the Submit Form button again to submit the form Click the DLN link displayed in the Your form was submitted successfully message to return to the form 10 Click the Print button in the yellow Form Actions bar to print the completed form Form 3071 and 3074 Corrections Hospice providers must submit Forms 3071 and 3074 corrections directly on the LTC Online Portal All fields except the Contract Number can be corrected on the Forms 3071 and 3074 Correction to Forms 3071 and 3074 1 2 Bs Nn Y 9 Log in to the LTC Online Portal Click the Form Status Inquiry link in the blue navigational bar Search for Form 3071 or 3074 using the recipient s SSN Medicaid recipient number First and Last Name or DLN Click the Search button Click the View Detail link Click the Correct this form button Complete only the fields needing correction Click the Submit Form button Note Ifthe form is successfully submitted a DLN will be assigned and the LTC Online Portal will show Your form was submitted successfully If there are errors they will be displayed in a box at the top of the screen These errors will need to be resolved before the form will be successfully submitted Once all errors are resolved click the Submit Form button again to submit the form Click the DLN link displayed in the Your form was submitted successfully message to return to the form 10 Clic
167. considered incomplete Recurring up to 60 days Prior authorization requests for recurring transports are for those residents whose medical condition is such that use of an ambulance is the only appropriate means of transport The authorization period for a short term request is from 2 to 60 days The request must be signed and dated by a physician PA NP or CNS Stamped or computerized signatures and dates are not accepted Without a signature and date the form will be considered incomplete If a prior authorization request has been approved and additional procedure codes are needed because the client s condition has deteriorated or the need for equipment has changed the requesting provider must submit a new Nonemergency Ambulance Prior Authorization Request form If the resident already has a valid short term or long term PAN the PAN may be used for the ambulance transport Nonemergency Ambulance Exception Request Residents may qualify for an exception to the 60 day prior authorization request if their physician has documented a debilitating condition that requires recurring trips over more than 60 days For exception requests the provider must submit the following completed forms and documentation e Nonemergency Ambulance Exception form e Nonemergency Ambulance Prior Authorization Request form e Medical records that support the resident s debilitating condition Supporting Documentation Supporting documentation is required to b
168. contributory factors More than one factor may apply to a fall Indicate the number of SE NEO Rhone falls for each contributory factor 1 Environmental debris slick or wet floors lighting etc 2 Medication s 3 Major Change in Medical Condition Myocardial Infarction MI Heart Attack Cerebrovascular Accident CVA Stroke Syncope Fainting etc 4 Poor Balance Weakness 5 Confusion Disorientation 6 Assault by Individual or Caregiver 30 of 32 Individual Identifier Date LTC Medicaid Information S9 Medications List all medications that the individual received during the last 30 days Include scheduled medications that are used regularly but less than weekly Medication Certification certify this individual is taking no medications OR the medications listed below are correct 1 Medication Name and Dose Ordered MN and LOC 3 0 V 15 31 of 32 Individual Identifier Date LTC Medicaid Information S10 Comments 11 Advance Care Planning S11a Does the individual caregiver report having a legally authorized representative Y N S11b Does the individual caregiver report having a Directive to Physicians and Family or Surrogates Y N S11c Does the individual caregiver report having a Medical Power of Attorney Y N S11d Does the individual caregiver report having an Out of Hospital Do Not Resuscitate Order Y N S12 LAR
169. creening aie rt A erba rti UE PIRE A EEEE etos b Ra Ra Po Me GF ORE RUM ER 42 Medical Necessity and the MN Determination Process ccscsscsseesesseseeseeeesseseeaeenceaeeesecaeeaeeeceecaeeaeeaeeeeaaeass 43 Definition of Medical Necessity pecteiiebesis boi onu Uu ivti eb aed nudato cauta beducb bet ud as bsp etos Roske Qu udo du pita 43 General Qualifications for Medical Necessity Determinations 2e sdsxblas eese ctu edo rt tO hoa bas Ves PT P UE P2 ENS po dE raus 44 Medical Necessity Determination Process ecce eteete ertet eger Ee rto cen DAE DURER OR Dre RC Rx Ee a 45 Upcoming Changes to the MN Determination Process for PASRR Individuals eese 46 Regusst gt Wa earning coss eas Aee tesco cel dubbed E EER er eta ect pe I pr ud epit duct du 46 Forms to be Submitted uo opas cn Aa cease sao bad UBL Drs E EE EAE EE E A woven Bun Mp PN ad eds Ap lE 48 Formos Resident Transaction NOU und eec ec uo ducis nae s ado bn up I LEUR pol REOS EEEE ERE 48 Purposcof Form 3618 NN liens 48 Repercussions ar Submitting Porn 3019 Latesan enen RR S PU rd bd b Km NEQU SEXE o eed lai 49 How to Submit Form 251 8 adeste amare acia bv eee ey DD E Oe Mee eer anne octo ee i ent oT ney 49 Form 3619 Medicare Skilled Nursing Facility Patient Transaction Notice ssssccssacicessievsasasitesesatdssarsteseseaslacnans ad Purtposeof Form 3G T c M 51 Repercussions af Submitting Form 3619 Late uie atit renibus
170. cted discharge and new admission on the same day v 2013 1127 115 LTC Nursing Facility Hospice User Guide Form Assessment 3619 Discharge Mod Provider Message Displayed in History NF 0058 This discharge modifica tion cannot be processed because the new discharge date would Suggested Action For each Medicare Spell of Illness the state will pay a maximum of 80 days of Medicare Part A Coinsurance to one or more providers The recipient will exceed the 80 day limit if this correction is pro result in more than 80 days of Medicare Part A Coinsurance for this Spell of Illness Confirm the 80 days of Coinsurance and submit any additional modifications NF 0059 This discharge modifica tion cannot be processed because the new discharge would create an overlap with an existing Service Authorization Verify the Service Authorizations already established and submit any additional modifi cations 3618 3619 Discharge Mod cessed as submitted Review the facility s records to determine the recipient s admission and discharge dates and identify the Spell of Illness Pull a MESAV and review the Service Authorizations to determine the number of Coinsurance days on file plus the number of new days that would be added by the rejected later discharge date Verify the begin and end dates of the Service Authorizations on file based on the actual admissions and discharges that have occurred Remember that the
171. d Notification Complete IDD Section on the PE Complete MI Section on the PE v 2013 1127 125 LTC Nursing Facility Hospice User Guide 4 Enter the PLI Screening DLN or PE DLN if applicable 5 Enter the Vendor No and Contract No for the LA to whom the alert will be sent a Enter client identifying information 7 Click the Send Alert button The Create Alert window will close and you will be returned to the Alerts page Deleting Alerts Alerts can be deleted by a user When you have completed the action requested on an alert you may want to delete the alert Once an alert is deleted it cannot be retrieved 1 Select the alert you wish to delete by clicking the box in the Select column next to the alert You can select multiple alerts TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR Home Submit Form Form Status Inquiry Current Activity Drafts Vendors Printable Forms Alerts Alerts Create Alert Delete Alert Outgoing Alerts vi 4 28 2013 MI El Conduct 4 27 2013 IDD Second Notification 2 Click the Delete Alert button above the alert list 3 Aconfirmation message is displayed Click che OK button to delete the alert click the Cancel button if you do not want to delete the alert 126 v 2013 1127 LTC Nursing Facility Hospice User Guide Corrections and Updates Corrections can be made to certain fields on
172. d call 512 438 2200 Option 3 or fax the Medicare Replace ment s EOB with a copy of the 3619 to 512 438 3400 attention Medicare Advantage Plan For each Medicare Spell of Illness the state will pay a maximum of 80 days of Medicare Part A Coinsurance to one or more providers The recipient will exceed the 80 day limit if the admission is pro cessed as submitted Review the recipient s Medicare remittance to determine the Medicare dates for the Spell of Illness for this admission Pull a MESAV and review the Service Authorizations to determine which authorizations are covered by the Spell of Illness for this admission Validate the dates of the Spell of Illness to see if this admission is part of the prior stay or if it begins a new Spell of Illness more than 60 days between Code 3 Service Authorizations Submit corrections of any earlier 3619s as needed and resubmit this rejected admission accordingly If the prior Spell of Illness was not ended properly submit a 3619 discharge or 3619 correction to adjust the Code 3 to reflect the proper end date of that Spell of Illness Now that the 60 days between Spells of Illness has been resolved resubmit the rejected admission v 2013 1127 109 LTC Nursing Facility Hospice User Guide Form Assessment 3619 Discharge Provider Message Displayed in History NF 0032 This discharge cannot be processed because the client does not have a Service Authorization for
173. d days allowed for the recipient during a 12 month period Medicaid Swing Bed services are limited to 30 days per stay Verify dates and if the submitted date is wrong correct the rejected admission and resubmit v 2013 1127 103 LTC Nursing Facility Hospice User Guide Provider Message Form Displayed in History Assessment NF 0012 This form cannot be 3618 3619 processed because the client is cur rently in Hospice If the client is no longer enrolled in the Hospice pro gram contact the Hospice provider and request that they discharge the client from the program Once the Hospice discharge is processed resubmit your form If the client is a Hospice recipient inactivate your form NF 0013 This admission cannot be 3618 Admit processed because it is effective during a Service Authorization for a different provider Correct the admission date or contact the other provider to determine proper dates NF 0014 This admission cannot 3618 Admit be processed because an earlier admission into your facility has already been processed Verify the discharges and admissions for this client and submit the missing discharge Resubmit this admis sion once the previous discharge is submitted Suggested Action The recipient has a Service Authorization for Hospice as of the effec tive date of the submitted form Review the facility s records to determine if the recipient is Hospice If the recipie
174. d nurses supervision assessment planning and intervention that are avail able only in an institution 2 wa The individual must require medical or nursing services that A are ordered by the physician B are dependent upon the individual s documented medical conditions C require the skills of a registered nurse or licensed vocational nurse D are provided either directly by or under the supervision of a licensed nurse in an institu tional setting and E are required on a regular basis Note Medical Necessity is not the only prerequisite to qualify for Medicaid eligibility 44 v 2013 1127 LTC Nursing Facility Hospice User Guide Medical Necessity Determination Process TMHP reviews assessment to determine medical necessity Pending Denial NF provides NF does not provide additional information additional information TMHP TMHP physician approves TMHP physician denies TMHP nurse approves physician approves The individual has the right to appeal Individual s physician provides additional information MN approved MN denied 1 MN determinations are made on MDS assessments The flowchart above provides a high level overview of the process used for MN determination Providers can use the LTC Online Portal to check the status of MN determination 2 Submissions are reviewed by the TMHP nurse for MN determination withi
175. d resubmit GN 9254 This form cannot be pro cessed because the provider is not authorized to provide services on the effective date of the form Cor rect the effective date as needed For 3619 admissions resubmit once the Medicare contract is effective in the system Suggested Action The recipient s applied income is not available to DADS Pull a MESAV for the recipient covering the date requested on the form or assessment Note f the recipient does not already have Service Authorizations for your contract this information will not be available on the MESAV If the MESAV does not show an Applied Income for the dates of the form or assessment contact the HHSC Eligibility Worker to update the Applied Income records Once the Applied Income has been updated resubmit the rejected form or assessment If the recipient is already estab lished in your facility you may monitor the MESAV for updated Applied Income If the MESAV does show an Applied Income for the dates of the form or assessment resubmit the rejected form or assessment The recipient s Medicaid eligibility is not available to DADS Pull a MESAV for the recipient covering the date requested on the form or assessment Note f the recipient does not already have Service Authorizations for your contract this information will not be available on the MESAV If the MESAV does not show Long Term Care Financial Eligibility for the dates of the form or asse
176. d through parenteral or tube feeding 1 25 or less 2 26 5096 3 5196 or more B Average fluid intake per day by IV or tube feeding 1 500 cc day or less 2 501 cc day or more Oral Dental Status L0200 Dental J Check all that apply A Broken or loosely fitting full or partial denture chipped cracked uncleanable or loose B No natural teeth or tooth fragment s edentulous C Abnormal mouth tissue ulcers masses oral lesions including under denture or partial if one is worn D Obvious or likely cavity or broken natural teeth E Inflamed or bleeding gums or loose natural teeth F Mouth or facial pain discomfort or difficulty with chewing G Unable to examine Z None of the above were present MDS 3 0 Nursing Home Comprehensive NC Version 1 11 2 Effective 10 01 2013 Page 24 of 41 Resident Identifier Date SectionM _ Skin Conditions Report based on highest stage of existing ulcer s at its worst do not reverse stage M0100 Determination of Pressure Ulcer Risk J Check all that apply A Resident has a stage 1 or greater a scar over bony prominence or a non removable dressing device B Formal assessment instrument tool e g Braden Norton or other C Clinical assessment Z None of the above M0150 Risk of Pressure Ulcers Enter Code Is this resident at risk of developing pressure ulcers 0 No
177. date of the rejected discharge is later than the Service Authorization end date by more than one day the discharge exceeds the 80 day limit of Coinsurance An earlier discharge and readmission may be needed prior to the rejected discharge to allow for additional days before reaching 80 day limit If so submit the missing or rejected forms If the transaction date of the rejected discharge is earlier than the Service Authorization end date the forms may have attempted to process out of order If the admission was processed after the 3619 rejected resubmit the rejected discharge Once the missing or rejected forms are processed resubmit the rejected discharge This discharge is part of a retroactive pair Review the facility s records to determine which admission is after this discharge Pull a MESAV and review the Service Authorizations The discharge and admission should split one of the authorizations when these forms process Once identified the discharge and admission must be submitted on the same day as a pair If the form is not part of a pair it should be a correcting discharge not a new discharge Inactivate this form and correct the transac tion date of the later discharge This form is part of a retroactive pair The other half of the pair failed to process so this form could not be processed alone Determine how to resolve the problem that caused the other half of this pair to be rejected Review the facility s recor
178. day or less 2 501 cc day or more Oral Dental Status L0200 Dental J Check all that apply A Broken or loosely fitting full or partial denture chipped cracked uncleanable or loose F Mouth or facial pain discomfort or difficulty with chewing MDS 3 0 Nursing Home Quarterly NQ Version 1 11 2 Effective 10 01 2013 Page 20 of 35 Resident Identifier Date SectionM _ Skin Conditions Report based on highest stage of existing ulcer s at its worst do not reverse stage M0100 Determination of Pressure Ulcer Risk J Check all that apply A Resident has a stage 1 or greater a scar over bony prominence or a non removable dressing device B Formal assessment instrument tool e g Braden Norton or other C Clinical assessment Z None of the above M0150 Risk of Pressure Ulcers Enter Code Is this resident at risk of developing pressure ulcers 0 No 1 Yes M0210 Unhealed Pressure Ulcer s Enter Code Does this resident have one or more unhealed pressure ulcer s at Stage 1 or higher 0 No gt Skip to M0900 Healed Pressure Ulcers 1 Yes Continue to M0300 Current Number of Unhealed Pressure Ulcers at Each Stage M0300 Current Number of Unhealed Pressure Ulcers at Each Stage Number of Stage 1 pressure ulcers Stage 1 Intact skin with non blanchable redness of a localized area usually over a bony prominence Darkly pigmented skin may not
179. de of the resident s MD DO mailing address This information is used to mail MN determination letters S3m MD DO Phone Optional This field is optional if S3f License State is NOT Texas Enter the telephone number of the resident s MD DO This information is used to contact MD DO if necessary S4 Licenses Provider Certification On behalf of this facility certify to the completeness of the MDS Assessment S4a RN Coordinator Last Name Required Enter the last name of the RN Assessment Coordinator v 2013 1127 73 LTC Nursing Facility Hospice User Guide LTCMI Fields S4b RN Coordinator License Required Enter the license number of the RN Coordinator Licenses issued in Texas will be validated against the Texas BON Board of Nursing or Compact License will be validated with the issuing state s nursing board This number is validated to ensure RUG training requirements have been met The license numbers supplied at S4b must be RUG trained as offered by Texas State University The assessment will not be accepted on the LTC Online Portal if the license is not indicated as having completed the RUG training The RUG training is online web based training as offered by Texas State University The training is valid for two years The name entered in S4a should match the name in section Z0500A Note An error will occur if the license number does not pass validation The asses
180. der Self Reported Incidents jaasiwccctssnceassiswceeensncstsnsercdidpevnctassonalaalowestlaencetinsovccsusevcclaaionetiavoessesavervins Option 5 Survey Documents DADS literatttE riesieiisiy ecesscsiues sucnoannsspeventcewadeiaauwsvavencadiaisdaanep ie PREN SEAE Option 6 Community Services Contracts Unit Sup pet ts issceepaneesonsnnreseseseanenneetarenen decent cosornatestecntrenenmtnnoanetiaens 512 438 2080 Community Services Contracts Voice Mail Contract Applications Reenrollments and Reporting Changes such as address and telephone number 512 438 3550 Criminal History TIN Cv cece weit vee EUR een eee un tasas ke heen tna we ae Orr punt EEEN EE TEES 512 438 2363 Facility Licensure Certification Reporting Changes such as Service Area and Medical Director 512 438 2630 Home and Community Support Services Unit Hospice Regulatory Requirements 512 438 3161 156 v 2013 1127 LTC Nursing Facility Hospice User Guide Hospice Policy Medicaid Program Support and Special Services Unit hospice dads state tx us Institutional Services CORSEBEBTB oo i tie was cece bio HG tee vnica Econ uU UE AR RET E N 512 438 2546 Medication Aide Program P M 512 231 5800 Bluse Aide Registry ss leo decmitnevitre atena Mr ekepi cerae oae peu a epi EEEE Ea eO 1 800 452 3934 Nurse Aide Vireo eei bei b Rubi Veri dat Go ede Seca obe to M t eb ea UR can olt idu
181. der clicks the Correct this form button a parent child DLN relationship will be created 14 If the provider clicks the Inactivate Form button the provider will receive the following confirmation window v 2013 1127 ue LTC Nursing Facility Hospice User Guide From here you have two choices a Click the OK button to inactivate and the form or assessment status will be set to status Form Inactivated or b Click the Cancel button to cancel the Inactivation request keeping the form or assessment set to status Provider Action Required TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR Home Submit Form Form Status Inquiry Current Activity Drafts Vendors Printable Forms Alerts Help UnLock Form 3618 RESIDENT TRANSACTION NOTICE Current Status Provider Action Required Name 9 8 DIN Form Actions Workflow Actions Print Use as template Correct this form Add Note Inactivate Form Resubmit Form Provider Information OR SS ae Peete St eye Ce 4 GO Ano WRN CR tm m db itd Microsoft Internet Explorer AA a Vendor Number ti 3 ore yo Sure YOu act bo Iniactiyatn this Forma Contract Number Va HB He NPI Number ramen Ca Cem Recipient Information 1 Medicaid Recipient No 4 e Recipient s Last 5 Address Address 2 Social Security No Name NER City 3 Medicare or RR o Reaperi ise Cc State Reti laim No etirement Ca
182. dicaid MDS 3 0 A0700 Medicare MDS 3 0 A0600B First Name and Last Name MDS 3 0 A0500A and A0500C Information used to identify the resident associated with the submission Status The status of the assessment at the time of the search RUG The assigned Resource Utilization Group RUG value RN Signature Date Date assessment was completed as identified in field 3 0 Z0500B Purpose Code if applicable Purpose Code E Missed Assessment Purpose Code M Used when three month prior retroactive eligibility has been established Contract Number The nine digit provider number Vendor Number Ihe four digit site identification number Reason for Assessment MDS 2 0 AA8a MDS 3 0 A0310A MDS 2 0 Reason for Assessment Codes 01 Admission assessment required by day 14 MDS 3 0 Reason for Assessment Codes 01 Admission assessment required by day 14 02 Annual assessment 02 Quarterly review assessment 03 Significant change in status assessment 03 Annual assessment 04 Significant correction of prior full assessment 04 Significant change in status assessment 05 Quarterly review assessment 05 Significant correction to prior comprehensive assessment 10 Significant correction of prior quarterly assessment 06 Significant correction to prior quarterly assessment Delete Providers are able to delete unwanted or unnecessary comprehensive
183. dicators of Psychosis i Check all that apply Z None of the above Behavioral Symptoms E0200 Behavioral Symptom Presence amp Frequency Note presence of symptoms and their frequency A Hallucinations perceptual experiences in the absence of real external sensory stimuli B Delusions misconceptions or beliefs that are firmly held contrary to reality i Enter Codes in Boxes A Coding Behavior not exhibited Behavior of this type occurred 1 to 3 days Behavior of this type occurred 4 to 6 days but less than daily C Behavior of this type occurred daily E0800 Rejection of Care Presence amp Frequency Physical behavioral symptoms directed toward others e g hitting kicking pushing scratching grabbing abusing others sexually Verbal behavioral symptoms directed toward others e g threatening others screaming at others cursing at others Other behavioral symptoms not directed toward others e g physical symptoms such as hitting or scratching self pacing rummaging public sexual acts disrobing in public throwing or smearing food or bodily wastes or verbal vocal symptoms like screaming disruptive sounds Did the resident reject evaluation or care e 9 bloodwork taking medications ADL assistance that is necessary to achieve the resident s goals for health and well being Do not include behaviors that have already been addressed e g by discussion or care plann
184. dified inactivated osos social Security Number on esing recordo be modero 0000 X0600 Type of Assessment on existing record to be modified inactivated A Federal OBRA Reason for Assessment 01 Admission assessment required by day 14 02 Quarterly review assessment 03 Annual assessment 04 Significant change in status assessment 05 Significant correction to prior comprehensive assessment 06 Significant correction to prior quarterly assessment 99 None of the above Enter Code PPS Assessment PPS Scheduled Assessments for a Medicare Part A Stay 01 5 day scheduled assessment 02 14 day scheduled assessment 03 30 day scheduled assessment 04 60 day scheduled assessment 05 90 day scheduled assessment 06 Readmission return assessment PPS Unscheduled Assessments for a Medicare Part A Stay 07 Unscheduled assessment used for PPS OMRA significant or clinical change or significant correction assessment Not PPS Assessment 99 None of the above PPS Other Medicare Required Assessment OMRA No Start of therapy assessment End of therapy assessment Both Start and End of therapy assessment Change of therapy assessment X0600 continued on next page Enter Code Enter Code MDS 3 0 Nursing Home Quarterly NO Version 1 11 2 Effective 10 01 2013 Page 31 of 35 Resident Identifier Date SectionX Correction Request X0600 Type of Assessment Continued EnterCode D Is this a Swing Bed c
185. discharge date results in a Service Authorization end date one day earlier than the transaction date Submit any corrections needed because of incorrect begin or end dates If these corrections will reduce the total number of Coinsur ance days to 80 days or less the rejected discharge should be resubmitted once the new correction forms have processed If the begin and ends on file are correct and the recipient has a Medicare Replacement policy that allows more than 80 days state this in the comment section of the 3619 and call 512 438 2200 Option 3 or fax the Medicare Replacement EOBs with a copy for the 3619 to 512 438 3400 attention Medicare Advantage Plan If the Spell of Illness involved another facility and your facility s begin and end dates are correct except for the correction review your Medicare Remittance If the Medicare Remittance advice validates that Coinsurance is due for the time period that your 36195 indicate fax them with a copy of the 3619s to 512 438 3400 attention ECF Form Processing or call 512 438 3400 Option 3 If all the begin and end dates on the MESAV are correct except for the discharge the rejected form is attempting to correct the last discharge date will need to be adjusted so the total of the new days added plus the adjusted existing dates equal 80 or less days The rejected discharge should then be resubmitted The later discharge date on this correction will create an overlap with existin
186. discharge to the hospital prior to the Medicare stay has been submitted If not submit that 3618 discharge If it was rejected resolve the issue and resubmit that 3618 discharge Determine if the 3619 admission to begin Medicare Part A Coinsurance has been submitted If not submit that 3619 admission If it was rejected resolve the issue and resubmit that 3619 admission Resubmit the rejected 3619 discharge after the missing or corrected forms have been processed If the recipient should not be classified as Medicare on this discharge date Determine if the discharge should be a 3618 discharge instead If so inactivate the rejected form and submit a 3618 discharge to close the recipient s file The recipient has a Service Authorization with a different provider as of the submitted discharge date e Review the facility s records to identify the Medicare Part A Coin surance admission date prior to this discharge Determine if the 3619 admission prior to this discharge has been submitted If not submit that 3619 admission If it was rejected resolve the issue and resubmit that 3619 admission Resubmit the rejected 3619 discharge after the missing or corrected admission has been processed The recipient has a Service Authorization with a different pro vider that begins after the submitted discharge date The rejected discharge and matching admission and must be submitted as a retroactive pair Review the facility recor
187. ds to determine which transaction is the other half of the pair If the discharge date is before the admission date the pair is creating a gap in a Service Authorization Pull a MESAV and review the Service Authorizations The discharge and admission should split one of the authorizations when these forms process If the admission date is before the discharge date the pair is filling a gap between or prior to Service Authorizations Pull a MESAV and review the Service Authorizations to see if a gap exists for the period that will be created by the admission and discharge pair Once resolved resubmit the pair together on the same date 110 v 2013 1127 LTC Nursing Facility Hospice User Guide Form Assessment 3618 Admit Mod Provider Message Displayed in History NF 0046 This admission modifica tion cannot be processed because the new admission date of this modification is later than the exist ing enrollment end date Modify the admission date and resubmit this form or inactivate this form and modify the correspond ing discharge form to make it a counteracting form cancelling the admission timeframe NF 0047 This assessment modifica MDS Mod tion cannot be processed because Admit Annual it is an invalid change to an existing Quarterly Purpose Code NF 0048 This assessment cannot be processed because more than one assessment was submitted on the same day with the same assess ment effec
188. ds to identify the Medicare Part A Coin surance admission date prior to this discharge Determine if the 3619 admission prior to this discharge has been submitted If not submit that 3619 admission If it was rejected resolve the issue and resubmit that 3619 admission Resubmit the rejected 3619 discharge on the same day as the missing or corrected admission The recipient has a Service Authorization that begins after the submitted discharge date The rejected discharge and matching admission and must be submitted as a retroactive pair Review the facility records to identify the Medicare Part A Coin surance admission date prior to this discharge Determine if the 3619 admission prior to this discharge has been submitted If not submit that 3619 admission If it was rejected resolve the issue and resubmit that 3619 admission Resubmit the rejected 3619 discharge on the same day as the missing or corrected admission 118 v 2013 1127 LTC Nursing Facility Hospice User Guide Form Assessment 3618 Discharge Provider Message Displayed in History NF 0069 This discharge cannot be processed because the client is admitted by a different provider If an admission prior to this discharge is missing or rejected the admis sion must be processed prior to this discharge NF 0070 This admission cannot be processed because it would cancel the client s Enrollment with a dif ferent provider Verify the effective da
189. e LTCMI Fields Important Ensure that the information entered in the LTCMI does not conflict with information entered in the MDS assessment E eee TMHP ASTATE MEDICAID CONTRACTOR Home Submit Form Form Status Inquiry Current Activity Drafts Vendors Printable Forms Alerts Help a UnLock Form MINIMUM DATA SET MDS Version 3 0 RESIDENT ASSESSMENT AND CARE SCREENING Nursing Home Comprehensive NC Item Set Current Status Awaiting LTC Medicaid Information Name DLN RUG SE2 Form Actions Print Add Note T Save TeMi Populate remi T3 Section A Section B Section c al Section D m Section E n Section F Section G Section H i JL Section K Section L J Section O Section P Section Q Section V Section X l Section Z ection Medicaid Information S1 Claims Processing Information Sia DADS Vendor Site ID Number Sib Contract Provider Number Sic Service Group Sid Hospice Contract Number Sie Purpose Code m M sif I j nent ri tar t inal Sig Missed Assessment Prior E inal S2 PASARR Information S2a To your knowledge does the resident have an intellectual x disability S2b To your knowledge does the resident have a developmental a disability S2c To your knowledge does the resident have a condition of mental illness according to the PASARR guidelines S2d Is th
190. e is rejected and the Date of Above Transaction is prior to the most recent Service Authorization begin date on the recipient s Medicaid Eligibility Service Authorization Verification MESAV contact DADS PCS to request manual processing Ifa Form 3618 or 3619 needs to be resubmitted and is set to status Submitted to manual workflow click the Correct this form button add a comment example Resubmit then click the Submit Form button If the steps above do not resolve the error message continue on to the Specific Instructions section for the specific Provider Message displayed in the History trail of the form or assessment and its Suggested Action to correct the message 100 v 2013 1127 LTC Nursing Facility Hospice User Guide Specific Instructions Form Assessment 3618 3619 MDS Provider Message Displayed in History GN 9101 GN 9105 This form cannot be processed because the client s Applied Income is not avail able to DADS Contact the HHSC Eligibility Worker to update the client s Applied Income Once the Applied Income has been updated this form can be resubmitted GN 9106 This form cannot be processed because DADS does not have Long Term Care Financial Eligi bility for this client and timeframe Contact the HHSC Eligibility Worker or SSI office 3618 3619 MDS GN 9248 This form cannot be pro cessed due to one or more invalid Diagnosis Codes Correct the Diag nosis Codes an
191. e LTC Online Portal 2 Click the Form Status Inquiry or Current Activity link in the blue navigational bar a Ifusing FSI you may search for an MDS using SSN Medicaid Number or DLN Click the Search button then click the View Detail link b Ifusing Current Activity click the DLN link v 2013 1127 127 LTC Nursing Facility Hospice User Guide 3 Click the Correct this form button Home Submit Form Form Status Inquiry Current Activity Drafts Vendors Printable Forms Alerts Help amp MINIMUM DATA SET MDS VERSION 3 0 RESIDENT ASSESSMENT AND CARE SCREENING Nursing Home Comprehensive NC Item Set Current Status Processed Complete Name W E 884 DLN RUG RAA Form Actig C correctthis form Casin Section A Section B Section C Section D Section E Section F Section G Section H Section I Section J E Section K Section L Section M Section N Section O Section P l _Section Q Ik Section V Section X Section Z Section LTCMI 4 Click the Section LTCMT tab and complete only the fields needing correction Texas MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR Home Submit Form Form Status Inquiry Current Activity Drafts Vendors PrintableForms Alerts Help MINIMUM DATA SET MDS VERSION 3 0 RESIDENT ASSESSMENT AND CARE SCREENING Nursing Home Comprehensive NC I
192. e Missed Assessment or Prior Start Date must be on or after 09 01 2008 End date cannot be prior to the Start Date ment or Prior r ment or Prior En 88 v 2013 1127 LTC Nursing Facility Hospice User Guide MDS Purpose Code M The Purpose Code M is used when Prior Medicaid Eligibility has been established Prior eligibility can begin up to three months prior to certifica Note A Purpose Code M can tion of Medicaid Purpose Code M can only be submitted on the Admission only fill a gap for which prior assessment Annual assessment or Quarterly review assessment eligibility has previously been established Payment is made at Missed Assessment Start and End Dates are used by the provider to identify the full calculated RUG rate the Prior Medicaid period The MESAV must reflect a Medicaid coverage Check MESAV to ensure eligibil type of P prior eligibility ity code of P or TP11 BEFORE The LTCMI section should include the submission ofa PC M e Sle M Purpose Code Coverage Code must be P Home TMHP com My Account IMHP R a TexMedConnect Authorization Message me aai r No Data p Monthly Units oap Template Service Group Service Code Effective Year Month Max Units Available Units Paid MESAV Batch History Claims Claims Entry Individual Template Eligibility Group Template Drafts Pending Batch Batch History End Date 10 31 2010 Begin Date Co
193. e Nursing Facility www dads state tx us providers nf index cfm Nursing Facility MDS Coordinator Support Site http qmweb dads state tx us mdsweb ovr e PASRR www dads state tx us providers pasrr index html e Provider Letters www dads state tx us providers communications letters cfm such as 2011 128 2011 38 2010 89 and 0927 Resources for DADS Service Providers www dads state tx us providers index cfm Department of State Health Services DSHS www dshs state tx us DSHS Local Mental Health Authority Search www dshs state tx us mhservices search e DSHS PASRR Information http www dshs state tx us mhsa pasrr Health and Human Services Commission HHSC www hhsc state tx us index shtml e HHSC Regions www hhsc state tx us research dssi brt IM0 pdf e Vendor Drug Program www hhsc state tx us hcf vdp vdpstart html 158 v 2013 1127 LTC Nursing Facility Hospice User Guide Other e Centers for Medicare amp Medicaid Services www cms gov e Department of State Health Services www dshs state tx us e National Provider Identifier NPI To obtain https nppes cms hhs gov NPPES Inform DADS www dads state tx us providers hipaa forms html e Texas Administrative Code www sos state tx us tac index shtml e Texas State RUG Training www txstate edu continuinged professional development PD Online RUG Training html Federal MDS 3 0 site www cms gov NursingHomeQualityIni
194. e Quarterly NQ Version 1 11 2 Effective 10 01 2013 Page 3 of 35 Resident Identifier Date SectionA Identification Information A1550 Conditions Related to ID DD Status If the resident is 22 years of age or older complete only if A0310A 01 If the resident is 21 years of age or younger complete only if A0310A 01 03 04 or 05 J Check all conditions that are related to ID DD status that were manifested before age 22 and are likely to continue indefinitely ID DD With Organic Condition A Down syndrome C Epilepsy D Other organic condition related to ID DD ID DD Without Organic Condition E ID DD with no organic condition No ID DD Z None of the above A1600 Entry Date date of this admission entry or reentry into the facility A1700 Type of Entry Enter Code 1 Admission LI 2 Reentry A1800 Entered From EROR Community private home apt board care assisted living group home Another nursing home or swing bed LI Acute hospital Psychiatric hospital Inpatient rehabilitation facility ID DD facility Hospice Long Term Care Hospital LTCH Other A2000 Discharge Date Complete only if A0310F 10 11 or 12 A2100 Discharge Status Complete only if A0310F 10 11 or 12 EET CAE Community private home apt board care assisted living group home Another nursing home or swing bed LII Acute hospital Psychiatric hospital Inpa
195. e TexMedConnect would like to Einen quc Program Information Click the links below to perform tasks and access provider applications online claims filing Click DADS Information Letters Unsecured Provider Tasks here w The following tasks can be performed without logging to a provider account a Forms ctivate my account ases Provider Support Se MDS 3 0 pide 6 From here you have two choices a To create a new TMHP User Account without an existing provider vendor account click the New Username and Enroll link ifselected go to step 8 Provider Type step b To create a new TMHP User Account with an existing provider vendor account click the New Username and Activate Existing Provider link if selected go to step 7 6 v 2013 1127 LTC Nursing Facility Hospice User Guide va IMHP Navigation amp S TMHP com Account Activation Home TMHP com My Account Welcome to the Account Activation portion of TMHP com The following instructions will help providers choose the correct option for creating TMHP User Accounts and activating Texas Medicaid or Children with Special Health Care Needs Services Program CSHCN Provider Vender Accounts online If you do not have a TMHP User Account choose one of the following options o To create a TMHP User Account and begi Medicaid or the CSHCN Services Program fclick New Username and Enroll o To create a TMHP User
196. e can be submitted Rejection of 3619 Discharge following a 3618 3619 discharge received following a 3618 regardless of contract on form Submit either a 3618 discharge or 3619 admission as appropriate prior to this 3619 Discharge Date of Above Transaction is over one year old do you want to continue When submitting a form that is between one and five years old providers will receive this warning message The provider will have an option to select OK or Cancel before the form will continue to process If a provider submits a Date of Above Transaction that is equal to or more than five years old the form will not be accepted onto the LTC Online Portal Additionally forms with a future date in the Date of Above Transaction field will not be accepted onto the LTC Online Portal Please provide a reason in the comments field why the Dates of Qualifying Stay for this client do not equal 20 The Dates of Qualifying Stay must add up to exactly 20 non duplicative days If the Dates of Qualifying Stay do not equal 20 a comment is required in the Comments field Correct the Dates of Qualifying Stay to equal 20 If the dates do not equal 20 days because additional space is needed add a comment to the form indicating that additional forms are being submitted to capture the full 20 days If the client has a Medicare replacement policy indicate the following information in the comments e Med
197. e cannot be corrected or resubmitted The inactivation request will be submitted against assessments that have processed If the assessment can be located and the HHSC Office of Inspector General OIG has not addressed the assessment the assessment will be canceled and any associated payments will be recouped If the inactivation is submitted on an assessment that has been chosen by OIG the inactivation will reject with an appropriate error message If the system fails to identify the assessment the inactivation will also reject and be researched manually by DADS With each situation a response will be posted on the LTC Online Portal Note Refer to the MDS 3 0 RAI User s Manual Chapter 5 for detailed instructions on completing an MDS Inactivation The Users Manual can be found under Downloads on the CMS website at www cms gov NursingHomeQualityInits 25 NHQIMDS30 asp Note Providers should only submit an inactivation on dually coded assessments after attempting to submit a modification via CMS An inactivation will affect Medicare as well as Medicaid reimbursement Forms 3618 and 3619 Inactivations Forms 3618 and 3619 inactivations must be submitted directly on the LTC Online Portal after being located by a search using FSI or Current Activity Once the inactivation is submitted and accepted the form is set to status Form Inactivated and is unavailable for any further action v 2013 1127 137 LTC Nursing Facility Hospice User Gu
198. e comments section of Form 3619 e Medicare Replacement e Name of the insurance carrier e Number of Co insurance payment days allowed under the Medicare replacement policy e Daily Co payment amount 54 v 2013 1127 LTC Nursing Facility Hospice User Guide Hospice Form 3071 Election Cancellation Discharge Notice Form 3071 is used to notify DADS of a Medicaid Hospice recipient s voluntary election or cancellation of the Texas Hospice program or to update changes in the Medicaid Hospice recipient s location and status Each Form 3071 should be completed by the Hospice staff either as an election an update or a cancellation If the form is intended to elect a recipient into the Hospice program check the ELECT box and include only the FROM Date An Individual or Responsible Party signature is required on all Elect form types If the form will update information already provided on an existing election document check the UPDATE box include only the FROM Date and complete the appropriate fields Forms indicating Update do not require an Indi vidual or Responsible Party signature Complete an update transaction to document if the contract numbers change because of a Change in Ownership or a transfer between Hospice providers or if the recipient changes location from to community or nursing home Updates should be submitted when a provider needs to change the informa tion for future services If it is necessary to correct previously s
199. e form restarted If different the incorrect information will need to be corrected and the form or assessment resubmitted Note Correctable fields vary by form or assessment type See the Corrections section of this User Guide on page page 127 Ifthe Medicaid card MESAV is incorrect contact the local eligibility worker to have the file corrected Med ID Check Inactive In this status the Medicaid ID validation was attempted nightly for six months and either failed or the request was canceled If the resident is certified for Medicaid after six months the form or assessment can be reactivated by the provider by clicking on the Reactivate form button v 2013 1127 91 LTC Nursing Facility Hospice User Guide 3 Pending Medicaid Eligibility validation will result in either Medicaid Eligibility Confirmed If confirmed it continues to next validation Pending Medicaid Eligibility In this status validation attempts will occur nightly until eligibility is found the request is canceled or until six months has expired whichever comes first If Medicaid Eligibility has already been established the provider may contact TMHP to have the form or assessment restarted After Medicaid Eligibility has been established the provider must allow 14 days for the systems to interface AFTER 14 days the provider may call TMHP to have the form or assessment restarted ME Check Inactive In this status
200. e health care programs As of January 1 2004 Reporting Fraud ACS State Healthcare LLC under contract with the Texas Health and Human Services Commission HHSC assumed k administration of claims processing for Texas Medicaid and Provider Lookup other state health care programs ACS a XEROX All Sites v P Advanced Search Log In Log in to My Account Go to TexMedConnect va TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR Click here to Medicaid Home t changes to procedure Texas Medicaid Provi age All Sites v P Advanced Search Log In va TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR Log In to LTC Online Portal Jj Log In to TexMedConnect 5 Enter your User name and Password v 2013 1127 11 LTC Nursing Facility Hospice User Guide 6 Click the OK button After log in Form Status Inquiry FSI will display by default Home Submit Form va TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR Form Status Inquiry Form Status Inquiry Current Activity Drafts Vendors Printable Forms Alerts Help Form Select Type of Form vendor Number e Form Status Inquiry DLN Last Name Form Status SSN CARE ID From Date PASRR Eligibility Discharged Deceased Medicaid Number E First Name
201. e maintained by both the ambulance provider and the requesting provider including an NE physician health care provider or other responsible party LTC Nursing Facility Hospice User Guide An ambulance provider is required to maintain documentation that represents the resident s medical condition s and other clinical information to substantiate MN and the level of service and mode of transportation requested This supporting documentation is limited to documents developed or maintained by the ambulance provider Nursing facilities physicians health care providers or other responsible parties are required to maintain physi cian orders related to requests for prior authorization of nonemergency and out of state ambulance services These providers must also maintain documentation of medical necessity for the ambulance transport Appeals A denial of a prior authorization request may be appealed Residents may appeal prior authorization request denials by contacting TMHP Client Notification at 1 800 414 3406 v 2013 1127 149 LTC Nursing Facility Hospice User Guide RUG Training Requirements RUG training is intended for long term care nurses RUG training is designed to provide providers the requirements for completing RUG fields in assessments for Texas Medicaid payment Texas State University in cooperation with the OIG has made this training available through the Office of Continu ing Education s online course program
202. e new admission date would create an overlap with an existing Service Authorization Verify the Service Authorizations already established and submit any ad ditional modifications Suggested Action This form has been identified as part of a retroactive pair attempting to process together However a discharge marked Deceased cannot be processed as part of a retroactive pair since there is a subse quent admission on file Review the facility s records to determine the recipient s admission and discharge dates Pull a MESAV and review the Service Authorizations for this recipient Compare those dates to the dates that the recipient was in your facility If the discharge of the pair was submitted as a Death in error inactivate the form then resubmit it as a Discharge If the form was correctly used to report the recipient s death validate the transaction date and correct the form as needed If the transaction type Death and transaction date are correct identify the admission form that was submitted with an effective date after the death and correct the transaction date on that admission It may be necessary to contact DADS Provider Claims Services at 512 438 2200 Option 1 for assistance The earlier admission date on this correction will create an overlap with an existing Service Authorization if this correction is processed Review the facility s records to determine the recipient s admission and discharge dates and ident
203. e of Above Transaction minus one day Exception For a 3618 discharge marked Deceased use Date of Above Transaction instead because DADS pays for the date of death Confirm the transaction date for the rejected form and submit a correction of the date as needed If the date is correct but the form is under the incorrect contract inactivate the form and resubmit with the proper contract If there is not an active contract for the transaction date the submission will have to be held until the contract has been approved v 2013 1127 119 LTC Nursing Facility Hospice User Guide Provider Message Form Displayed in History Assessment NF 0075 This discharge cannot 3618 be processed because a different Discharge Contract Number for the same Ven dor Number is valid as of the form effective date Adjust the effective date or inactivate this discharge and submit for the correct Contract Number NF 0076 This admission assess MDS Admit ment cannot be processed because the Entry Date is earlier than the Service Authorization begin date Verify the Entry Date and correct it as needed or submit an ear lier 3618 3619 admission If the 3618 3619 admission and MDS Entry Date are correct contact Pro vider Claims Services for assistance NF 0077 This admission modifica 3619 Admit tion cannot be processed because Mod the new Full Medicare period would create an overlap with an existing Service Au
204. e processed date on the admission is prior to the MDS rejection contact DADS Provider Claims Services at 512 438 2200 Option 1 for assistance An assessment with the same effective date and a different As sessment Reason is already on file A Quarterly assessment cannot replace it Verify if the MDS Assessment Complete Date on the rejected assessment is correct If not submit a modification to the federal CMS database to correct it If the MDS Assessment Completion Date is correct determine which Reason for Assessment is appropriate and inactivate the other MDS If the processed assessment is inactivated the rejected assessment can be resubmitted once the inactivation is processed If the rejected assessment is inactivated no further actions are needed An assessment other than a Quarterly with the same effective date is already on file A Significant Correction to a Prior Quarterly cannot replace it Verify if the MDS Assessment Completion Date on the rejected assessment is correct If not submit a modification to the federal CMS database to correct it If the MDS Assessment Complete Date is correct determine which Reason for Assessment is appropriate and inactivate the other MDS If the processed assessment is inactivated the rejected assessment can be resubmitted once the inactivation is processed If the rejected assessment is inactivated no further actions are needed The provider has reached the limit of Swing Be
205. e resident a danger to himself herself E S2e Is the resident a danger to others vj S2f Are specialized services indicated Click this button to calculate recalculate the value in field S2f Determine Specialized Services S3 Physician s Evaluation amp Recommendation S3a Does the MD DO have plans for the eventual discharge of this resident sj S3b Rehabilitative Potential E S3c Did an MD DO certify that this resident requires continues to require nursing facility care E S3d MD DO Last Name S3e MD DO License S3f MD DO License State v S3g MD DO Military Spec Code E The following MD DO information is required if MD DO is not licensed in Texas S3h MD DO First Name S3i MD DO Address 1 S3j MD DO City 1 S3k MD DO State S3l MD DOZIPCode S3m MD DO Phone u S4 Licenses Provider Certification On behalf of this facility I certify to the completeness of the MDS Assessment S4a RN Coordinator Last Name S4b RN Coordinator License S4c RN Coordinator License State S5 Primary Diagnosis S5a Primary Diagnosis ICD Code amp S5b Primary Diagnosis ICD Description S6 Additional MN Information S6a Tracheostomy Care Seb entilator Respiratc S6c Number of hospitalizations in the last 90 days Sed Number of emergency room visits in the last 90 days S6e e Oxygen Therapy v sef Special
206. ead or of hurting yourself in some way D0300 Total Severity Score Add scores for all frequency responses in Column 2 Symptom Frequency Total score must be between 00 and 27 Enter score Enter 99 if unable to complete interview i e Symptom Frequency is blank for 3 or more items D0350 Safety Notification Complete only if D0200l1 1 indicating possibility of resident self harm EnterCode Was responsible staff or provider informed that there is a potential for resident self harm 0 No 1 Yes Copyright Pfizer Inc All rights reserved Reproduced with permission MDS 3 0 Nursing Home Comprehensive NC Version 1 11 2 Effective 10 01 2013 Page 9 of 41 Resident Identifier Date D0500 Staff Assessment of Resident Mood PHQ 9 OV Do not conduct if Resident Mood Interview D0200 D0300 was completed Over the last 2 weeks did the resident have any of the following problems or behaviors If symptom is present enter 1 yes in column 1 Symptom Presence Then move to column 2 Symptom Frequency and indicate symptom frequency 1 Symptom Presence 2 Symptom Frequency 0 No enter 0 in column 2 0 Never or 1 day Symptom Symptom 1 Yes enter 0 3 in column 2 1 2 6 days several days Presence Frequency 2 7 11 days half or more of the days 3 12 14 days nearly every day J Enter Scores in Boxes J Us 2 A Little interest or pleasure in doing things B Feeling or appearing down depressed or hopeless
207. ecent admission entry or reentry 0 No 1 Yes Enter Code F Entry discharge reporting 01 Entry tracking record 10 Discharge assessment return not anticipated 11 Discharge assessment return anticipated 12 Death in facility tracking record 99 None of the above Enter Code G Type of discharge Complete only if A0310F 10 or 11 1 Planned 2 Unplanned A0410 Submission Requirement Enter Code 1 Neither federal nor state required submission 2 State but not federal required submission FOR NURSING HOMES ONLY 3 Federal required submission A0500 Legal Name of Resident A First name B Middle initial TT ETT Titty ty C Last name D Suffix ITI A0600 Social Security and Medicare Numbers A Social Security Number ITHIL B Medicare number or comparable railroad insurance number ITIITI A0700 Medicaid Number Enter if pending N if not a Medicaid recipient A o A0800 Gender Enter Code 1 Male 2 Female A0900 Birth Date A1000 Race Ethnicity Check all that apply A American Indian or Alaska Native B Asian C Black or African American D Hispanic or Latino E Native Hawaiian or Other Pacific Islander MDS 3 0 Nursing Home Quarterly NQ Version 1 11 2 Effective 10 01 2013 Page 2 of 35 Resident Identifier Date SectionA Identification Information A1100 Language A Does the resident need or want an
208. ection G Section H Section I Section J Section K Section L Section M Section N Section O Section P Section Q Section V Section X Section Z Section LTCMI Parent Assessment History Trail Pending Changed by System on 10 7 2010 7 00 34 AM LTCMI Corrected 10 7 20 10 7 15 34 AM stem Correction request submitted from MDS database bae ahis 136 v 2013 1127 LTC Nursing Facility Hospice User Guide Inactivations MDS Assessment For MDS Inactivations NF providers complete the MDS Correction Request Form ensuring field X1050 on 3 0 corrections reason for inactivation was completed prior to submitting it to CMS TMHP will retrieve all suc cessfully submitted MDS Inactivation Requests from CMS for processing When the inactivation is placed on the LTC Online Portal TMHP will automatically inactivate the associated LTCMI and the assessment will set to status Form Inactivated unless the original assessment has been set to status Processed Complete However the LTCMI will not automatically be inactivated on the LTC Online Portal if the assessment had a previous status of Processed Complete which means it was already processed by the Service Authorization System SAS the assessment status will be set to SAS Request Pending and will be processed by SAS in their nightly batch routines Any MDS assess ment set to status Form Inactivated or Invalid Complet
209. ed a DLN when successfully submitted The provider can access the PL1 and the PE through FSI or Current Activity for status information Overview of PASRR Processes There are five different PASRR Processes Exempted Hospital Discharge Process Expedited Admission Process Preadmission Process Alternate Placement Process and Resident Review Process Below are diagrams explaining the different processes at a high level v 2013 1127 35 LTC Nursing Facility Hospice User Guide Admission Process for Exempted Hospital Discharge RE performs PL1 Expedited Admission Does individual meet criteria for Exempted Hospital Discharge No pacc ce RE follows Preadmission or Process EE RE sends PL1 to NF with individual NF submits PL1 on Portal immediately on receipt Is individual in NF after 30 days No gt NF indicates on PL1 that individual was discharged Portal alerts LA to perform PE gt LA performs PE within 72 hours of notification LA submits PE within 7 days of notification gt Payment for PE NF reviews PE and certifies able unable gt to serve on PL1 LA coordinates placement if NF is unable to serve 1 The Referring Entity RE performs the PL1 and determines if individual is eligible for Exempted Hospital Discharge If the individual does not meet Exempted Ho
210. ed in Bed A Bed rail B Trunk restraint C Limb restraint Coding 0 Not used 1 Used less than daily 2 Used daily Used in Chair or Out of Bed E Trunk restraint F Limb restraint G Chair prevents rising EEEE HEE SectionQ Participation in Assessment and Goal Setting Q0100 Participation in Assessment Enter Code A Resident participated in assessment 0 No 1 Yes B Family or significant other participated in assessment Enter Code 0 No 1 Yes 9 Resident has no family or significant other C Guardian or legally authorized representative participated in assessment Enter Code 0 No 1 Yes 9 Resident has no guardian or legally authorized representative Q0300 Resident s Overall Expectation Complete only if A0310E 1 A Select one for resident s overall goal established during assessment process Expects to be discharged to the community Expects to remain in this facility Expects to be discharged to another facility institution Unknown or uncertain Enter Code B Indicate information source for Q0300A 1 Resident 2 If not resident then family or significant other 3 If not resident family or significant other then guardian or legally authorized representative 9 Unknown or uncertain Q0400 Discharge Plan Enter Code Enter Code A Is active discharge planning already occurring for the resident to return to the community 0 No 1 Yes Skip to Q0600 Referral MDS 3 0 Nur
211. ed questions but responded to voice or touch stuporous very difficult to arouse goes changes in and keep aroused for the interview comatose could not be aroused severity Psychomotor retardation Did the individual have an unusually decreased level of activity such as sluggishness staring into space staying in one position moving very slowly C1600 Acute Onset Mental Status Change Is there evidence of an acute change in mental status from the individual s baseline 0 No 1 Yes No information not assessed Copyright 1990 Annals of Internal Medicine All rights reserved Adapted with permission MN and LOC 3 0 V 15 5 of 32 Individual Identifier Date SM Mood SSS D0100 Should Individual Mood Interview be Conducted Attempt to conduct interview with the individual 0 No Individual is rarely never understood OR individual is less than 7 years of age Skip to and complete D0500 D0600 Caregiver Assessment of Individual Mood PHQ 9 OV 1 Yes Continue to D0200 Individual Mood Interview PHQ 9 D0200 Individual Mood Interview PHQ 9 Say to individual Over the last 2 weeks have you been bothered by any of the following problems If symptom is present enter 1 yes in column 1 Symptom Presence If yes in column 1 then ask the individual About how often have you been bothered by this Read and show the individual a card with the symptom frequency choices
212. eference DADS Information Letter 06 83 found at www dads state tx us providers communications 2006 letters IL2006 83 pdf for additional information Note The reference to the 2006 TMHP Texas Medicaid Provider Procedures Manual in the DADS Informational Letter should instead reference the 2011 TMHP Texas Medicaid Provider Procedures Manual Volume 2 Ambulance Services Handbook To avoid liability for requested nonemergency ambulance transports be sure to follow Medicaid s requirements for prior authorization TMHP responds to nonemergency transport prior authorization requests within 48 hours of receipt of the request It is recommended that all requests for a prior authorization number PAN be submitted in sufficient time to LTC Nursing Facility Hospice User Guide allow TMHP to issue the PAN before the date of the requested transport If the resident s medical condition is not appropriate for transport by ambulance nonemergency ambulance services are not a benefit Prior authorization is a condition for reimbursement for the ambulance provider but is not a guarantee of payment The resident and the ambulance provider must meet all of the Medicaid requirements such as resident eligibility and claim filing deadlines The TMHP Ambulance Unit reviews the prior authorization requests to determine whether the resident s medical condition is appropriate for transport by ambulance Incomplete information may cause the request to be
213. ent on the assessment from the current Form 3618 Admission the provider will have to submit an MDS modi fication to allow the LTC Online Portal to retrieve the assessment Modifications should be submitted to CMS in accordance with the RAJ Users Manual Note Jf the last name on the assessment does not exactly match the Medicaid identification card there will be a conflict Correct the assessment to match the Medicaid Identification card if the card is correct If the name on the Medicaid Identification card is incorrect contact the appropriate Medicaid Eligibility worker to make name corrections so that there is an exact match Full Medicare Transitioning to Medicaid Full Form 3619 Days 21 100 Form 3619 Form 3618 Medicare Admission y Discharge Admission This flow chart displays the process of a recipient that is Full Medicare and transitioning to Full Medicaid e Full Medicare reimburses for the first 20 days e The facility must submit a 3619 Admission on day 21 within 72 hours of Medicare payment to begin Medicare Co insurance up to a maximum of 80 days The entire Medicare stay cannot exceed 100 days The facility must submit a 3619 Discharge on the 101st day or the day of discharge from Medicare Co insur ance and a 3618 Admission on the same day to admit the recipient to Full Medicaid e 3619 Discharge and 3618 Admission changing to Full Medicaid will be the same date unless the recipient physi cally went out of the facility
214. eports performing Medicaid Eligibility Service Authorization Verification MESAV and to submit Hospice Forms 3071 and 3074 Home TMHP com My Account TMHP Welcome Log Off Navigation amp ft TMHP Use the following guidelines to determine your selection from the Provider Type menu below Account Activation Option 1 If you are a provider enrolled by TMHP choose Acute Care 3071s and 3074s choose Long Term Care Option 3 If you want to submit 3618s 3619s MDS MDS Quarterly MN LOC PASRR Level 1 Screenings and PASRR Evaluations choose NF Waiver Programs Option 4 If you are attempting to become a Texas Medicaid or CSHCN Services Program provider and currently do not have a TPI NPI choose Provider Enrollment Provider Type Select v Select Acute Care Li Provider Enrollment Option 2 If you are a provider enrolled by DADS and would like to view R amp S reports and submit 9 Enter your provider number vendor number and vendor password TMHP Navigation amp ft TMHP Account Activation Home TMHP com My Account Welcome Use the following guidelines to determine your selection from the Provider Type menu below e Option 1 If you are a provider enrolled by TMHP choose Acute Care 3071s and 3074s choose Long Term Care Option 3 If you want to submit 3618s 3619s MDS MDS Quarterly MN LOC PASRR Level 1 Screenings and PASRR Evaluation
215. er 5 Click the Enter Form button and the form will display for data entry 6 Enter all required information as indicated by the red dots Note Additional information about required fields marked with a red dot can be found in the Other Basic Infor mation section 14 v 2013 1127 LTC Nursing Facility Hospice User Guide v TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TM A STATE MEDICAID CONTRACTOR Home Form Status Inquiry Current Activity Drafts Vendors Printable Forms Alerts Help 3618 RESIDENT TRANSACTION NOTICE Current Status Name DLN 0 ZQ MET Vendor Number Contract Number Lm NPI Number Recipient Information 1 Medicaid Recipient No 4 Recipient s Last Name 5 Address Address 2 Social Security No Name Recipient s First Name City 3 Medicare or RR Retirement 1 Recipient s Middle 1 State Y Claim No Initial ZIP Recipient Name Suffix Transaction Information e Service Group s e Transaction v Discharge Type E Location v Date of Physical Admission to Private bal Pay If Newly Admitted From Discharged To Hospital Enter ti Date e Date of Above Transaction tv Administrator Information I certify that to the best of my knowledge the date in Item 11 Date of Above Transaction is for services provided
216. er the entire 7 day period Enter Code g Support provided Bathing support codes are as defined in item G0110 column 2 ADL Support Provided above G0300 Balance During Transitions and Walking After observing the resident code the following walking and transition items for most dependent J Enter Codes in Boxes Coding Not steady but able to stabilize without staff assistance i Mo ee assistance E Surface to surface transfer transfer between bed and chair or wheelchair G0400 Functional Limitation in Range of Motion Code for limitation that interfered with daily functions or placed resident at risk of injury J Enter Codes in Boxes Coding 0 No impairment A Upper extremity shoulder elbow wrist hand 1 Impairment on one side 2 Impairment on both sides B Lower extremity hip knee ankle foot G0600 Mobility Devices J Check all that were normally used A Cane crutch B Walker C Wheelchair manual or electric D Limb prosthesis Z None of the above were used G0900 Functional Rehabilitation Potential Complete only if A0310A 01 Enter Code A Resident believes he or she is capable of increased independence in at least some ADLs 0 No 1 Yes 9 Unable to determine Enter Code B Direct care staff believe resident is capable of increased independence in at least some ADLs 0 No 1 Yes MDS 3 0 Nursing Home Comprehensive NC Ver
217. er to submit an MDS assessment in Awaiting LTC Medicaid Information status without requiring a Purpose Code PC E or M Finding Assessments Using Form Status Inquiry 1 Click the Form Status Inquiry link in the blue navigational bar 2 Type of Form Choose one of the following options from the drop down box MDS 2 0 Minimum Data Set Comprehensive MDSQTR 2 0 Minimum Data Set Quarterly MDS 3 0 Minimum Data Set Comprehensive MDSQTR 3 0 Minimum Data Set Quarterly 64 v 2013 1127 LTC Nursing Facility Hospice User Guide Note The following is an example of an MDS 3 0 Comprehensive assessment v a TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR Home Submit Form Form Status Inquiry Current Activity Drafts Vendors Printable Forms Alerts Help Form Status Inquiry Form Select Type of Form MDS 3 0 Minimum Data Set Comprehensive Vendor Number for Contract Number vi Form Status Inquiry DLN Medicaid Number Last Name First Name Form Status E AI Check Inactive From Date e Appealed To Date e 5 20 2013 Y Approved Purpose Code Awaiting LTC Medicaid Information Coach Pending More Info Reason for Assessment Coach Review v Corrected Denied Form Inactivated ID Invalid Invalid Complete ME Check Inactive Med ID Check Inactive Medicaid ID Pending Out of State RN License Invalid Overturned Doctor Review
218. eral CMS database as needed If an earlier 3618 or 3619 admission is needed submit a matching admission and discharge pair then resubmit the rejected MDS admission If the 3618 or 3619 admission date and the MDS Entry Date are correct contact DADS Provider Claims Services at 512 438 2200 Option 1 for assistance The adjusted days of Full Medicare on this correction would create an overlap with Service Authorizations already in the recipient s file if this correction is processed as submitted Review the Medicare Remittances for this Spell of Illness to determine the Full Medicare and Medicare Part A Coinsurance dates Pull a MESAV and compare the Service Authorizations on file and the Full Medicare Qualifying Stay dates to the remittance dates The system has determined that the additional Qualifying Stay dates would create an overlap with existing Service Autho rizations Also consider the Qualifying Stays reported on the processed 3619s These dates create Full Medicare periods which do not appear on the MESAV Submit any additional 3619 corrections to adjust begin or end dates to allow this admission correction to process The difference between the earliest Qualifying Stay date and the transaction date is too great for this admission to be processed automatically Review the Medicare Remittances for this Spell of Illness to determine the Full Medicare and Medicare Part A Coinsurance dates If the dates on the form are c
219. erapy assessment Change of therapy assessment X0600 continued on next page Enter Code MDS 3 0 Nursing Home Comprehensive NC Version 1 11 2 Effective 10 01 2013 Page 37 of 41 Resident Identifier Date SectionX Correction Request X0600 Type of Assessment Continued Enter Code D Is this a Swing Bed clinical change assessment Complete only if X0150 2 L 0 No 1 Yes Enter Code F Entry discharge reporting EE 01 Entry tracking record 10 Discharge assessment return not anticipated 11 Discharge assessment return anticipated 12 Death in facility tracking record 99 None of the above X0700 Date on existing record to be modified inactivated Complete one only A Assessment Reference Date Complete only if XO600F 99 Month Day B Discharge Date Complete only if XO600F 10 11 or 12 Month Day C Entry Date Complete only if X0600F 01 Month Day Correction Attestation Section Complete this section to explain and attest to the modification inactivation request X0800 Correction Number Enter Number L EI Enter the number of correction requests to modify inactivate the existing record including the present one X0900 Reasons for Modification Complete only if Type of Record is to modify a record in error A0050 2 J Check all that apply Z Other error requiring modification If Other checked please specify X1050 Reasons for Inactivat
220. esident a danger to others Required Choose from the drop down box 0 No 1 Yes gt If unknown then reply with 0 No S2f Are specialized services indicated Disabled This field is disabled Click the Determine Specialized Services button to calculate and populate a value in S2f S3 Physician s Evaluation amp Recommendation S3a Does the MD DO have plans for the eventual discharge of this resident Conditional Choose from the drop down box 0 No 1 Yes This field is required if Admission assessment SCSA or Recovery of Lost Payment Purpose Code E S3b Rehabilitative Potential Conditional Choose from the drop down box 1 good 2 fair 3 minimal This field is required if Admission assessment SCSA or Recovery of Lost Payment Purpose Code E S3c Did an MD DO certify that this resident requires continues to require Nursing Facility care Conditional Choose from the drop down box 0 No 1 Yes This field is required if Admission assessment SCSA or Recovery of Lost Payment Purpose Code E S3d MD DO Last Name Required Enter the last name of the MD DO S3e MD DO License Conditional This field is required if S39 MD DO Military Spec Code is not populated Enter the license number of the MD DO This number is validated against the Texas Medical Board file Physicians are not required to complete the RUG training 72 v 2013 1127
221. esident is presently living This information is used to mail MN determination letters S8d ZIP CODE Required Enter the ZIP code where the resident is presently living This information is used to mail MN determination letters S8e Phone Optional Enter the contact telephone number for the resident if known If the resident is residing in an NF and no other direct contact telephone number is known enter the telephone number of the NF S9 Medications Medication Certification checkbox Required Providers are required to check the Medication Certification checkbox to certify that the resident is taking no medica tions or the medication listed are correct S9 Medications S9 1 Medication Name and Dose Ordered Free form text Identify and record all medications that the resident received in the last 30 days Also identify and record any medica tions that may not have been given in the last 30 days but are part of the resident s regular medication regimen e g monthly B 12 injections Do not record PRN medications that were not administered in the last 30 days S9 2 RA Route of Administration Select from the list of options Determine the Route of Administration RA used to administer each medication The MAR and the physician s orders should identify the RA for each medication Record the RA in column 2 S9 3 Freq Frequency Select from the list of options Determine the
222. esidents If resident is comatose skip to J1100 Shortness of Breath dyspnea Enter Code 0 No resident is rarely never understood gt Skip to and complete J0800 Indicators of Pain or Possible Pain 1 Yes Continue to J0300 Pain Presence Pain Assessment Interview J0300 Pain Presence Enter Code Ask resident Have you had pain or hurting at any time in the last 5 days 0 No Skip to J1100 Shortness of Breath 1 Yes Continue to J0400 Pain Frequency 9 Unable to answer Skip to J0800 Indicators of Pain or Possible Pain J0400 Pain Frequency Ask resident How much of the time have you experienced pain or hurting over the last 5 days Almost constantly Frequently Occasionally Rarely Unable to answer J0500 Pain Effect on Function Enter Code A Askresident Over the past 5 days has pain made it hard for you to sleep at night Enter Code 0 No 1 Yes 9 Unable to answer B Askresident Over the past 5 days have you limited your day to day activities because of pain Enter Code 0 No 1 Yes 9 Unable to answer J0600 Pain Intensity Administer ONLY ONE of the following pain intensity questions A or B A Numeric Rating Scale 00 10 Ask resident Please rate your worst pain over the last 5 days on a zero to ten scale with zero being no pain and ten as the worst pain you can imagine Show resident 00 10 pain scale Enter two digit response Enter 99 if unable to answer Verbal Descr
223. esolving error Same contract An admission has already been received for the Date of Above Transaction OR Different contract An admission from another provider has already been received for the Date of Above Transaction Rejection of New Admission for Same Date of Above Transaction New admission has same Date of Above Transaction as an admission already received i e 11 1 2008 admission 11 1 2008 admission Same contract Possibly attempting to submit a duplicate form OR Different contract A different provider has previously submitted an admission for the same Date of Above Transaction date One provider is in error Contact other provider Same contract A discharge has already been received for the Date of Above Transaction OR Different contract A discharge from another provider has already been received for the Date of Above Transaction Rejection of New Discharge for Same Date of Above Transaction New discharge has same Date of Above Transaction as a discharge already received i e 11 1 2008 discharge 11 1 2008 discharge Same contract Possibly attempting to submit a duplicate form OR Different contract A different provider has previously submitted a discharge for the same Date of Above Transaction date One provider is in error Contact other provider Previous form was a 3618 A 3618 discharge or 3619 admission as appropriate must be submitted before a 3619 discharg
224. essment OBRA or scheduled PPS 0 No Skip to M1030 Number of Venous and Arterial Ulcers 1 Yes Continue to M0900B Stage 2 Indicate the number of pressure ulcers that were noted on the prior assessment OBRA or scheduled PPS that have completely closed resurfaced with epithelium If no healed pressure ulcer at a given stage since the prior assessment OBRA or scheduled PPS enter 0 B Stage 2 C Stage 3 D Stage4 M1030 Number of Venous and Arterial Ulcers Enter Number Enter the total number of venous and arterial ulcers present M1040 Other Ulcers Wounds and Skin Problems J Check all that apply Foot Problems A Infection of the foot e g cellulitis purulent drainage B Diabetic foot ulcer s C Other open lesion s on the foot Other Problems D Open lesion s other than ulcers rashes cuts e g cancer lesion E Surgical wound s F Burn s second or third degree H Moisture Associated Skin Damage MASD i e incontinence IAD perspiration drainage None of the Above Z None of the above were present M1200 Skin and Ulcer Treatments J Check all that apply A Pressure reducing device for chair B Pressure reducing device for bed C Turning repositioning program D Nutrition or hydration intervention to manage skin problems E Pressure ulcer care
225. essments end up in the provider workflow as a result of the system s processing discovering an error while attempting to process the form or assessment System processing errors including rejection messages are found within the History trail of the form or assessment and the form or assessment is set to status Provider Action Required Once a form or assess ment is set to status Provider Action Required the form or assessment will require provider action before process ing on that particular form or assessment continues Type of Forms being sent to the provider workflow include 3618 3619 MDS 3 0 and MDSQTR 3 0 Ifa batch error occurs the error will display in the History trail of the form or assessment The form or assessment will set to status Provider Action Required Finding Forms and Assessments with Provider Action Required Status Using FSI To find the items in your provider workflow i e those items with system processing errors to be resolved by the provider 1 Click the Form Status Inquiry link in the blue navigational bar 2 Type of form Choose Type of Form e g 3618 from the drop down box Note Form 3618 or 3619 MDS 3 0 Minimum Data Set Comprehensive and MDSQTR 3 0 Minimum Data Set Quarterly Type of Form in the drop down box could result in status Provider Action Required Therefore 94 v 2013 1127 LTC Nursing Facility Hospice User Guide each of these Type of Form optio
226. et Address BO08001 City e B0800 J State v 2013 1127 129 LTC Nursing Facility Hospice User Guide e B0800K ZIP Code Updates to PASRR Level 1 Screening 1 Log in to the LTC Online Portal 2 Click the Form Status Inquiry link in the blue navigational bar 3 Search for the PL1 using the recipients SSN Medicaid recipient number First and Last Name or DLN 4 Click the Search button 5 Click the View Detail link 6 Click the Update Form button TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR Home Submit Form Form Status Inquiry Current Activity Drafts Vendors Printable Forms Alerts Help amp PASRR LEVEL 1 SCREENING Current Status Form Submitted Name DLN Form Actions Print Use as template f update Form Initiate PE SECTION B SECTION C SECTION D SECTION E SECTION F SECTION A Submitter Information A0100 Name A0200 Address A Street Address id B City C State D ZIP Code Texas T m A0300 NPI API 7 Complete only the fields needing updates 8 Click the Submit Form button Form 3618 and 3619 Corrections NF providers must submit Forms 3618 and 3619 corrections directly on the LTC Online Portal Correctable Fields on Forms 3618 and 3619 e Administrator Signature Date Administrator License Number Comment Section e Date of Above Transaction e Discharge Type
227. ew discharge Inactivate the rejected discharge and correct the transaction date of the later discharge This discharge is part of a retroactive pair Review the facility records to identify the admission prior to this discharge Pull a MESAV and review the Service Authorizations There should be no other authorization during the admission and discharge timeframe when these forms process The admission and discharge pair must be submitted at the same time If the form is not part of a pair it should be a correcting discharge not a new discharge Inactivate the rejected discharge and correct the transaction date of the earlier discharge The corresponding Nursing Facility admission is not in the recipi ent s file Review the facility s records to determine the admission prior to this discharge Pull a MESAV and review the Service Authorizations to determine if the prior admission has processed and authorized services If the MDS for the admission has not processed you will not have services authorized If the MESAV reflects that the recipient is currently in the facility per an admission prior to the admission that corresponds with this discharge research the recipient s records to identify the discharge between those two admissions Submit that missing or rejected discharge followed by the admission that corresponds with this rejected discharge Resubmit this rejected discharge If this rejected discharge is reflected on
228. f Above Transaction First verify that the rejected form is a valid submission If the Form Type or Transaction is incorrect submit an inactivation of that form and submit the correct type or transaction If the Date of Above Transaction is incorrect submit a correction for the correct date and resolve any missing form issues If the MDS Reason for Assessment is incorrect or the MDS is invalid submit an inactivation to CMS If the Entry Date MDS 3 0 field A1600 submitted is incorrect submit a modification to CMS in accordance with the RAI Users Manual General Instructions l Review the effective date on the form or assessment to ensure it is correct For Forms 3618 and 3619 the effec tive date is the Date of Above Transaction For Minimum Data Set MDS Admission assessments the effective date is the MDS Entry Date A1600 Date For all other MDS assessments the effective date is the MDS assess ment Completion Date Z0500B Date Ifthe effective date is incorrect take the appropriate action to correct the form or assessment gt Form 3618 or 3619 Correct the form on the LTC Online Portal and submit MDS Correct the assessment by following the guidelines in the RAJ Users Manual and submit the modified MDS to the federal CMS database then complete the Long Term Care Medicaid Information LT CMI section on the LTC Online Portal Ifthe effective date is correct continue to step 2 Ifa Form 3619 admission or discharg
229. f Care MN LOC 3 0 Assess ments required on October 1 2013 MDS 3 0 Changes Removed K0700 field New field K0710 Percent Intake by Artificial Route Includes options K0710 A1 K0710 A3 K0710B1 B3 Modified O0400A3A Co treatment minutes record the total number of minutes this therapy was adminis tered to the resident in co treatment sessions in the last 7 days New field O0400B3A Co treatment minutes record the total number of minutes this therapy was adminis tered to the resident in co treatment sessions in the last 7 days New field O0400C34A Co treatment minutes record the total number of minutes this therapy was adminis tered to the resident in co treatment sessions in the last 7 days New field O0420 Distinct Calendar Days of Therapy record the number of calendar days that the individual received Speech Language Pathology and Audiology Services Occupational Therapy or Physical Therapy for at least 15 minutes in the past 7 days On MDS 3 0 NQ only field H0200A currently present on MDS 3 0 NC will also be added to MDS 3 0 NQ Has a trial of a toileting program e g scheduled toileting prompted voiding or bladder training been attempted on admission entry or reentry or since urinary incontinence was noted in this facility Modified M0300 Changes item label from Current Number of Unhealed non epithelialized Pressure Ulcers at Each Stage to Current Number of Unhealed Pressure Ulcers at Each Stage
230. f Persons Completing the Assessment or Entry Death Reporting certify that the accompanying information accurately reflects resident assessment information for this resident and that collected or coordinated collection of this information on the dates specified To the best of my knowledge this information was collected in accordance with applicable Medicare and Medicaid requirements understand that this information is used as a basis for ensuring that residents receive appropriate and quality care and as a basis for payment from federal funds further understand that payment of such federal funds and continued participation in the government funded health care programs is conditioned on the accuracy and truthfulness of this information and that may be personally subject to or may subject my organization to substantial criminal civil and or administrative penalties for submitting false information also certify that am authorized to submit this information by this facility on its behalf Date Section Signature Sections Completed Z0500 Signature of RN Assessment Coordinator Verifying Assessment Completion A Signature B Date RN Assessment Coordinator signed assessment as complete Af Am ee Month Day Legal Notice Regarding MDS 3 0 Copyright 2011 United States of America and InterRAI This work may be freely used and distributed solely within the United States Portio
231. f the Dates of Qualifying Stay on the form are wrong correct the admission and resubmit To determine if the Qualifying Stay dates from the Medicare remittance advice are on file contact DADS Provider Claims Services at 512 438 2200 Option 1 for assistance If a different 3619 admission was submitted with incorrect Dates of Qualifying Stay submit a correction for that form prior to resubmitting this rejected admission If this form cannot be corrected inactivate the form Note f this is not traditional Medicare document this in the comment section and call 512 438 2200 Option 3 or fax the Medicare Replace ment explanation of benefits EOB with a copy of the 3619 to 512 438 3400 attention Medicare Advantage Plan 108 v 2013 1127 LTC Nursing Facility Hospice User Guide Provider Message Form Displayed in History Assessment NF 0029 The days of Qualifying 3619 Admit Stay have been recorded However Admit Mod the admission for Medicare Part A Coinsurance cannot be processed because the Qualifying Stay days plus any Full Medicare days already documented are less than the 20 days required for this Spell of Illness NF 0030 This admission cannotbe 3619 Admit processed because it has not been more than 60 consecutive days since the client was discharged from Medicare cannot begin a new Spell of Illness Review Medicare remittance to determine when Medicare Part A Coinsurance i
232. federal MDS 3 0 RAI User s Manual for submission of an assessment If the provider follows the federal guidelines for submission and completes the LTCMI on the LTC Online Portal there will not be a lapse in Texas Medicaid coverage v 2013 1127 63 LTC Nursing Facility Hospice User Guide MDS Dually Coded Assessments Dually coded assessments will be retrieved and loaded onto the LTC Online Portal nightly if the retrieval criteria above are present If the assessment is processed successfully for Medicare but fails due to the Medicaid ID Recipi ent name the provider should refer to the MDS 3 0 RAI Users Manual Chapter five for further instructions and guidelines for submitting modifications to key resident identifying information fields The MDS 3 0 RAJ Users Manual can be found under Downloads on the CMS website www cms gov NursingHomeQualityInits 25_NHQIMDS30 asp TopOfPage Dually coded assessments can be submitted as multiple combinations If the client has been established with MDS RUGS for the facility discharges to the hospital and returns to Medicare the assessment can be dually coded for the appropriate Medicaid assessment due and the proper Medicare assessment due An assessment for an estab lished client admitting to Medicare can be coded as a Medicaid Quarterly and a Medicare five day assessment If an assessment is coded for a Medicaid Admission assessment and a Medicare five day assessment and the resident has a curre
233. fered Inability to obtain vaccine due to a declared shortage None of the above Enter Code 00300 Pneumococcal Vaccine Enter Code A Is the resident s Pneumococcal vaccination up to date 0 No gt Continue to O0300B If Pneumococcal vaccine not received state reason 1 Yes gt Skip to 00400 Therapies Enter Code B If Pneumococcal vaccine not received state reason 1 Not eligible medical contraindication 2 Offered and declined 3 Not offered MDS 3 0 Nursing Home Quarterly NO Version 1 11 2 Effective 10 01 2013 Page 25 of 35 Resident Identifier Date SectionO Special Treatments Procedures and Programs 00400 Therapies A Speech Language Pathology and Audiology Services Enter Number of Minutes 1 Individual minutes record the total number of minutes this therapy was administered to the resident individually in the last 7 days Enter Number of Minutes 2 Concurrent minutes record the total number of minutes this therapy was administered to the resident concurrently with one other resident in the last 7 days Enter Number of Minutes 3 Group minutes record the total number of minutes this therapy was administered to the resident as part of a group of residents in the last 7 days If the sum of individual concurrent and group minutes is zero skip to O0400A5 Therapy start date Enter Number of Minutes 3A Co treatment minutes record the total number of minutes this therapy was admi
234. ffec tive date of the decision or from the notice of adverse action date whichever is later by calling TMHP at 46 v 2013 1127 LTC Nursing Facility Hospice User Guide 1 800 626 4117 Option 5 When a individual receives a letter denying MN and giving the individual the right to request a fair hearing the individual must request a fair hearing within ten days of the date of the letter for Medicaid payment to continue until the fair hearing decision Medicaid payment will only continue if the indi vidual was already receiving services If the individual requests a fair hearing later than ten days of the date of the letter Medicaid payment will not be made for days past day ten The individual can request a fair hearing up to 90 calendar days after the date of the letter Form 4803 Acknowledgement and Notice of Fair Hearing serves as a notice of the fair hearing It is sent to the appellant to acknowledge the receipt of a request for a hearing and to set a time date and place for the hearing Form 4803 will be sent to all known parties and required witnesses at least ten calendar days in advance of the hearing The fair hearing is held at a reasonable place and time They are normally scheduled in the order in which requests are received and are usually held via teleconference Appellants may present their own case or bring a friend relative or attorney to present their case DADS Health and Human Services enterprise does not pay att
235. fficulty difficulty in some environments e g when person speaks softly or setting is noisy 2 Moderate difficulty speaker has to increase volume and speak distinctly 3 Highly impaired absence of useful hearing B0300 Hearing Aid Enter Code Hearing aid or other hearing appliance used in completing B0200 Hearing 0 No 1 Yes B0600 Speech Clarity Enter Code Select best description of speech pattern 0 Clear speech distinct intelligible words 1 Unclear speech slurred or mumbled words 2 No speech absence of spoken words B0700 Makes Self Understood Enter Code Ability to express ideas and wants consider both verbal and non verbal expression 0 Understood 1 Usually understood difficulty communicating some words or finishing thoughts but is able if prompted or given time 2 Sometimes understood ability is limited to making concrete requests 3 Rarely never understood B0800 Ability To Understand Others Understanding verbal content however able with hearing aid or device if used 0 Understands clear comprehension 1 Usually understands misses some part intent of message but comprehends most conversation 2 Sometimes understands responds adequately to simple direct communication only 3 Rarely never understands B1000 Vision Ability to see in adequate light with glasses or other visual appliances Adequate sees fine detail such as regular print in newspapers books Impaired sees large p
236. fied G0900B Functional Rehabilitation Potential field to enable providers to select the No information Not assessed option e Removed blood pressure reading fields 10799b 10899a and 10899b New field K0710 Percent Intake by Artificial Route field is replacing K0700 It includes K0710A1 through K0710B3 e Modified M0210 Unhealed Pressure Ulcer to remove Non epithelialized from Option 1 e Modified M0300 Current Number of Unhealed Pressure Ulcers at Each Stage to remove Non epithelialized from the field label e Modified M0610 Dimensions of Unhealed Stage 3 or 4 Pressure Ulcers or Eschar field to remove Non epithe lialized from the field instructions e Modified M0700 Most Severe Tissue Type for Any Pressure Ulcer field to change Option 4 from Necrotic tissue Eschar to Eschar e Modified O0400A3A Co treatment minutes record the total number of minutes this therapy was adminis tered to the individual in co treatment sessions in the last 7 days e New field O0400B3A Co treatment minutes record the total number of minutes this therapy was adminis tered to the individual in co treatment sessions in the last 7 days e New field O0400C3A Co treatment minutes record the total number of minutes this therapy was adminis tered to the individual in co treatment sessions in the last 7 days e New field 00420 Distinct Calendar Days of Therapy record the number of calendar days
237. for this resident for this care area A CAA Results A B Care Area Care Planning Location and Date of Triggered Decision CAA documentation J Check all that apply Care Area 01 Delirium 02 Cognitive Loss Dementia 03 Visual Function 04 Communication 05 ADL Functional Rehabilitation Potential 06 Urinary Incontinence and Indwelling Catheter 07 Psychosocial Well Being 08 Mood State 09 Behavioral Symptoms 10 Activities 12 Nutritional Status 13 Feeding Tube 14 Dehydration Fluid Maintenance 15 Dental Care 16 Pressure Ulcer 17 Psychotropic Drug Use 18 Physical Restraints 20 Return to Community Referral B Signature of RN Coordinator for CAA Process and Date Signed 1 Signature C Signature of Person Completing Care Plan Decision and Date Signed 1 Signature MDS 3 0 Nursing Home Comprehensive NC Version 1 11 2 Effective 10 01 2013 Page 36 of 41 Resident Identifier Date SectionX Correction Request Complete Section X only if A0050 2 or 3 Identification of Record to be Modified Inactivated The following items identify the existing assessment record that is in error In this section reproduce the information EXACTLY as it appeared on the existing erroneous record even if the information is incorrect This information is necessary to locate the existing record in the National MDS Database X0150 Type of Provider Enter Code Type of provider 1 Nursin
238. forms with a future date in the Date of Above Transaction field will not be accepted onto the LTC Online Portal v 2013 1127 141 LTC Nursing Facility Hospice User Guide Edit Description System Message displayed at time of submission System Message Clarification System Message Resolution assistance for resolving error Previous form was a 3619 A 3619 discharge or 3618 admission as appropriate must be submitted before a 3618 discharge can be submitted Applicable for same or different contract Rejection of 3618 Discharge following a 3619 3618 discharge received following a 3619 regardless of contract Submit either a 3619 discharge or 3618 admission as appropriate prior to this 3618 Discharge Scenarios 3619 admit exists in Processed Complete status for client A provider A transaction date 10 20 08 3618 admit submitted for client A provider A transaction date 10 21 08 Submit not allowed 3619 discharge exists in Processed Complete status for client A provider A transaction date 10 20 08 3618 discharge submitted for client A provider A transaction date 10 21 08 Submit not allowed 3619 admit exists in Processed Complete status for client A provider A transaction date 10 19 08 3619 discharge exists in Processed Complete status for client A provider A transaction date 10 19 08 3618 discharge submitted for client A provider A transaction
239. further actions allowed on the form or assessment ID Invalid Medicaid ID validation failed Cannot be processed until Medicaid ID is corrected Contact Medicaid Eligibility Worker to verify recipient s name Social Security number and Medicaid ID A new form or assessment must be submitted with correct information The name entered must match the name shown on the recipient s Medicaid ID card Invalid Complete DADS processing deemed this form or assessment invalid See the History trail for details Invalid Form Sequence Only applies for Forms 3618 and 3619 Form 3618 3619 sequence is invalid For example Form 3618 needs to be submitted before the MDS can be accepted ME Check Inactive Medicaid Eligibility validation attempted nightly for six months and failed or the request was canceled Med ID Check Inactive Medicaid ID validation attempted nightly for six months and failed or the request was canceled The provider may restart the assessment once the reason for the failed validation has been resolved by the Medicaid Eligibility Worker by clicking the Reactivate Form button Medicaid ID Pending Medicaid ID validation is pending Validation attempts occur nightly until deemed valid invalid or until six months has expired whichever comes first Contact the Medicaid Eligibility Worker to verify recipients name Social Security number and Medicaid ID This status will also apply to private pay residents whose assessments are su
240. g Section TE eit ath e ea e Don nbn E apa EEEE EE ET SEE 176 PASRR Devel 1 Scicening Section RH S EER REESEN E EE ENESE N REER 177 Appendix F Pending Denial Review ttt ttt ttti ttt 179 App ndit G LTC Jumble T 181 Appendix H LTC Word Sab RC 183 v 2013 1127 v LTC Nursing Facility Hospice User Guide Learning Objectives After attending the Long Term Care LTC Nursing Facility Hospice Workshop you will be able to Understand the Medicaid team roles Identify National Provider Identifier NPI requirements Obtain an LTC Online Portal administrator account Understand basic LTC Online Portal features Understand Medical Necessity MN and the MN Determination Process including the fair hearing process Identify the forms and screenings to be submitted and their sequencing including when and how to submit them Understand the Long Term Care Medicaid Information LTCMI section submission process Understand the Preadmission Screening and Resident Review PASRR process Understand and differentiate between the Minimum Data Set MDS purpose code E and M Understand the provider workflow process which includes dividing into two sections corrections and updates in provider workflow Understand how to correct modify or inactivate forms or assessments and the consequences of doing so Identify form and assessment statuses and how to resolve issues Understand how to properly request prior
241. g Service Authorizations if this correction is processed as submitted Review the facility s records to determine the recipient s admission and discharge dates and identify the Spell of Illness Pull a MESAV and compare the Service Authorizations to the later discharge date that would be created by the rejected discharge Consider the Qualifying Stays reported on the processed 3619s These dates create Full Medicare periods which do not appear on the MESAV If the begin date of an existing Service Authorization needs to be changed submit a correction to that admission If the submitted discharge date would overlap with a reported Qualifying Stay period submit a correction to adjust the Qualifying Stay dates To determine if the Qualifying Stay dates from the Medicare remittance advice correspond with those on file contact DADS Provider Claims Services at 512 438 2200 Option 1 for assistance If the recipient is currently receiving Hospice services verify the dates of service with the Hospice Provider and make corrections as needed This rejected discharge should be resubmitted once the file has been adjusted 116 v 2013 1127 LTC Nursing Facility Hospice User Guide Provider Message Displayed in History NF 0061 This admission cannot be processed because a Nursing Facil ity admission is not appropriate for a PACE client Contact the client s PACE organization NF 0062 This discharge cannot be
242. g home SNF NF 2 Swing Bed X0200 Name of Resident on existing record to be modified inactivated A First name TT ETT TET tt C Last name X0300 Gender on existing record to be modified inactivated Enter Code 1 Male LI 2 Female X0400 Birth Date on existing record to be modified inactivated Month Day Year X0500 Social Security Number on existing record to be modified inactivated X0600 Type of Assessment on existing record to be modified inactivated A Federal OBRA Reason for Assessment 01 Admission assessment required by day 14 02 Quarterly review assessment 03 Annual assessment 04 Significant change in status assessment 05 Significant correction to prior comprehensive assessment 06 Significant correction to prior quarterly assessment 99 None of the above Enter Code PPS Assessment PPS Scheduled Assessments for a Medicare Part A Stay 01 5 day scheduled assessment 02 14 day scheduled assessment 03 30 day scheduled assessment 04 60 day scheduled assessment 05 90 day scheduled assessment 06 Readmission return assessment PPS Unscheduled Assessments for a Medicare Part A Stay 07 Unscheduled assessment used for PPS OMRA significant or clinical change or significant correction assessment Not PPS Assessment 99 None of the above Enter Code PPS Other Medicare Required Assessment OMRA No Start of therapy assessment End of therapy assessment Both Start and End of th
243. h a nurse If Add Note is chosen for any assessment or screening in Pending Denial need more information status the assessment or screening will be reviewed again for medical necessity If the nurse is unable to approve the assessment or screening with the additional information provided the assessment or screening will be sent to the TMHP Medical Director for review and determination of MN Inactivate Form The Inactivate Form feature is used when Forms 3618 and 3619 cannot be corrected and a new form must be sub mitted It can also be used if a Form 3618 or 3619 was submitted in error However inactivations are not allowed if 28 v 2013 1127 LTC Nursing Facility Hospice User Guide a document is set to status Corrected or Form Inactivated Forms 3618 and 3619 that are set to status Processed Complete or that contain the message code GN 9004 anywhere in the history of the form cannot be inactivated To cancel a successfully processed form that should not have been submitted providers must submit the appropriate counteracting form If an attempt is made to inactivate a successfully processed form the following message will be displayed to the provider This form has been successfully processed at DADS and cannot be inactivated If this form is invalid should not have been submitted submit the appropriate form to counteract this form Otherwise correct this form and resubmit Note Additional information regarding counter
244. h cheeks or residual food in mouth after meals C Coughing or choking during meals or when swallowing medications D Complaints of difficulty or pain with swallowing Z None of the above K0200 Height and Weight While measuring if the number is X 1 X 4 round down X 5 or greater round up A Height in inches Record most recent height measure since the most recent admission entry or reentry B Weight in pounds Base weight on most recent measure in last 30 days measure weight consistently according to standard facility practice e g in a m after voiding before meal with shoes off etc K0300 Weight Loss Loss of 596 or more in the last month or loss of 1096 or more in last 6 months Entencode 0 Noor unknown 1 Yes on physician prescribed weight loss regimen 2 Yes not on physician prescribed weight loss regimen MDS 3 0 Nursing Home Quarterly NQ Version 1 11 2 Effective 10 01 2013 Page 19 of 35 Resident Identifier Date SecionK Swallowing Nutritional Status K0310 Weight Gain Gain of 596 or more in the last month or gain of 1096 or more in last 6 months Enten Code 0 Noor unknown 1 Yes on physician prescribed weight gain regimen 2 Yes not on physician prescribed weight gain regimen K0510 Nutritional Approaches Check all of the following nutritional approaches that were performed during the last 7 days 1 While NOT a Resident Performed while NOT a resident of this facilit
245. harge Process 1 2 0r3 4or5 When is PE required 6 7 Portal alerts LA to perform PE 7 days after NF admission date Portal alerts LA to perform PE once PL1 is submitted Portal alerts LA to perform PE 14 days after NF admission date Portal alerts LA to perform PE once MDS indicates individual is no longer comatose LA submits PE within 7 days of notification Payment for PE LA performs PE within 72 hours of notification gt NF reviews PE and certifies able unable to 3 serve on PL1 LA coordinates placement if NF is unable to serve 1 RE performs the PL1 and screens for Expedited Admission using the following categories Category Category Name Description Convalescent Care Individual is admitted from an acute care hospital to a Nursing Facility for convales cent care with an acute physical illness or injury which required hospitalization and is expected to remain in the Nursing Facility for greater than 30 days Terminal Illness Individual has a medical prognosis that his or her life expectancy is 6 months or less if the illness runs its normal course An individual s medical prognosis is documented by a physician s certification which is kept in the individual s medical record maintained by the Nursing Facility Severe Physical An illness resulting in ventilator dependence or d
246. hat the use of an ambulance is the only appropriate means of transportation i e alternate means of transportation are medically contra indicated According to Human Resource Code HRC 32 024 t a Medicaid enrolled physician Nursing Facility health care provider or other responsible party is required to obtain authorization before an ambulance is used to transport a resident in circumstances not involving an emergency Facilities and other providers must request and obtain prior authorization before contacting the ambulance provider for nonemergency ambulance services The HRC states that a provider who is denied payment for nonemergency ambulance transport may be entitled to payment from the Nursing Facility health care provider or other respon sible party that requested the service if payment under the Medical Assistance Program is denied because of lack of prior authorization and the provider submits a copy of the bill for which payment was denied Ambulance providers may file complaints with DADS Complaint Hotline at 1 800 458 9858 The complaint will be referred to DADS Regulatory Services Department for review Should DADS Regulatory Services confirm that the Nursing Facility failed to properly obtain prior authorization and then subsequently failed to properly reimburse the ambulance provider the Nursing Facility will be cited for non compliance with 19 2320 and a plan of correction will be necessitated Nursing facilities can also r
247. have services on the LTC Online Portal Provider contract number assigned by DADS when the provider signs the contract to provide Medicaid Vendor number four digit number assigned by DADS when the provider signs the contract to submit forms Vendor password provider must call the Electronic Data Interchange EDI Help Desk at 1 888 863 3638 to obtain their vendor password Please note that it may take three to five business days to receive the password which is randomly generated by TMHP How to Create an LTC Online Portal Administrator Account 1 Goto www tmhp com 2 Click providers in the green bar located at the top of the screen va TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR clients providers l vt English Espanol J a lt KKA A TMHP Home m i Not yet a provi Welcome to Texas Medicaid amp Healthcare Partnership 433 ua What is TMHP Click here to find e Thank you for visiting the Texas Medicaid amp Healthcare a i eee k Privacy HIPAA Partnership s TMHP Internet website for Texas Medicaid ure er and other state health care programs As of January 1 2004 eu MEME Reporting Fraud ACS State Healthcare LLC under contract with the Texas mur Health and Human Services Commission HHSC assumed s administration of claims processing for Texas Medicaid and Provider Lookup other state health care programs ACS a XEROX n company meets its
248. have a visible blanching in dark skin tones only it may appear with persistent blue or purple hues Enter Number Stage 2 Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed without slough May also present as an intact or open ruptured blister Enter Number 1 Number of Stage 2 pressure ulcers If 0 Skip to M0300C Stage 3 Enter Number Number of these Stage 2 pressure ulcers that were present upon admission entry or reentry enter how many were noted at the time of admission entry or reentry Date of oldest Stage 2 pressure ulcer Enter dashes if date is unknown Month Day Year Stage 3 Full thickness tissue loss Subcutaneous fat may be visible but bone tendon or muscle is not exposed Slough may be present but does not obscure the depth of tissue loss May include undermining and tunneling Enter Number 1 Number of Stage 3 pressure ulcers If 0 Skip to M0300D Stage 4 Enter Number 2 Number of these Stage 3 pressure ulcers that were present upon admission entry or reentry enter how many were noted at the time of admission entry or reentry Stage 4 Full thickness tissue loss with exposed bone tendon or muscle Slough or eschar may be present on some parts of the wound bed Often includes undermining and tunneling Enter Number 1 Number of Stage 4 pressure ulcers If 0 Skip to M0300E Unstageable Non removable dressing Enter Number 2 Number of these
249. he LTCMI is not required for Medicare recipi ents or Co insurance If the provider expects that the MDS will be used for Medicaid within the Texas Medicaid quarter it covers it is recommended that the LTCMI be completed to begin the MN process Note DADS recommends completing the LTCMI if the resident could possibly become Full Medicaid during the time period the assessment represents The LTCMI cannot be submitted until an admission either Form 3618 3619 has been submitted Upcoming Changes to the MDS Process The first release of PASRR establishes the requirements for submission of the PL1 and PE With full PASRR imple mentation the MDS assessments will be placed in a pending status awaiting completion of the PASRR processes e APLI will be required prior to establishment of a service authorization for MDS payment purposes e fan individual is PASSR Negative based on a PL1 then no PE is required and MDS assessments for that individual are not affected e Ifa Resident Review has been requested or is required by the state the MDS assessments for that individual will be in a pending status until the submission of the PE e fan individual is being admitted under the Preadmission process the MDS Admission assessments for that individual will be in a pending status until the submission of the PE More information will be available as the MDS PASRR Release goes into effect 68 v 2013 1127 LTC Nursing Facility Hospice User Guid
250. her people have noticed Or the opposite being so fidgety or restless that s he has been moving around a lot more than usual States that life isn t worth living wishes for death or attempts to harm self Being short tempered easily annoyed D0600 Total Severity Score EM The sum of the scores for all frequency responses in Column 2 Symptom Frequency The sum should be a number 00 30 WLIW WLI LILI LILI m E E E _ E m Enter Score D0650 Safety Notification Complete only if D050011 1 indicating possibility of individual self harm Was responsible caregiver provider or appropriate entity informed that there is a potential for individual self harm 0 No 1 Yes Copyright Pfizer Inc All rights reserved MN and LOC 3 0 V 15 7 of 32 Individual Identifier Date Section E E0100 Potential Indicators of Psychosis Check all that apply A Hallucinations perceptual experiences in the absence of real external sensory stimuli B Delusions misconceptions or beliefs that are firmly held contrary to reality Z None ofthe above Behavioral Symptoms E0200 Behavioral Symptom Presence amp Frequency Note presence of symptoms and their frequency Enter Codes in Boxes Coding A Physical behavioral symptoms directed toward others e g hitting kicking pushing scratching grabbing abusing others sexually Behavior not exhibited
251. hin seven calendar days of notification Individual was admitted under Exempted Hospital Dis Perform Face to Face Interview with resident charge and the resident has stayed more than 30 days Complete and submit a new PE within seven calendar days of notification Nursing Facility DADS or DSHS requests a review Perform Face to Face Interview with resident Complete and submit a new PE within seven calendar days of notification 2 heLA performs a PE within 72 hours of notification 3 TheLA submits the PE on the LTC Online Portal within seven calendar days of notification Note For every PE that is submitted on the Portal the NF must certify that they are able or unable to serve the individual If they continue to serve the individual in their facility the NF also needs to click on the Admitted to NF button v 2013 1127 4l LTC Nursing Facility Hospice User Guide How to Perform a PASRR Level 1 Screening Detailed instructions for the PL1 can be found online at www dads state tx us providers pasrr index html How to Submit a PASRR Level 1 Screening 1 Log in to the LTC Online Portal PL1s cannot be submitted by a third party software vendor 2 Click the Submit Form link located in the blue navigational bar 3 Type of Form Choose PL1 PASRR Level 1 Screening from the drop down box 4 Vendor Number Choose the submitter Vendor Number Contract Number from the drop down box 5 Click the Enter For
252. hing or their heart stops If a resident does not have one of these forms filled out EMS workers will ALWAYS give the person Cardiopulmonary Resuscitation CPR or advanced life support even if the advance care planning forms say not to A person should complete this form as well as the Directive to Physicians and Family or Surrogates and the Medical Power of Attorney form if they do NOT want CPR S12 LAR Address Legally Authorized Representative LAR Address is required if S11a Does the resident report having a legally authorized representative Is indicated as 1 Yes 78 v 2013 1127 LTC Nursing Facility Hospice User Guide LTCMI Fields S12a LAR First Name Conditional This field is required if field S11a 1 Yes Enter the first name of the Legally Authorized Representative S12b LAR Last Name Conditional This field is required if field S11a 1 Yes Enter the last name of the Legally Authorized Representative 12c Address Conditional This field is required if field S11a 1 Yes Enter the street address of the Legally Authorized Representative 12d City Conditional This field is required if field S11a 1 Yes Enter the city of the Legally Authorized Representative 12e State Conditional This field is required if field 11a 1 Yes Enter the state of the Legally Authorized Representative S12f ZIP Code Conditiona
253. how resident the response options and say While you are in this facility J Enter Codes in Boxes A how important is it to you to choose what clothes to wear B how important is it to you to take care of your personal belongings or things C how important is it to you to choose between a tub bath shower bed bath or sponge bath D how important is it to you to have snacks available between meals E how important is it to you to choose your own bedtime F howimportant is itto you to have your family or a close friend involved in discussions about your care G how important is it to you to be able to use the phone in private H howimportant is itto you to have a place to lock your things to keep them safe F0500 Interview for Activity Preferences Show resident the response options and say While you are in this facility J Enter Codes in Boxes A how important is it to you to have books newspapers and magazines to read G howimportant is it to you to go outside to get fresh air when the weather is good H how important is it to you to participate in religious services or practices F0600 Daily and Activity Preferences Primary Respondent Coding 1 Very important Somewhat important Not very important Notimportant at all Important but can t do or no choice Noresponse or non responsive LILILILILILIELIL Coding 1 Very important Somewhat important Not very important Notimportan
254. i uo Hu Aq 1uauussesse LAV ue JN suyuouJ 9 193Je poyl9 JW S U P S I J x pe y eq o1 spaau uoneoi dde mau e qe ieAe aq jou IM Y abeJaAO2 JN 1224402 ALY JOU SBOP JUApISAL J 93ON WOJ 34 1521 01 CHWL 120102 ANS3W 30U INQ SYS U J S5d 3202002 y OU J SHALL 49 JOM 4W peuo Iy OU 4 SYSIL UON IERIE IEEE E E I i py awodu paddy j Iy Buipu d r 4 i epieAAsenbey v peces eee wees 42A2eU 235 IV pe y aq 01 spaau 1 uone ijdde mau ou J eDej8A02 4N 1224102 9A eU jou Aew Juapisay pre SOIJEAIDEOY JOPIAOI Hisp d PoWdYUO IW S 1 EIEIO TEETE E Lp AW Aatiqi6 3 preoipew 4 3 JW bulpuad 4 3 __ eepiyeyisenbey dui mom 49AD2eu ypau IW aici E E c RU 3Wbuppued 1 J9 JOM JW 3De UOD e3ep uone ijdde ay wo peuuguo ql sKep Sp uey SOW J i uw um um um um m p Meme denen amp 49 ID28U AyD Lp CI pIe2tpelw QI pre ipelw 4 Duipuad QI PIEXIp9IW 1 ejyepijeAisenbag ae eee Bulpuad ql 3 eessesscssseseeceeseosccssescescoont oe pe ouddy NW genome DP JO paMalA9H JU USS SSY aai O ii KIAL preipaw Burpuag uir yuapisay uoneoyua A preoipaw Iy Bulpuag Bulpuad isenbay SYS pauuuyuo y plesu ql PIeAU Gl NW Auissa2an e2rpew 167 2013 1127 V LTC Nursing Facility Hospice User Guide
255. iagnosis such as chronic obstructive Illness pulmonary disease Parkinson s disease Huntington s disease amyotrophic lateral sclerosis congestive heart failure which result in a level of impairment so server that the individual could not be expected to benefit from specialized services Delirium Provisional admission pending further assessment in case of delirium where an ac curate diagnosis cannot be made until the delirium clears Emergency Provisional admission pending further assessment in emergency situations requiring Protective Services protective services with placement in the Nursing Facility not to exceed seven days Respite Very brief and finite stay of up to a fixed number of days to provided respite to in home caregivers to whom the individual with MI or IDD is expected to return follow ing the brief Nursing Facility stay Severe illness or injury resulting in inability to respond to external communication or stimuli such as coma or functioning at brain stem level v 2013 1127 37 LTC Nursing Facility Hospice User Guide 2 If the individual does not meet Expedited Admission criteria then the RE follows the Preadmission or Exempted Hospital Discharge process described in diagrams in this section If the individual does meet Expedited Admission criteria then a The RE sends the PL1 to the admitting NF with the individual b The NF submits the PL1 on the Portal immediately on receipt The LA is required to
256. ias e g bradycardias and tachycardias Coronary Artery Disease CAD e g angina myocardial infarction and atherosclerotic heart disease ASHD Deep Venous Thrombosis DVT Pulmonary Embolus PE or Pulmonary Thrombo Embolism PTE Heart Failure e g congestive heart failure CHF and pulmonary edema Hypertension Orthostatic Hypotension Peripheral Vascular Disease PVD or Peripheral Arterial Disease PAD Gastrointestinal 11100 Cirrhosis 11200 Gastroesophageal Reflux Disease GERD or Ulcer e g esophageal gastric and peptic ulcers 11300 Ulcerative Colitis Crohn s Disease or Inflammatory Bowel Disease 11400 Benign Prostatic Hyperplasia BPH 11500 Renal Insufficiency Renal Failure or End Stage Renal Disease ESRD 11550 Neurogenic Bladder 11650 Obstructive Uropathy Multidrug Resistant Organism MDRO Pneumonia Septicemia Tuberculosis Urinary Tract Infection UTI LAST 30 DAYS Viral Hepatitis e g Hepatitis A B C D and E Wound Infection other than foot Metabolic Diabetes Mellitus DM e g diabetic retinopathy nephropathy and neuropathy Hyponatremia Hyperkalemia Hyperlipidemia e g hypercholesterolemia Thyroid Disorder e g hypothyroidism hyperthyroidism and Hashimoto s thyroiditis
257. ical record J Enter Codes in Boxes A Inattention Did the resident have difficulty focusing attention easily distracted out of touch or Coding difficulty following what was said 0 Behavior not present 1 Behavior continuously present does not fluctuate C Altered level of consciousness Did the resident have altered level of consciousness e g vigilant 2 Behavior present startled easily to any sound or touch lethargic repeatedly dozed off when being asked questions but fluctuates comes and responded to voice or touch stuporous very difficult to arouse and keep aroused for the interview goes changes in severity comatose could not be aroused Disorganized thinking Was the resident s thinking disorganized or incoherent rambling or irrelevant conversation unclear or illogical flow of ideas or unpredictable switching from subject to subject D Psychomotor retardation Did the resident have an unusually decreased level of activity such as sluggishness staring into space staying in one position moving very slowly C1600 Acute Onset Mental Status Change Enter Code Is there evidence of an acute change in mental status from the resident s baseline 0 No 1 Yes Copyright 1990 Annals of Internal Medicine All rights reserved Adapted with permission MDS 3 0 Nursing Home Quarterly NQ Version 1 11 2 Effective 10 01 2013 Page 8 of 35 Resident Identifier Date D0100 Should Resident Mood Interview
258. icare replacement Name of the insurance carrier Number of co pay days allowed Daily co pay amount v 2013 1127 143 LTC Nursing Facility Hospice User Guide Form and Assessment Statuses Providers can retrieve the status of their forms and assessments by using FSI or Current Activity on the LTC Online Portal The following are statuses that a provider may see and their definition AI Check Inactive Applied Income validation attempted nightly for up to six months and failed or the request was canceled Appealed A resident has appealed the MN determination and the provider has provided more information for consideration Assessment is now awaiting TMHP doctor review or a fair hearing has been requested Awaiting LTC Medicaid Information MDS has been retrieved by TMHP from CMS If LTCMI is submitted assessment will be processed by DADS Awaiting PE A PL1 has been submitted but the PE for this individual has not been submitted Coach Pending More Info DADS Provider Claims Services is reviewing Coach Review DADS Provider Claims Services is reviewing Corrected Forms are moved into a corrected status when the form is corrected by another form View the History trail to find the child DLN No further actions are allowed on a form or assessment with status Corrected Form Complete A previous valid PASARR Screening has been located and MN has been approved Form Inactivated Assessment form has been inactivated No
259. ice a day 5 3 11 times a day 6 6 23 hours 7 24 hour continuous gt This field is only required and available for data entry if O0100F Ventilator or respirator column 2 While a Resident is checked Do not include BiPAP CPAP e S6c Number of hospitalizations in the last 90 days Required Record the number of times the resident was admitted to hospital with an overnight stay in the last 90 days or since last assessment if less than 90 days Enter O zero if no hospital admissions Valid range includes 0 90 e S6d Number of emergency room visits in the last 90 days Required Record the number of times the resident visited the Emergency Room ER without an overnight stay in the last 90 days or since the last assessment if less than 90 days Enter O zero if no ER visits Valid range includes 0 90 S6e Oxygen Therapy Conditional Choose from the drop down box 1 Less than once a week 2 1 to 6 times a week 3 Once a day 4 Twice a day 5 3 11 times a day 6 6 23 hours 7 24 hour continuous gt This is a required field is only available for data entry if O0100C Oxygen therapy column 2 While a Resident is checked S6f Special Ports Central Lines PICC Optional Choose from the drop down box 0 N none present 1 Y 1 or more implantable access system or CVC 2 U unknown gt Use this field to indicate if the resident has any type of implantable access system or cen
260. ices at 512 438 2200 Option 1 for assistance This 3619 has been identified as part of a retroactive pair attempt ing to process together The Qualifying Stay dates fall between the admission and discharge dates submitted which is not allowed Full Medicare Qualifying Stay days cannot split a single admission and discharge pair Two pairs of retroactive 3619s must be submitted instead e Verify the Medicare Part A Coinsurance dates through the Medicare Remittance advice Resubmit the rejected 3619 admission for the first day of Coin surance paired with a discharge matching the first day of Full Medicare which will end the Coinsurance Service Authorization the day before the Qualifying Stay included on the admission of the pair Then resubmit the rejected 3619 discharge from Coinsurance paired with an admission beginning after the Full Medicare Qualifying Stay ends 112 v 2013 1127 LTC Nursing Facility Hospice User Guide Form Assessment 3618 3619 Pair Provider Message Displayed in History NF 0051 This form cannot be pro cessed as a retroactive pair because the discharge of pair is marked as a death and a subsequent admission has already been processed Verify that the client was discharged and correct the form as needed If the client is deceased contact Provider Claims Services for assistance 3618 3619 Admit Mod NF 0052 This admission modifica tion cannot be processed because th
261. ide How to Inactivate 1 Log in to the LTC Online Portal 2 Click the Form Status Inquiry or Current Activity link in the blue navigational bar a Ifusing FSI you may search for Form 3618 or 3619 using SSN Medicaid Number or DLN Click the Search button then click the View Detail link b Ifusing Current Activity click the DLN link 3 Click the Inactivate Form button 4 Click the OK button when the pop up window asks Are you sure you want to Inactivate this form If so click Ok and enter a note to explain the reason for inactivation 5 When the Change Status window appears enter a note for the inactivation and click the Change Status button The form or screening will be set to status Form Inactivated Forms 3618 and 3619 that are set to status Processed Complete Corrected Form Inactivated or have been suc cessfully processed or that contain provider workflow message code GN 9004 anywhere in the History trail of the form cannot be inactivated If a provider attempts to inactivate a Form 3618 or 3619 and one of the above circum stances exists the provider will receive the following error message This form has been successfully processed at DADS and cannot be inactivated If this form is invalid should not have been submitted submit the appropriate form to counteract this form Otherwise correct this form and resubmit To cancel a form that is set to status Processed Complete a
262. idual by working with the RE and the identified NFs on the PL1 updating the PL1 with the admitted to date Note f the individual is PASRR Negative based on a PL1 then existing procedures for nursing home admissions are followed A PE is not performed unless requested by DADS DSHS or a Nursing Facility Ifthe individual is is PASRR Negative based on the PE a letter will be provided to the individual If the individual does not agree with this result then he she can contact the Evaluator at the Local Authority stated on the letter v 2013 1127 39 LTC Nursing Facility Hospice User Guide Alternate Placement Process LA is notified that Is individual individual requests a current Yes Alternate Placement NF resident LA performs Section LA coordinates EonthePLi P Ppmate Placement LA completes and updates Section E on the PL1 on the LA submits PL1 L RE faxes PL1 to LA pene i P Portal after submission by clicking on the Enter Disposition button The LA is notified that the individual requests Alternate Placement The notification could come from DADS DSHS or the NE If this is a current NF resident then the notification can be a manually generated alert on the Portal If the individual is NOT a current resident the LA is notified by the RE If the individual is a current resident of an NF a The LA performs Sect
263. iew assessment A0310A 02 Annual assessment A0310A 03 Significant change in status assessment A0310A 04 Significant correction to prior comprehensive assessment A0310A 05 Significant correction to prior quarterly assessment A0310A 06 e National Provider ID MDS 3 0 A0100A should be entered for Nursing Facilities to locate assessments Awaiting LTC Medicaid Information e Medicaid Number MDS 3 0 A0700 contains or a nine digit numeric value Note Once accepted by CMS it may be up to 48 hours before the MDS 3 0 assessment is accessible on the LTC Online Portal for data entry in Awaiting LTC Medicaid Information status Note The effective date of quarterly review assessments with a date after the 30 day submission period can be adjusted by contacting Dads Provider Claim Services PCS directly to make the adjustment Assessments loaded onto the LTC Online Portal are assigned a DLN and set to status Awaiting LTC Medicaid Information Providers must log in to the LTC Online Portal and use FSI or Current Activity to find the submitted MDS assess ment set to status Awaiting LTC Medicaid Information Complete the LTCMI and submit The MDS assessment must be accepted by the LTC Online Portal and have an LTCMI completed to begin the MN determination process Periodically review the status of the MDS assessment for MN and Medicaid Processing using FSI or Current Activity Note Providers should follow the
264. ify the Spell of Illness Pull a MESAV and compare the Service Authorizations to the earlier admission date that would be created by the rejected admission Consider the Qualifying Stays reported on any processed 3619s These dates create Full Medicare periods which do not appear on the MESAV If the end date of an existing Service Authorization needs to be changed submit a correction to that discharge If the submitted admission date would overlap with a reported Qualifying Stay period submit a correction to adjust the Qualifying Stay dates To determine if the Qualifying Stay dates from the Medicare remittance advice correspond with those on file contact DADS Provider Claims Services at 512 438 2200 Option 1 for assistance If the recipient was previously receiving Hospice services verify the dates of service with the Hospice Provider and make correc tions as needed This rejected admission should be resubmitted once the file has been adjusted v 2013 1127 113 LTC Nursing Facility Hospice User Guide Provider Message Form Displayed in History Assessment Suggested Action NF 0055 This admission modifica 3619 Admit For each Medicare Spell of Illness the state will pay a maximum of tion cannot be processed because Mod 80 days of Medicare Part A Coinsurance to one or more providers the new admission date would The recipient will exceed the 80 day limit if this correction is pro result in more than
265. ilities ID or Develop mental Disabilities DD prior to admission into a certified Nursing Facility The screening must be submitted to TMHP via the LTC Online Portal e PICC Peripherally Inserted Central Catheter e PMN Permanent MN e PNA Personal Needs Allowance Payments e PRN Pro Re Nada or as needed e QTSO QIES Technical Support Office RA Route of Administration e RAI Resident Assessment Instrument includes instructions as to how to complete the MDS assessment e RE Referring Entity e Resident Assessment Validation and Entry RAVEN Free MDS data entry software that offers users the ability to enter and transmit assessments to CMS The Centers for Medicare amp Medicaid Services CMS provides this free MDS data entry software Provides can download the free software at the federal CMS website indicated on the slide RN Registered Nurse e RUG Resource Utilization Group SCSA Significant Change in Status Assessment e SNF Skilled Nursing Facility e SSI Supplemental Security Income 162 v 2013 1127 LTC Nursing Facility Hospice User Guide e TMHP Texas Medicaid amp Healthcare Partnership e TAC Texas Administrative Code e Z0500B Date RN Assessment Coordinator signed as complete MDS 3 0 v 2013 1127 163 LTC Nursing Facility Hospice User Guide Appendix A Medicaid Eligibility Verification Resident with Medical Eligibility 164 v 2013 1127 LTC Nur
266. ill begin MDS 3 0 Admission assessments are effective based on the Entry Date entered into field A1600 System process ing will start the Level record either based on the Entry Date or the completion date Z0500B minus 30 days whichever is later If the begin date of the Level record needs to be adjusted because the timeframe between Entry Date and the completion date is over 30 days a call is required to DADS Provider Claims Services 512 438 2200 Option 1 for the additional days The other assessment types will be effective based on the completion date Z0500B With the changes from CMS on April 1 2012 the LTC Online Portal will change to display the revisions of the MDS 3 0 Comprehensive and Quarterly assessments based on the Assessment Reference Date ARD A2300 MDS 3 0 assessments with an ARD prior to April 1 2012 will display in the previous format regardless of extraction date This use of the ARD does not alter DADS use of the Entry Date A1600 as the effective date of MDS 3 0 Admission assessments and the Date Signed as Complete Z0500b as the effective date of all other MDS 3 0 assessments All assessments without a Purpose Code are valid for 92 days from the completion date Expiration dates on the MESAV also include a 31 day grace period for the next submission An MDS 3 0 Admission assessment is valid in three situations 1 Fora first physical admission into a Nursing Facility an Admission assessment is valid Regardles
267. information or click the Populate LTCMT button and modify data as necessary Note To ensure that the LTCMI can be submitted once completed first check for the Submit Form button at the bottom of the screen If the assessment is being used locked by another user the Submit Form button will not be available displayed Additionally a message will display in the upper right of the screen This form is being viewed by another user and cannot be changed 3 Click the Print button located in the yellow Form Actions bar to print the LTCMI in progress a Printer Choose the appropriate printer name from drop down box b Print Range Click the Pages radio button c Enter the pages to print As an example pages for the LTCMI for the MDS 3 0 Comprehensive are 39 42 Pages for the LTCMI for the MDS 3 0 Quarterly are 34 37 Print Range OA O Current view Current page Pages 34 37 Subset All pages in range x C Reverse pages d Click the OK button 66 LTC Nursing Facility Hospice User Guide 4 From here you have two choices a Click the Submit Form button located at the bottom right of the screen if ready to submit for processing zT Submit Form or b Click the Save LTCMI button located in the yellow Form Actions bar if you would like to save the LTCMI prior to submission The saved LTCMI will remain in status Awaiting LTC Medicaid Information Reminder 75e LTCMI will not
268. ing and Disability Services DADS Texas state agency that provides long term services and supports to older persons and individuals with physical intellectual and developmental disabilities DADS also regulates providers of long term services and supports and administers the state s guardianship program Texas Health and Human Services Commission HHSC Provides administrative oversight of Texas health and human services programs including the Medicaid acute care program Children s Health Insurance Plan CHIP State of Texas Access Reform STAR State of Texas Access Reform PLUS STAR PLUS and provides direct administration of some programs Texas HHSC s Office of Eligibility Services OES determines eligibility for Medicaid Texas Medicaid amp Healthcare Partnership TMHD Contracted by the state as the claims administrator to process claims for providers under traditional Medicaid TMHP processes and approves claims for traditional Long Term Care LTC TMHP does not pay LTC claims this is done by the comptroller Responsibilities also include the following Determination of MN Provider Education Provide timely processing of claims except for services covered by the STAR PLUS premium and repre sents DADS at Fair Hearings Provide yearly program manuals quarterly LTC Provider Bulletins and Remittance and Status R amp S Reports Maintain the TMHP Call Center Help Desk Monday through Friday
269. ing assistance from TMHP or DADS To unlock a document click the UnLock Form button located at the top right corner of the screen v 4 Texas MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR Printable Forms Alerts Help Home Submit Form Form Status Inquiry Current Activity Drafts Vendors PASRR LEVEL 1 SCREENING Current Status Awaiting PE Name DLN Form Actions section B Section C section D Section E Section F v 2013 1127 32 LTC Nursing Facility Hospice User Guide Error Messages Upon submission if required information is missing or information is invalid error message s will display and you will not be able to continue to the next step until resolved You may need to scroll to the top of the screen since any error message s will be displayed at the top You may click the error message hyperlink to automatically go to the field s containing the error v TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR Home Submit Form Form Status Inquiry Current Activity Drafts Vendors Printable Forms Alerts The following errors must be fixed before the form will submit MD DO Last Name is a required field MD DO License State is a required field MD DO First Name is a required field M Addr is a required fiel MD DO City is a required field MD DO State is a required field MI IP is a required field RI rdin fie
270. ing with the resident or family and determined to be consistent with resident values preferences or goals Enter Code 0 Behavior not exhibited L 1 Behavior of this type occurred 1 to 3 days 2 Behavior of this type occurred 4 to 6 days but less than daily 3 Behavior of this type occurred daily E0900 Wandering Presence amp Frequency Enter Code Has the resident wandered 0 Behavior not exhibited Behavior of this type occurred 1 to 3 days 1 2 Behavior of this type occurred 4 to 6 days but less than daily 3 Behavior of this type occurred daily MDS 3 0 Nursing Home Quarterly NQ Version 1 11 2 Effective 10 01 2013 Page 11 of 35 Resident Identifier Date SectionG _ Functional Status G0110 Activities of Daily Living ADL Assistance Refer to the ADL flow chart in the RAI manual to facilitate accurate coding Instructions for Rule of 3 m When an activity occurs three times at any one given level code that level m When an activity occurs three times at multiple levels code the most dependent exceptions are total dependence 4 activity must require full assist every time and activity did not occur 8 activity must not have occurred at all Example three times extensive assistance 3 and three times limited assistance 2 code extensive assistance 3 m When an activity occurs at various levels but not three times at any given level apply the following o When there is a combination of f
271. injury in evolution f O Skip to M0610 Dimension of Unhealed Stage 3 or 4 Pressure Ulcers or Eschar Enter Number Number of these unstageable pressure ulcers that were present upon admission entry or reentry enter how many were noted at the time of admission entry or reentry M0610 Dimensions of Unhealed Stage 3 or 4 Pressure Ulcers or Eschar Complete only if M0300C1 M0300D1 or M0300F1 is greater than 0 If the resident has one or more unhealed Stage 3 or 4 pressure ulcers or an unstageable pressure ulcer due to slough or eschar identify the pressure ulcer with the largest surface area length x width and record in centimeters A Pressure ulcer length Longest length from head to toe B Pressure ulcer width Widest width of the same pressure ulcer side to side perpendicular 90 degree angle to length C Pressure ulcer depth Depth of the same pressure ulcer from the visible surface to the deepest area if depth is unknown enter a dash in each box M0700 Most Severe Tissue Type for Any Pressure Ulcer Select the best description of the most severe type of tissue present in any pressure ulcer bed Enter Code 1 Epithelial tissue new skin growing in superficial ulcer It can be light pink and shiny even in persons with darkly pigmented skin Granulation tissue pink or red tissue with shiny moist granular appearance 2 3 Slough yellow or white tissue that adheres to the ulcer bed in strings or thick clumps or is m
272. ion Complete only if Type of Record is to inactivate a record in error A0050 3 J Check all that apply A Event did not occur Z Other error requiring inactivation If Other checked please specify MDS 3 0 Nursing Home Comprehensive NC Version 1 11 2 Effective 10 01 2013 Page 38 of 41 Resident Identifier Date SectionX Correction Request X1100 RN Assessment Coordinator Attestation of Completion A Attesting individual s first name ILITIIIILITLLEL B Attesting individual s last name LILIIIIILILLILLILLLILI C Attesting individual s title E Attestation date LILII MDS 3 0 Nursing Home Comprehensive NC Version 1 11 2 Effective 10 01 2013 Page 39 of 41 Resident Identifier Date SectionZ Assessment Administration Z0100 Medicare Part A Billing A Medicare Part A HIPPS code RUG group followed by assessment type indicator TT tT TI B RUG version code LIT LT T T4 1j EnterCode C Is this a Medicare Short Stay assessment 0 No 1 Yes Z0150 Medicare Part A Non Therapy Billing A Medicare Part A non therapy HIPPS code RUG group followed by assessment type indicator B RUG version code TT TET TI Z0200 State Medicaid Billing if required by the state A RUG Case Mix group TT TTT ty B RUG version code ITIITI Z0250 Alternate State Medicaid Billing if required by the state A RUG Case Mix group TTT TTT tty
273. ion E on the PL1 by clicking on the Enter Disposition button b The LA coordinates Alternate Placement c The NF will also indicate discharge of the individual on the PL1 If the individual is NOT a current resident of an NF a The RE faxes the PLI to the LA b The LA submits the PL1 on the Portal c The LA completes and updates Section E of the PL1 on the portal after submission by clicking on the Enter Disposition button 40 v 2013 1127 LTC Nursing Facility Hospice User Guide Resident Review Process LA is notified to LA performs PE LA submits PE within 72 hours within 7 days of perform a RR igi nee Spee as of notification notification bL CMM 1 A Resident Review takes place when a LA is notified to perform a PE on a resident of a Nursing Facility The notification is normally generated as an automatic Alert in the LTC Online Portal although the request could come as a manually generated Alert in the LTC Online Portal from DADS DSHS or the Nursing Facility Resident Review Triggers Trigger Action MDS Significant Change in Status Assessment SCSA is Perform Face to Face Interview with resident submitted Complete and submit a new PE within seven calendar days of notification Individual was admitted under Expedited Admission and Perform Face to Face Interview with resident the Expedited Admission time frame has expired Complete and submit a new PE wit
274. ion K Section L Section M Section N Section O Section P Section Q Section V Section X Section Z Section LTCMI 34 v 2013 1127 LTC Nursing Facility Hospice User Guide Preadmission Screening and Resident Review PASRR PASRR is a review process that is federally mandated requiring that all individuals seeking Medicaid certified Nursing Facility admissions are screened for Mental Illness Developmental Disability Related Condition or Intel lectual Disability Mental Retardation At least one of these diagnoses must be indicated for the individual to be considered PASRR positive The PASRR Evaluation PE is used to perform a Level II evaluation to determine if the NF is the appropriate place ment for the individual and if the individual could benefit from specialized services The PE can only be performed face to face by the Local Authority LA and must be completed within 72 hours and submitted on the Portal within seven calendar days from the time that the request for the PE was received Every time a PE is submitted the NF must certify able or unable to serve the needs of the individual An individual cannot be admitted to the Nursing Facility through the Preadmission process until a PL1 and PE have been submitted on the Portal and the Nursing Facility has indicated that they can meet the needs of the individual PASRR Level 1 PL1 Screenings are submitted directly on the LTC Online Portal and assign
275. ior to the expiration date of the recertification period e Medicaid payment will not be made for any period where a gap exists in the certification periods This form must be completed in order for the recipient to receive Medicaid Hospice services and for the provider to be paid for those services For Hospice forms policy questions should be directed to the DADS Hospice Policy Medicaid numbers located in the back of this User Guide Helpful Telephone Numbers TMHP only addresses technical questions related to using the LTC Online Portal for Hospice form submission 58 v 2013 1127 LTC Nursing Facility Hospice User Guide How to Submit Form 3074 Instructions for completing Form 3074 can be found in Module 6 Form 3074 in the Long Term Care LTC Nursing Facility Hospice CBT found at the following link http learn tmhp com Log in to the LTC Online Portal l 2 svo ame O9 Click the Submit Form link located in the blue navigational bar Type of Form Choose 3074 Physician Certification of Terminal Illness from the drop down box Click the Enter Form button Enter all required information as indicated by the red dots Verify the following is complete before submission of the form Complete at least one of the following Medicaid number SSN or Medicare Number Election Start Date is the Election date from the Form 3071 Elect Recertification If this form is a recertification check this box Cert Recert
276. ior to this discharge is rejected the rejected admission must be processed first This dis charge can then be resubmitted 3618 Discharge Suggested Action A later admission is already in the recipient s file This admission will have to be submitted with a matching discharge to process as a retroactive pair Review the facility s records to determine which discharge follows this admission Pull a MESAV and review the Service Authorizations to see if a gap exists for the period that will be created by the admission and discharge pair If a gap exists resubmit the rejected admission then submit the following discharge Both forms must be submitted on the same day The system will process both forms as a pair If a gap does not exist review the facility s records to determine if a discharge prior to the rejected admission is reflected on the recipient s MESAV If the discharge is not reflected on the recipient s MESAV submit the missing or rejected discharge followed by the admission and discharge pair If the discharge is reflected on the recipient s MESAV contact DADS Provider Claims Services at 512 438 2200 Option 1 for assistance The recipient has a Service Authorization for Medicare Part A Coin surance as of the submitted discharge date Review the facility s records to determine which admission is prior to this discharge Pull a MESAV and review the Service Authorizations to determine if Coin
277. iptor Scale Ask resident Please rate the intensity of your worst pain over the last 5 days Show resident verbal scale Mild Moderate Severe Very severe horrible Unable to answer Enter Rating Enter Code MDS 3 0 Nursing Home Comprehensive NC Version 1 11 2 Effective 10 01 2013 Page 20 of 41 Resident Identifier Date Section Health Conditions J0700 Should the Staff Assessment for Pain be Conducted Enter Code No J0400 1 thru 4 gt Skip to J1100 Shortness of Breath dyspnea LI 1 Yes J0400 9 Continue to J0800 Indicators of Pain or Possible Pain Staff Assessment for Pain J0800 Indicators of Pain or Possible Pain in the last 5 days J Check all that apply A Non verbal sounds e g crying whining gasping moaning or groaning B Vocal complaints of pain e 9 that hurts ouch stop C Facial expressions e g grimaces winces wrinkled forehead furrowed brow clenched teeth or jaw E D Protective body movements or postures e g bracing guarding rubbing or massaging a body part area clutching or holding a body part during movement L Z None of these signs observed or documented If checked skip to J1100 Shortness of Breath dyspnea J0850 Frequency of Indicator of Pain or Possible Pain in the last 5 days Frequency with which resident complains or shows evidence of pain or possible pain Enter Code 1 Indicators of pain or possible pain observed 1
278. iral Hepatitis e g Hepatitis A B C D and E Wound Infection other than foot Metabolic 12900 Diabetes Mellitus DM e g diabetic retinopathy nephropathy and neuropathy 13100 Hyponatremia 13200 Hyperkalemia 13300 Hyperlipidemia e 9 hypercholesterolemia Musculoskeletal 13900 Hip Fracture any hip fracture that has a relationship to current status treatments monitoring e g sub capital fractures and fractures of the trochanter and femoral neck 14000 Other Fracture Neurological Alzheimer s Disease Aphasia Cerebral Palsy Cerebrovascular Accident CVA Transient Ischemic Attack TIA or Stroke Non Alzheimer s Dementia e g Lewy body dementia vascular or multi infarct dementia mixed dementia frontotemporal dementia such as Pick s disease and dementia related to stroke Parkinson s or Creutzfeldt Jakob diseases Hemiplegia or Hemiparesis Paraplegia Quadriplegia Multiple Sclerosis MS Huntington s Disease Parkinson s Disease Tourette s Syndrome Seizure Disorder or Epilepsy Traumatic Brain Injury TBI 15600 Malnutrition protein or calorie or at risk for malnutrition MDS 3 0 Nursing Home Quarterly NO Version 1 11 2 Effective 10 01 2013 Page 15 of 35 Resident Identifier Date Secti
279. ission MDS assessment required by day 14 Submit MDS 3 0 A0310A 02 Quarterly MDS assessment within 92 days of Admission MDS assessment Unless a SCSA MDS 3 0 A0310A 04 ora Significant Correction of Prior Assessment MDS 3 0 A0310A 05 06 was completed prior to Quarterly MDS assessment 84 v 2013 1127 LTC Nursing Facility Hospice User Guide Resident Returns Prior Discharge Return Anticipated e Refer to Preadmission process for steps associated with PL1 and PE e Submit a 3618 within 72 hours of admission e Ifthe recipient returns after a 30 day absence an MDS 3 0 Admission assessment will be due even if the Dis charge indicated Return Anticipated e fthere has been a change in condition submit a SCSA e Ifthe previous MDS assessment is less than 92 days old has not expired and the recipient has not had a change in condition no additional assessment is required e If the previous MDS assessment has expired complete the next scheduled assessment per the federal guidelines Refer to Preadmission process for steps associated with PL1 and PE Resident returns to full Medicaid Form 3618 must be signed and electronically submitted within 72 hours of admission Has the previous assessment expired Has there been a 30 day absence Has resident had a change in condition Federal guidelines will require submission of an MDS 3 0 Admission assessment even if Retu
280. it To save information entered onto an LTCMI click the Save LTCMI button located in the yellow Form Actions bar Once an LTCMI is saved a message will display at the top of the screen with a date and time indicating that the LTCMI has been saved and it will automatically unlock the assessment allowing other users to access it The assessment will remain in Awaiting LTC Medicaid Information status until it is successfully v 2013 1127 29 LTC Nursing Facility Hospice User Guide submitted The assessment can then be accessed by all users who have the same vendor contract number access as the person who originally saved the information by using FSI The LTCMI will not be saved to Drafts Populate LTCMI The Populate LTCMI feature allows providers to use a resident s previously submitted assessment to populate infor mation on a new LTCMI However it will only populate information from an assessment with the same vendor contract number and it will only populate information if the previous LTCMI was submitted within the last six months The following error will be displayed if there is not a previous assessment available 1 e No previous LTCMI for this resident and contract number received within the last 6 months can be found to populate the LTCMI 1 Two important reminders 1l Ifinformation has been entered onto the LTCMI and saved prior to clicking the Populate LTCMI button the Populate LTCMI button will not
281. it the rejected admission Two assessments attempted to process on the same day using the same assessment effective date Validate the effective dates on the MDSs submitted Ifthe assessment effective date is incorrect on one MDS submit a modification to the federal CMS database for that assessment and resubmit the other rejected assessment If one of the assessments was submitted in error inactivate the assessment that is not needed and resubmit the other rejected assessment v 2013 1127 111 LTC Nursing Facility Hospice User Guide Provider Message Form Displayed in History Assessment NF 0049 This assessment cannot MDS Admit be processed because an admission assessment is not appropriate or the Date of Entry does not corre spond with the correct admission If an admission assessment is not appropriate inactivate this assess ment and submit the appropriate MDS assessment type If the admis sion assessment is appropriate modify the Date of Entry NF 0050 This form cannot be pro cessed as a retroactive pair because the effective date on the discharge of pair is later then the Qualifying Stay begin date on the admission of pair The discharge prior to the Qualifying Stay begin date anda subsequent admission are needed along with this pair to process automatically 3619 Pair Suggested Action An assessment that covers the Date of Entry is already on file for this resident and provider
282. it the rejected form once the Medicare contract is effective in the system v 2013 1127 101 LTC Nursing Facility Hospice User Guide Provider Message Form Displayed in History Assessment NF 0001 This form cannot be pro MDS 3619 cessed because the client s Applied Admit Income is not available to DADS Contact the HHSC Eligibility Worker to update the client s Applied Income Once the Applied Income has been updated this form can be resubmitted NF 0002 This assessment cannot MDS Admit be processed because there is no Annual gap in the Level records for this Quarterly client for the Purpose Code time frame on the assessment NF 0003 This assessment cannot MDS Admit be processed because the client Annual does not have 3 month prior Med Quarterly icaid or SSI eligibility Contact the HHSC Eligibility Worker or SSI office Suggested Action The recipient s Applied Income is not available to DADS Pull a MESAV for the recipient covering the date requested on the form or assessment Note f the recipient does not already have Service Authorizations for your contract this information will not be available on the MESAV If the MESAV does not show an Applied Income for the dates of the form or assessment contact the HHSC Eligibility Worker to update the Applied Income records Once the Applied Income has been updated resubmit the rejected form or assessment If the recipient i
283. ithin the last 14 calendar days After 14 days providers must use the FSI query tool to locate a document Current Activity will display MDS 3 0 Comprehensive and MDS 3 0 quarterly assessments in addition to PL1 and Forms 3071 3074 3618 and 3619 1 Click the Current Activity link in the blue navigational bar 2 Click the appropriate vendor number if applicable Note The initial Current Activity page will display a list of all vendor contract numbers to which the user is linked TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR Home Submit Form Form Status Inquiry Current Activity Drafts Vendors Printable Forms Alerts Help Current Activity The user name is associated with the following Vendor Contract numbers Select the vendor Contract number to configure a administrator account Vendor Numbers B for Contract Number i 1 fer Contract Number i i 3 The results will display a summary of all document submissions or status changes within the last 14 calendar days v a TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR Home Submit Form Form Status Inquiry Current Activity Drafts Vendors Printable Forms Alerts Help Received Medicaid Medicare Name Status fee eme e 10 7 2010 5 47 11 PM Pending Review M D 10 8 2010 9 02 06 AM ID Invalid e 10 9 20109 42 43 AM Pending Review Received Medicaid Medicare Name Status M 10 7 2010 5 47 17
284. itional training resources Types of Calls to Refer to DSHS PASRR Call DSHS PASRR at 1 866 378 8440 Option 1 about the following e Assistance or cooperation from a Referring Entity or Local Authority e Assistance with locating information to perform and submit the PL1 Screening e Assistance with locating screenings and evaluations individuals or additional training resources v 2013 1127 155 LTC Nursing Facility Hospice User Guide Types of Calls to Refer to DADS PCS Call DADS PCS at 512 438 2200 Option 1 about the following e Denials or pending denials of residents who have established prior permanent medical necessity after verifying MDS 3 0 A0700 Medicaid Number contains a nine digit numeric rather than or N e A 3618 3619 admission submitted under the wrong contract that process must have a counteracting discharge submitted and the provider must call to request that DADS PCS set the incorrect form to status Invalid Complete A third form for the same Date of Above Transaction cannot be submitted until the forms with the incorrect contract have been set to status Invalid Complete Types of Calls to Refer to a Local Authority e Fora true preadmission when an individual just shows up at the NF when not Expedited Admission or Exempted Hospital Discharge e For an individual who just shows up at the NF with a PASRR Negative Letter and needs help calling the LA e When the NF needs to follow up after an alert
285. ity Hospice Workshop Jumble Use this activity to reinforce the terminology learned throughout this workshop Unscramble each of the clue words LN Take the letters that appear in boxes and unscramble them for the final message VSRPREIDO rEsMESSASN _ E LL IIMEDDAC PIYHANCIS WOOFRWLK TOLRPA IL LLLLJ IPHAA OIl DSDA mag PTHM LLLI RPRAS IL LLLI sixsoablM LILLLLLLELJI SERDEITN PEOCISH IL EELLELJ TMCIL te B FF tT v 2013 1127 181 LTC Nursing Facility Hospice User Guide Answers PROVIDERS ASSESSMENT MEDICAID PHYSICIAN WORKFLOW PORTAL HIPAA DADS TMHP PASRR ADMISSION RESIDENT HOSPICE LTCMI Final Message ELIGIBILITY 182 v 2013 1127 LTC Nursing Facility Hospice User Guide Appendix H LTC Word Search Long Term Care Nursing Facility Hospice Workshop Word Search Use this activity to reinforce the terminology learned throughout this workshop A p fa Quy D H O Z N Z Oo KG H di mM n ET E3 a m e Oo 4 N 4 n a KG O N O e E Ay H H e O H NRIIPXUREIQAGRZZGWAH EQFTONOSTLCSTATUSYND MNUGCYGAVTQVSIRKHBMI SEVAZEDPIKOQOXYISIYLEA SCCYRIRVNOITACIFIDOM EEIULTARECIPSOHGITVM SSVAATECORKUYFZWRGGZAZN SSVFIWURWCADMISSIONOQ AINOEGLOLDRLHOQOIISNOO UTNGRARKAYRKTWOUVNLK HYNNUKDKJRWAPCECOIRF MANNFADTKOQOZPYWMIXENM HPNLUHFYNUWXYTTJIVTZL LAOEVUZBWWHWSSSRHEKV EWLDLGTWEJSEATXANGRP HSZUCUTXQOCNFXIQM
286. jected 3619 discharge The recipient has a Service Authorization for Medicare Part A Coin surance with a different provider as of the submitted discharge date Review the facility s records to identify the Medicare Part A Coin surance admission date prior to this discharge Determine if the 3619 admission prior to this discharge has been submitted If not submit that 3619 admission If it was rejected resolve the issue and resubmit that 3619 admission Resubmit the rejected 3619 discharge after the missing or corrected admission has been processed The recipient has a Service Authorization with a different provider that begins after the submitted discharge date The rejected dis charge and matching admission must be submitted as a retroactive pair Review the facility records to identify the Medicare Part A Coin surance admission date prior to this discharge Determine if the 3619 admission prior to this discharge has been submitted If not submit that 3619 admission If it was rejected resolve the issue and resubmit that 3619 admission Resubmit the rejected 3619 discharge on the same day as the missing or corrected admission v 2013 1127 117 LTC Nursing Facility Hospice User Guide Provider Message Displayed in History NF 0065 This discharge cannot be processed because the client is cur rently authorized for Full Medicaid for this provider If a 3618 discharge prior to the Medicare stay and a 3619 admissio
287. k the Print button in the yellow Form Actions bar to print the completed form v 2013 1127 133 LTC Nursing Facility Hospice User Guide Counteracting Forms A counteracting form is a form submitted indicating the opposite transaction of the incorrect form admission versus discharge and with the same date in the Date of Above Transaction field Examples A discharge to the hospital is submitted in error because the admission to the hospital was for observation only and no form should have been submitted If the discharge processes before the mistake is corrected submit a counteracting form indicating an admission in the Transaction field and use the same date in the Date of Above Transaction field A Form 3618 admission is submitted but the resident is classified as Medicare If the admission processes before the mistake is corrected submit a counteracting form indicating Discharge to NF in the Transaction field and use the same date in the Date of Above Transaction field If an admission is submitted under the wrong contract and it processes onto the file a discharge must be submitted for the same incorrect contract using the same Date of Above Transaction Once both forms are available on the LTC Online Portal and are set to status Processed Complete or Provider Action Required the provider must contact DADS Provider Claims Services The correct admission cannot be submitted until DADS has set the status of both forms
288. k the Search button 5 Click the View Detail link v 2013 1127 131 LTC Nursing Facility Hospice User Guide 6 Click the Correct this form button Texas MEDICAID amp HEALTHCARE PARTNERSHIP TMHP _A STATE MEDICAID CONTRACTOR Pe ae Form Status Inquiry B a i36 3125 E 1 1 A 1 3 1 I E A E 02 E 3618 RESIDENT TRANSACTION NOTICE Current Status wt Name Ga DLN DT Soba t S EE a pu M M M aad note inactivate Form Provider Information BENDERS WEE AN CRN IR Ea ee ss oer HO eene Vendor Number we Contract Number s IE NPI Number Recipient Information 1 Medicaid Recipient No 4 Recipient s Last Name 5 Address Address 2 Social Security No Name Recipient s First Name eil City 3 Medicare or RR Retirement 1 Recipient s Middle State E Claim No Initial ZIP Recipient Name Suffix Transaction Information Service Group nursing Facility e Transaction 1 admission From Discharge Type vi Location 2 Nursing Facility v Date of Physical Admission to Private tvi Pay If Newly Adrnitted From Discharged To Hospital Enter tvi Date e Date of Above Transaction A Comments 7 Complete only the fields needing correction Vendor Number LIII Contract Number t NPI Number 3s e Recipient Information 1 Medicaid Recipient No
289. kshop User Guide The Long Term Care LTC Nursing Facility Hospice Workshop User Guide provides step by step instructions for how to use the various features of the portal each form type when to submit the various forms and assessments and managing forms and assessments set to status Provider Action Required e LTCMI Nursing Facility 2 0 Instructions The entry of 2 0 LTCMI Long Term Care Medicaid Information can ONLY occur after the submission of the Federal MDS 2 0 Assessments and retrieval on TMHP s LTC Online Portal This document covers only the LTCMI portion of the MDS 2 0 Assessments All other 2 0 Assessment field information can be found on the Federal CMS website www cms hhs gov e LTCMI Nursing Facility 3 0 Instructions The entry of 3 0 LTCMI Long Term Care Medicaid Information can ONLY occur after the submission of the Federal MDS 3 0 Assessments and retrieval on TMHP s LTC Online Portal This document covers only the LTCMI portion of the MDS 3 0 Assessments All other 3 0 Assessment field information can be found on the Federal CMS website www cms hhs gov e PASRR Screening Instructions PASRR Level I Screening Form The PASRR Level I screening form is designed to identify persons who may have indicators of mental illness intellectual disabilities or developmental disabilities to determine if a PASRR Evaluation is required The PASRR Level I Screening form must be completed and submitted in the Long Term Care Portal prio
290. l This field is required if field S11a 1 Yes Enter the ZIP code of the Legally Authorized Representative 12g Phone Optional This field is optional if field S11a 1 Yes Enter the contact telephone number for the Legally Authorized Representative if known v 2013 1127 79 LTC Nursing Facility Hospice User Guide Sequencing of Documents The PL1 must always be submitted prior to admission regardless of payor source Refer to the Overview of PASRR Processes section for details Admission as a Full Medicaid Recipient Submit Admission Submit Full Submit Comprehensive EMI Medicaid Form 3618 MDS per the CMS Guidelines This flow chart displays the process of a recipient who is admitted as a Full Medicaid recipient Nursing facilities are required to initiate the HHSC Medicaid Eligibility application process to ensure valida tions occur with the Medicaid ID Medicaid Eligibility and the Applied Income A facility must submit a Form 3618 for a recipient who has full Medicaid or is applying for Medicaid coverage within 72 hours of admission Federal CMS Resident Assessment Instrument RAI Users Manual requires completion of an admission compre hensive MDS within 14 days of admission MDS 3 0 A0310A 01 Submit the MDS to CMS in accordance with the RAI Users Manual Federal CMS guidelines allow providers up to 14 days to transmit MDS 3 0 assessments Please note waiting wi
291. l Individual has a medical prognosis that his or her life expectancy is 6 months or less if the illness runs its normal course An individual s medical prognosis is documented by a physician s certification which is kept in the individual s medical record maintained by the nursing facility 3 Severe Physical Illness An illness resulting in ventilator dependence or diagnosis such as chronic obstructive pulmonary disease Parkinson s disease Huntington s disease amyotrophic lateral sclerosis congestive heart failure which result in a level of impairment so severe that the individual could not be expected to benefit from specialized services O 4 Delirium Provisional admission pending further assessment in case of delirium where an accurate diagnosis cannot be made until the delirium clears 5 Emergency Protective Services Provisional admission pending further assessment in emergency situations requiring protective services with placement in the nursing facility not to exceed 7 days O 6 Respite Very brief and finite stay of up to a fixed number of days to provide respite to in home caregivers to whom the individual with MI or ID is expected to return following the brief NF stay 7 Coma Severe illness or injury resulting in inability to respond to external communication or stimuli such as coma or functioning at brain stem level v 2013 1127 177 LTC Nursing Facility Hospice User Guide Appendix F
292. l Name 9 A First Name B Middle Initial C Last Name D Suffix B0200 o Social Security and Medicare A Social Security No B Medicare No p B0300 Medicaid No Enter if pending N if not Medicaid recipient B0400 Birth Date vj B0500 Age at Time of Screening 0 B0600 Gender v B0650 Individual is deceased or has been v discharged B0655 Deceased Discharged Date vj B0700 Previous Residence o A Previous Residence Type be B Other Residence Type C Street Address D City E State F ZIP Code uj G County of Residence b B0800 Next of Kin A Relationship to Individual B Other Relationship to Individual NM C First Name D Middle Initial E Last Name F Suffix G Phone Number H Street Address I City J State K ZIP Code vv v 2013 1127 173 LTC Nursing Facility Hospice User Guide PASRR Level 1 Screening Section C va TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR Home Submit Form Form Status Inquiry Current Activity Drafts Vendors Letters Printable Forms Alerts Help PASRR LEVEL 1 SCREENING Current Status Name DLN 0 Save as Draft Section C PASRR Screen C0100 Mental Illness 9 Is there evidence or an indicator this is an individual that has a Mental Illness vv Intellectual Disability 9 Is there evidence or an indicator this is an individual that has an Intellectual Disability v
293. ladder training currently being used to manage the individual s urinary continence 0 No 1 Yes H0300 Urinary Continence Urinary continence Select the one category that best describes the individual Always continent Occasionally incontinent less than 7 episodes of incontinence Frequently incontinent 7 or more episodes of urinary incontinence but at least one episode of continent voiding Always incontinent no episodes of continent voiding Not rated individual had a catheter indwelling condom urinary ostomy or no urine output for entire 7 days H0400 Bowel Continence Bowel continence Select the one category that best describes the individual Always continent Occasionally incontinent one episode of bowel incontinence Frequently incontinent 2 or more episodes of bowel incontinence but at least one continent bowel movement Always incontinent no episodes of continent bowel movements Not rated individual had an ostomy or did not have a bowel movement for the entire 7 days H0500 Bowel Continence Program E Is an individualized continence promotion program currently being used to manage the individual s bowel continence 0 No 1 Yes H0600 Bowel Patterns Enter Constipation present L 0 No 1 Yes MN and LOC 3 0 V 15 12 of 32 Individual Identifier Date Section Active Diagnoses Active Diagnoses in the last 7 days Check all that apply Diagnoses listed in parentheses are
294. ld is a requir iel RN Coordinator License Number is a required field RN Coordinator License State field is a required field Primary Diagnosis ICD Code is a required field r thi r i hi ident has fallen i l i iri f lis li n physically restrained prior to the fall is a required field Confusion Disorientation is a required field E l Resident or ff is a required field Resident s Addr i required field Resident s Current Address City is a required field Resident s Current Address State is a required field Resident rrent Addri ZIP is a required field Medication Certification is a required field Does the resident report having an Out of Hospital Do Not Resuscitate Order is a required field hmm mmm mmm eee ee mmm 5 MINIMUM DATA SET MDS Version 3 0 RESIDENT ASSESSMENT AND CARE SCREENING Nursing Home Comprehensive NC Item Set Current Status Awaiting LTC Medicaid Information Name ww DLN RUG RAA Form Actions Add Note Save LTCMI Populate LTCMI Section A Section B Section C Section D Section E Section F Section G Section H Section I Section J Section K Section L Section M Section N Section O Section P Section Q Ji Section V Section X Section Z Section LTCMI Entering Dates To enter dates you have the option to click on the calendar icon next to any of the date fields to activate the dynamic calendar Choose the date desired Or yo
295. legally authorized representative 1 Yes v S11b e Does the resident report having a Directive to Physicians and Family or Surrogates v Sllc e Does the resident report having a Medical Power of Attorney L wl S11d e Does the resident report having an Out of Hospital Do Not Resuscitate Order L s S12 LAR Address Required if resident has reported having a legally authorized representative S12a e LAR First Name S12b LAR Last Name S12c Address S12d City S12e State NC S12f e ZIP Code S12g Phone Awaiting it ius iud LTG Medicaid Information Submit Form S1 Claims Processing Information S1a DADS Vendor Site ID Number Auto populated This field is auto populated based on the NPI number in field A0100A This field is not correctable If A0100A National Provider Identifier NPI is not correct on the MDS then the NPI must be fixed at the federal CMS level Sib Contract Provider Number Auto populated This field is auto populated based on the NPI number in field A01004A This field is not correctable If an NPI has more than 1 contract provider number associated with it be sure the correct contract provider number is selected from the drop down box Sic Service Group Auto populated This field is auto populated based on the user s log in credentials This field is not correctable on the TMHP LTC Online portal
296. linical change assessment Complete only if X0150 2 L 0 No 1 Yes Enter Code F Entry discharge reporting EE 01 Entry tracking record 10 Discharge assessment return not anticipated 11 Discharge assessment return anticipated 12 Death in facility tracking record 99 None of the above X0700 Date on existing record to be modified inactivated Complete one only A Assessment Reference Date Complete only if X0600F 99 Month Day Year B Discharge Date Complete only if X0600F 10 11 or 12 Month Day Year C Entry Date Complete only if X0600F 01 Day Month Year Correction Attestation Section Complete this section to explain and attest to the modification inactivation request X0800 Correction Number Enter Number Enter the number of correction requests to modify inactivate the existing record including the present one X0900 Reasons for Modification Complete only if Type of Record is to modify a record in error A0050 2 J Check all that apply Z Other error requiring modification If Other checked please specify X1050 Reasons for Inactivation Complete only if Type of Record is to inactivate a record in error A0050 3 J Check all that apply A Event did not occur Z Other error requiring inactivation If Other checked please specify MDS 3 0 Nursing Home Quarterly NQ Version 1 11 2 Effective 10 01 2013 Page 32 of 35 Re
297. ll blue _ 0 No could not recall 1 Yes after cueing a color 2 Yes no cue required Able to recall bed _ 0 No could not recall 1 Yes after cueing a piece of furniture 2 Yes no cue required C0500 Summary Score EE The sum of the scores for questions C0200 C0400 The sum should be a number 00 15 A score of 99 indicates that the individual was unable to complete the interview Enter Score MN and LOC 3 0 V 15 4 of 32 Individual Identifier Date ST i RO Cognitive Patterns C0600 Should the Caregiver Assessment for Mental Status C0700 C1000 be Conducted 0 No Individual was able to complete interview Skip to C1300 Signs and Symptoms of Delirium 1 Yes Individual was unable to complete interview OR individual is less than 7 years of age Continue to C0700 Short term Memory OK Caregiver Assessment for Mental Status Do not conduct if Brief Interview for Mental Status C0200 C0500 was completed C0700 Short term Memory OK Enter Seems or appears to recall after 5 minutes Enter Dash if unable to assess OR individual is less than 2 years of age L 0 Memory OK 1 Memory problem C0800 Long term Memory OK Enter Seems or appears to recall long past Enter Dash if unable to assess OR individual is less than 2 years of age L 0 Memory OK 1 Memory problem C0900 Memory Recall Ability Check all that the individual
298. ll cause a delay in MN determination and payment if the assessment is being used to establish Medicaid state payment Complete the MDS LTCMI on the LTC Online Portal within the covering quarter of the MDS MDS 3 0 Z0500B 91 days Reminder The above timeliness guidelines reflect the requirements of Texas Medicaid only For CMS timeliness guidelines please refer to the RAI Users Manual available at the following link Federal MDS 3 0 site www cms gov NursingHomeQualityInits 25 NHQIMDS30 asp Complete a quarterly assessment within 92 days of the Admission MDS unless a Significant Change in Status Assessment SCSA was completed prior to this 80 v 2013 1127 LTC Nursing Facility Hospice User Guide Recipient Transitioning to Full Medicaid Private basim Submit Loaded to Pay Form 3618 LTC Online Portal Submit LTCMI This flow chart displays the process of a private pay recipient that is transitioning to Full Medicaid Submission should occur upon notification of application for Medicaid e Facility should submit a 3618 Admission indicating admission from private pay e Once the 3618 has been submitted any MDS assessment will be loaded onto the LTC Online Portal within 24 to 48 hours Please remember that the MDS LTCMI must be completed and submitted before TMHP can process the assessment If TMHP is unable to retrieve the assessment from CMS because the recipients Medicaid number or SSN is dif fer
299. ll that apply A Indwelling catheter including suprapubic catheter and nephrostomy tube B External catheter C Ostomy including urostomy ileostomy and colostomy D Intermittent catheterization Z None of the above H0200 Urinary Toileting Program Enter Code A Has a trial of a toileting program e g scheduled toileting prompted voiding or bladder training been attempted on admission entry or reentry or since urinary incontinence was noted in this facility 0 No Skip to H0300 Urinary Continence 1 Yes gt Continue to H0200C Current toileting program or trial 9 Unable to determine Continue to H0200C Current toileting program or trial Enter Code C Current toileting program or trial Is a toileting program e g scheduled toileting prompted voiding or bladder training currently being used to manage the resident s urinary continence 0 No 1 Yes H0300 Urinary Continence EnterCode Urinary continence Select the one category that best describes the resident Always continent Occasionally incontinent less than 7 episodes of incontinence Frequently incontinent 7 or more episodes of urinary incontinence but at least one episode of continent voiding Always incontinent no episodes of continent voiding Notrated resident had a catheter indwelling condom urinary ostomy or no urine output for the entire 7 days H0400 Bowel Continence Enter C
300. lly in the last 7 days Enter Number of Minutes 2 Concurrent minutes record the total number of minutes this therapy was administered to the resident concurrently with one other resident in the last 7 days Enter Number of Minutes 3 Group minutes record the total number of minutes this therapy was administered to the resident as part of a group of residents in the last 7 days If the sum of individual concurrent and group minutes is zero skip to O0400A5 Therapy start date Enter Number of Minutes 3A Co treatment minutes record the total number of minutes this therapy was administered to the resident in co treatment sessions in the last 7 days Enter Number of Days x E i 4 Days record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days 5 Therapy start date record the date the most recent 6 Therapy end date record the date the most recent therapy regimen since the most recent entry started therapy regimen since the most recent entry ended enter dashes if therapy is ongoing Month B Occupational Therapy Month Day Enter Number of Minutes 1 Individual minutes record the total number of minutes this therapy was administered to the resident individually in the last 7 days Enter Number of Minutes 2 Concurrent minutes record the total number of minutes this therapy was administered to the resident concurrently with one other resident in the last 7 days Ente
301. lnutrition protein or calorie or at risk for malnutrition Psychiatric Mood Disorder Anxiety Disorder Depression other than bipolar Manic Depression bipolar disease Psychotic Disorder other than schizophrenia Schizophrenia e g schizoaffective and schizophreniform disorders Post Traumatic Stress Disorder PTSD 16200 Asthma Chronic Obstructive Pulmonary Disease COPD or Chronic Lung Disease e 9 chronic bronchitis and restrictive lung diseases such as asbestosis 16300 Respiratory Failure 16500 Cataracts Glaucoma or Macular Degeneration 18000 Additional active diagnoses Enter diagnosis on line and ICD code in boxes Include the decimal for the code in the appropriate box MDS 3 0 Nursing Home Comprehensive NC Version 1 11 2 Effective 10 01 2013 Page 19 of 41 Resident Identifier Date Section Health Conditions J0100 Pain Management Complete for all residents regardless of current pain level At any time in the last 5 days has the resident Enter Code A Received scheduled pain medication regimen 0 No 1 Yes Enter Code B Received PRN pain medications OR was offered and declined 0 No 1 Yes EnterCode C Received non medication intervention for pain 0 No 1 Yes J0200 Should Pain Assessment Interview be Conducted Attempt to conduct interview with all r
302. lows you to view system and user generated Alerts Alerts are electronic messages sent to a user notifying them that an action must be taken on a PL1 or PE Refer to the Alerts section in this User Guide for more information va TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR Home Submit Form Form Status Inquiry Current Activity Drafts Vendors Printable Forms Alerts Alerts Outgoing Alerts F _ _ _ e 9 MI Conduct w 4 28 2013 PASRR Evaluation Second Notification oO Conduct 900 9 4 27 2013 IDD PASRR Evaluation Second Notification 24 v 2013 1127 LTC Nursing Facility Hospice User Guide Help The Help feature at the far right in the blue navigational bar will display a Help page consisting of links to online guides that will assist with questions you may have about the LTC Online Portal V TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR Home Submit Form Form Status Inquiry Current Activity Drafts Vendors Printable Forms Alerts Help Help Information regarding claims submissions via TexMedConnect can be found in the TexMedConnect User Guide All user guides and manuals can be found on the TMHP website www tmhp com The following are links to online guides to be used in conjunction with TMHP s LTC Online Portal e Long Term Care Nursing Facility Hospice wor
303. luation amp Recommendation MN and LOC 3 0 V 15 S6c Number of hospitalizations in the last S7a Did an MD DO certify that this 90 days individual requires nursing facility S6d Number of emergency room visits in the services or alternative community last 90 days based services under the supervision 56a Oxygen Therapy of an MD DO Y N A dap A S7b Did a military physician providing 3 Once da healthcare according to requirements Twicea A stipulated in 10 US Code 1094 5 3 11 sud da provide the evaluation and 6 23 hours y recommendation for this individual 7 24 hour continuous YN S6f Special Ports Central Lines PICC S7c MD DO Last Name Miis S7d MD DO License S6g At what developmental level is the individual functioning 57e MD DO License State 1 1 Infant Indicate Physician Signature on file by checking box 2 1 2 Toddler Required for Initial Assessments A i s The following MD DO information is required if MD DO is not 5 11 15 Young Adolescence eensedm aoe 6 16 20 Older Adolescence S7f MD DO First Name Unknown or unable to assess S7g MD DO Address S6h Enter the number of times this individual has fallen in the last 90 days S6i In how many of the falls listed above was S7h MD DO City En physically restrained prior to S7 MD DO State S6j In the falls listed in S6h above how many had the S7j MD DO ZIP Code following
304. ly in the last 7 days Enter Number of Minutes Concurrent minutes record the total number of minutes this therapy was administered to the individual concurrently with one other individual in the last 7 days Enter Number of Minutes Group minutes record the total number of minutes this therapy was administered to the individual as part of a group of individuals in the last 7 days If the sum of individual concurrent and group minutes is zero skip to O0400C Physical Therapy Enter Number of Minutes 3A Co treatment minutes record the total number of minutes this therapy was administered to the individual in co treatment sessions in the last 7 days Enter Number of Days 4 Days record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days 5 Therapy start date record the date the most recent 6 Therapy end date record the date the most recent therapy regimen since the last assessment started therapy regimen since the last assessment ended CLI CL enter dashes if therapy is ongoing Month Day Month 00400 continued on next page 24 of 32 Individual Identifier Date Section O Special Treatments Procedures and Programs 00400 Therapies Continued C Physical Therapy Enter Number of Minutes Individual minutes record the total number of minutes this therapy was administered to the individual individually
305. m button 6 Enter all required information as indicated by the red dots Click on all section tabs and enter the information requested Sections A B C and D must be completed Remember that the individual must be admitted under Exempted Hospital Discharge or Expedited Admission for submission of the PL1 by an NE and indicated accordingly 7 Click the Print button located in the yellow Form Actions bar to print the screening in progress 8 From here you have two choices a Click the Submit Form button to submit the screening OR b Click the Save as Draft button to store the screening for future use but not submit it The screening does not have to be complete to save the draft Note f the screening is successfully submitted a DLN will be assigned and the LTC Online Portal will show Your form was submitted successfully If there are errors they will be displayed in a box at the top of the screen These errors will need to be resolved before the screening will be successfully submitted Once all errors are resolved click the Submit Form button again to submit the form When a PLI is submitted via the LTC Online Portal the system will check to see if there is an existing PL1 on file If a previous PL1 is found and the Date of Assessment is the same as the previously submitted screening the new form will not be accepted If a previous PL1 is found and the Date of Assessment is prior to the Date of Assess ment
306. m yo Recipient s Middle ZIP Initial Recipient Name 15 If the provider clicks the Resubmit Form button the following screen will appear allowing the provider to add any comments There is an option to select 2 System or 1 ProviderFacing 2 System will allow comments entered by the provider to be seen only by internal state staff The comments will not be seen by the provider l ProviderFacing will allow comments entered to be seen by both state staff and the provider In either case the comments will be seen in the History trail of the form or assessment and are for informational purposes only These comments will NOT be used in the system processing of the forms TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR Home Submit Form Form Status Inquiry Current Activity Drafts Vendors Printable Forms Alerts Help Change Status for form we sv 29 to Submit to SAS Enter the notes below If you would like the provider to see the note please select the provider facing option from the list below 1 ProviderFacing v Cancel Change Status 98 v 2013 1127 LTC Nursing Facility Hospice User Guide The provider may choose to enter comments Entering comments is optional a Click the Cancel button to cancel the request keeping the form or assessment set to status Provider Action Required or b Click the Change Status button form or assessment is
307. made at the PC E default rate To fill the gap submit an Admis sion Annual or Quarterly MDS assessment including the LTCMI by completing gt The Sle field on the LTCMI completed as the PC E gt The Missed or Prior Assessment Start Date S1f gt The Missed or Prior Assessment End Date S1g Note To submit a PC E for a one day gap the Missed Assessment Start Date and the Missed Assessment End Date must be the same v 2013 1127 87 LTC Nursing Facility Hospice User Guide 2 Missed MDS If an LTCMI is submitted more than 91 days after the R2b Z0500B date of the assessment the assessment will have to be submitted as a PC E Payment for this gap will be made at the PC E default rate Submit the assessment including the LTCMI by completing The Sle field on the LTCMI completed as the PC E The Missed or Prior Assessment Start Date S1f The Missed or Prior Assessment End Date S1g Prior to adding a Purpose Code to an LTCMI validate if payment has been made based on the MDS Entering a Purpose Code Start and End date cancels any prior services dates the assessment represented If necessary submit an off cycle MDS 3 0 assessment to submit a Purpose Code E or M PC E Start and End Date Limitations MDS 3 0 Only applicable for MDS 3 0 Admission Quarterly review and Annual assessments e Start date cannot be prior to September 1 2008 The following errors must be fixed before the form will submit i
308. may have to pay back any overpayments DADS made to the appellant because the appellant did not supply correct and complete information or was overpaid while waiting for the hearing decision v 2013 1127 47 LTC Nursing Facility Hospice User Guide Forms to be Submitted Form 3618 Resident Transaction Notice Purpose of Form 3618 Form 3618 is used when the recipient is in a Full Medicaid or Medicaid pending status refer to flow chart in the Sequencing of Forms and Assessments section of this User Guide A 3618 submission informs Medicaid Eligibil ity workers about transactions and status changes and provides DADS with information to initiate or close service authorizations or adjust provider payments Form 3618 is to be submitted for admissions discharges and death Form 3618 must be submitted on the LTC Online Portal MDS Discharge Tracking and Re Entry Tracking forms 3 0 A0310F are not used by Texas Medicaid The recipient must reside in a valid Medicaid contracted bed If Form 3618 is submitted it is assumed that the recipient is in a contracted bed Providers should submit Form 3618 when the recipient is being classified as Full Medicaid This can occur upon initial admission or can follow a Medicare stay it can also follow a change in payor source from private pay If the form is submitted for a change from private pay Medicare or Hospice to Medicaid this is the indicator for TMHP to retrieve the MDS for that reci
309. mpaired absence of useful hearing B0300 Hearing Aid Enter Code Hearing aid or other hearing appliance used in completing B0200 Hearing 0 No 1 Yes B0600 Speech Clarity Select best description of speech pattern 0 Clear speech distinct intelligible words 1 Unclear speech slurred or mumbled words 2 No speech absence of spoken words B0700 Makes Self Understood Ability to express ideas and wants consider both verbal and non verbal expression 0 Understood 1 Usually understood difficulty communicating some words or finishing thoughts but is able if prompted or given time 2 Sometimes understood ability is limited to making concrete requests 3 Rarely never understood B0800 Ability To Understand Others Understanding verbal content however able with hearing aid or device if used 0 Understands clear comprehension 1 Usually understands misses some part intent of message but comprehends most conversation 2 Sometimes understands responds adequately to simple direct communication only 3 Rarely never understands B1000 Vision Ability to see in adequate light with glasses or other visual appliances Adequate sees fine detail such as regular print in newspapers books Impaired sees large print but not regular print in newspapers books Moderately impaired limited vision not able to see newspaper headlines but can identify objects Highly impaired object identification in question but eyes
310. n Pending Doctor Review MN determination is pending TMHP Doctor Review Pending Medicaid Eligibility Medicaid Eligibility validation is pending Validation attempts occur nightly until eligibility is found the request is canceled or until six months has expired whichever comes first Pending More Info DADS Provider Claims Services needs more information from the provider See the History trail for further details on information required Pending Placement The individual has not been placed in a Nursing Facility On the PL1 NF Choices section no NF has indicated Admitted To nor has the individual been placed in an alternate setting Pending Placement in NF PE Confirmed When the PL1 is in this status the NF is required to review the associated PE which identifies the Recommended Specialized Services for the individual and certify if it is able or unable to serve the individual Pending Review MN determination is pending TMHP nurse review because the assessment was not approved through the automated MN determination process Pending RN License Verification RN License number is pending verification from the Texas BON or the licensing state from which the compact license was issued PL1 Inactive This PL1 status indicates that the individual is deceased or discharged Processed Complete Form or assessment has been processed and complete Please check MESAV Provider Action Required Form or assessment needs to be reviewed by
311. n Groups RUGs Information Nurse Specialist Reconsideration amp RUGS ieroci E Doc EE RE 512 491 1750 512 491 2074 512 491 2030 Texas State University RUG Training InformatioN ceneni a e E 512 245 7118 Texas State University Training Online Course CQUeSUODS ui opr troppe erint re rri inv up 512 245 7118 v 2013 1127 157 LTC Nursing Facility Hospice User Guide Informational Websites Texas Medicaid amp Healthcare Partnership TMHP www tmhp com e HIPAA information www tmhp com Pages TMHP TMHP HIPAA aspx Long Term Care Division www tmhp com Pages LTC Itc_home aspx e NF LTCMI and PASRR information is also available at www tmhp com Pages LTC Itc_home aspx Note Instructions for providers on how to access clarification notices posted on LTC TMHP website www tmhp com Pages LTC ltc home aspx Texas Department of Aging and Disability Services DADS www dads state tx us All DADS provider information can be found at www dads state tx us providers index cfm Please choose your particular provider type for available online resources e Assisted Living www dads state tx us providers alf index cfm e Consumer Rights and Services includes information about how to make a complaint www dads state tx us services crs index html e DADS Provider Claims Services https hhsportal hhs state tx us wps portal e Handbooks www dads state tx us news_info publications handbooks index html handbooks
312. n a box at the top of the screen These errors will need to be resolved before the form can be successfully submitted Once all errors are resolved click the Submit form button again to submit the form Important Validation is performed on the Medicaid SSN Medicare number and the Last Name of the recipient If the Medicaid SSN Medicare number and Last Name do not match processing will not occur The form will be set to status ID Invalid Validations are against the Medicaid Eligibility file Check the recipients Medicaid card or the MESAV and compare to the entry being made If the Medicaid card is incorrect contact the Medicaid Eligibility Worker Corrections are not allowed to the Name or Number fields on the form once submitted thus it is important to submit the correct informa tion Incorrect entries require inactivation and a new submission v 2013 1127 53 LTC Nursing Facility Hospice User Guide 5a TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TM A STATE MEDICAID CONTRACTOR Home Form Status Inquiry Current Activity Drafts Vendors Printable Forms Alerts 3619 Medicare SNF Patient Transaction Notice Provider Information Vendor Number Lii Contract Number f um NPI Number Recipient Information 1 Medicaid Recipient No 4 Name 9 Recipient Last Name 5 Address Address T m 1 2 Social Security No 1 Recipient
313. n an assessment MDS 3 0 submissions to CMS are retrieved nightly by TMHP Once retrieved MDS 3 0 assessments are loaded onto the LTC Online Portal MDS 3 0 submissions must meet the following criteria before being loaded onto the LTC Online Portal A valid Medicaid number or a must be entered into field 3 0 A0700 The Reason for Assessment must be one of the following gt Admission assessment Quarterly review assessment Annual assessment Significant change in status assessment Significant correction to prior comprehensive assessment Significant correction to prior quarterly assessment A valid NPI must be entered in field 3 0 AO100A Providers should allow 24 to 48 hours prior to using FSI or Current Activity for MDS 3 0 assessments submit ted to CMS All RN and MD DO licenses are validated against the appropriate licensing state board All RN licenses are validated against the appropriate Texas State University RUG Training database for success ful submission License renewals should be completed four to six weeks prior to the date of expiration to ensure that there is no interruption in a user s ability to submit documents Access your forms and assessments using Form Status Inquiry or Current Activity Print and sign forms and assessments prior to submission Submit additional information within 21 calendar days on the LTC Online Portal when the assessment is set to status Pending Denial need more inf
314. n are missing or rejected resubmit those forms and this discharge on the same day NF 0066 This discharge cannot be processed because the client is admitted by a different provider If an admission prior to this discharge is missing or rejected the admis sion must be processed prior to this discharge NF 0067 This discharge cannot be processed because an admission for a different provider has already been processed for the same day This discharge appears to be one of a retroactive pair If an admission prior to this discharge is missing or rejected resubmit the admission and this discharge on the same day NF 0068 This discharge cannot be processed because the client already has a subsequent authori zation This discharge appears to be one of a retroactive pair If an admission prior to this discharge is missing or rejected resubmit the admission and this discharge on the same day Form Assessment 3619 Discharge 3619 Discharge 3619 Discharge 3619 Discharge Suggested Action The recipient has a Service Authorization for Full Medicaid Code 1 with the same provider as of the submitted discharge date Review the facility records to determine the recipient s admission and discharge dates Pull a MESAV and verify the begin date and type of service currently authorized for the recipient If the recipient should be classified as Medicare on this discharge date Determine if the 3618
315. n error for full Hospice recipients How to Submit Form 3071 Instructions for completing Form 3071 can be found in Module 5 Form 3071 in the Long Term Care LTC Nursing Facility Hospice CBT found at the following link http learn tmhp com 1 Log in to the LTC Online Portal 2 Click the Submit Form link located in the blue navigational bar 3 Type of Form Choose 3071 Recipient Election Cancellation Discharge Notice from the drop down box 4 Click the Enter Form button 5 Enter all required information as indicated by the red dots Complete at least one of the following Medicaid number or SSN f Election choose Election and enter a From date only Elections must include a Client or Responsible Party signature If Update choose Update and enter a From date only IfTerminating the Hospice Program choose Cancel and enter a To date only Ifthe Cancel Code is 14 or 77 a Client or responsible Party signature is required Setting indicates where the client is receiving the Hospice services Ifthe client is in an Assisted Living facility Setting should indicate Home A setting of SNF indicates that the client is classified as Medicare for a non related condition Hospice services are waived until the Medicare stay is completed 6 From here you have two choices a Click the Submit Form button to submit the form Or b Click the Save as Draft button t
316. n three business days of successful submission In order to expedite processing TMHP automatically checks submitted assessments with a Medicaid Number to determine if the resident already has Permanent MN PMN If the resident has PMN the MN is automati cally approved The assessment History trail will state Client has permanent MN For residents who do not have PMN TMHP systems automatically review specific criteria on the assessments If the criteria are appropriately met MN is automatically approved If not the provider will see Ihe Form has failed Auto MN Approval displayed in the History trail The assessment will then be sent to a nurse for manual MN review The status will be set to Pending Review on the FSI search results however the last message showing in the History trail will be The Form has failed Auto MN Approval 3 Once reviewed the submission is either approved meeting MN or placed in a Pending Denial need more information status for up to 21 calendar days FSI or Current Activity can be used to view the status of MN determination whether Approved Denied or Pending Denial need more information status v 2013 1127 45 LTC Nursing Facility Hospice User Guide 4 The Director of Nursing DON or other licensed nurse within the facility must either add additional informa tion clarifying nursing medical needs through the Add Note feature or by calling TMHP and speaking with a TMHP nurse
317. nce is due for the time period that your 3619s indicate fax them with a copy of the 3619s to 512 438 3400 attention ECF Form Processing or call 512 438 3400 Option 3 If all the begin and end dates on the MESAV are correct the rejected form will need to be corrected so the total of the new days added plus the existing dates equal 80 or less days The effective date of the discharge correction is prior to the Service Authorization it is attempting to close Review the facility s records to determine the recipient s admission and discharge dates and identify the Spell of Illness Pull a MESAV and review the Service Authorizations to determine which Service Authorization ended based on the original discharge date The system has determined that the new discharge date is prior to that begin date Verify the begin and end dates of the Service Authorizations on file based on the actual admissions and discharges that have occurred Also compare the time periods for Medicare Part A Coinsurance to your Medicare remittance indicating what days should be Coinsurance Remember that the discharge date results in a Service Authorization end date one day earlier than the transaction date Verify if the new discharge date is actually part of a retroactive pair rather than a correction If so Correct the discharge date back to the original date Identify the admission that would complete the retroactive pair Submit the reje
318. nd has an error in a non correctable field or one that should not have been submitted providers must submit the appropriate counteracting form Please refer to the Counteracting Forms section of this User Guide for additional information PASRR Level 1 Screening Inactivations There is no Inactivate Form button for a PL1 If a new PL1 is submitted for an individual with an existing PL1 the previous PL1 and any associated PE will be inactivated automatically Upon submission of this new PL1 a message will appear prompting you to confirm inactivation of the previous PL1 and associated PE LTC Nursing Facility Hospice User Guide Form 3618 and 3619 Submission Validation Rules and Edits Based on information entered in certain fields and on the sequence in which the form is being submitted validation or front end edits will occur and may result in an error The form will not be accepted until all errors are resolved The system messages will display at the top of the LTC Online Portal submission page If you do not receive the DLN number assigned page after clicking the Submit Form button there are errors that need to be resolved The errors will be displayed at the top of the page and you may need to scroll to the top of the page to see the errors An example of a validation or front end edit occurs when the Date of Above Transaction is greater than one year old or greater than or equal to five years old A front end edit may also
319. ne 147 Nonemergency Prior Authorization and Retroactive Eligibility three rne respiro beta echt ot eina 148 Prior Authonzation lypes and Definitions siise bae E E rubet d ceste E uu a 148 One Time Non repeating Ul day do secco scient tke einen E E E AA e AE EREE 148 Keno Up tO GO AGS M EEEE EEEE E EAEE 148 Nonemergency Ambulance Exception RegUeStsesrsssrorciisssan nsr ereenn nease apa EE EEKE R 148 Supporting DOCUMENTATION mises essnessractessesederey seadue eina IEEE YI E EE EERE EERE SAR Ea EE ERE RSi 148 PI SE E M 0 149 RUG Training Requirements o Pene E EGRE OT ORI HERR ERR NEIEE E REIR ER e REI Satine E ERERUE 150 Benilodebs ce er cit ca cit hence sitet ech cco cca MEER o qr EQ da lp cepe biz tu aaa 151 Preventing Medicaid Waste Abuse and Fraud seen ene 153 How to Report Waste Abuse and Fraud 1 rir ninni aaa RE ERROR FREE U aera 153 HIPAA Guidelines and Provider Responsibilities eene 154 Resource nfotmatio T S 155 Types ot Calls ta Refer t TMH oos soda cioe irit t noniine EE A rua nbi cepere Fun ond RERUM 155 Typesof Calls to Refer to DADS PASRR Dulteaceeezeror itv eet od E2 p e kei EA A ARE EUR EK YE cans 153 Typesor Callsito Refer us DSEIS PASRR oereeccereti ere vhpthe rented Haro MERE HER MER e Mu ee ocio iventia a dne Breed 155 Types ef Calls to Refer to DADS POS ricrescere E UH REI ERO ETA 156 Types ot Callsqo Refet toa Lo
320. new consolidated health care Looking fora TEXAS MEDICAID responsibilities with a team of subcontractors under the name provider HEALTHCARE PARTNERSHIP ENS Click here to find ASTATE MEDICAID CONTRACTOR 3 Click Long Term Care in the yellow bar All Sites p Advanced Search v4 TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR Log in to My Account Go to TexMedConnect v 2013 1127 LTC Nursing Facility Hospice User Guide 4 Click I would like to in the blue bar located at the top of the screen All Sites x JO Advanced Search Loa In va TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR Log In to LTC Online Portal Log In to TexMedConnect Long Term Care Home TexMedConnect a Long Term Care Homepage Got started with The Texas Department of Aging and Disability Services DADS administers programs providing LTC onlines claims EOM eee Services and Institutional Care to eligible clients The Texas Medicaid amp Healthcare Partnership filing Click DADS Information Letters TMHP LTC team supports the LTC provider community in submitting claims through the Claims d att irani 5 Click the Activate my account link ea TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR Log In to LTC Online Portal Log In to TexMedConnect ong Term Care Hom
321. nistered to the resident in co treatment sessions in the last 7 days Enter Number of Days x E i 4 Days record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days 5 Therapy start date record the date the most recent 6 Therapy end date record the date the most recent therapy regimen since the most recent entry started therapy regimen since the most recent entry ended enter dashes if therapy is ongoing Month B Occupational Therapy Enter Number of Minutes 1 Individual minutes record the total number of minutes this therapy was administered to the resident individually in the last 7 days Enter Number of Minutes 2 Concurrent minutes record the total number of minutes this therapy was administered to the resident concurrently with one other resident in the last 7 days Enter Number of Minutes 3 Group minutes record the total number of minutes this therapy was administered to the resident as part of a group of residents in the last 7 days If the sum of individual concurrent and group minutes is zero skip to O0400B5 Therapy start date Enter Number of Minutes 3A Co treatment minutes record the total number of minutes this therapy was administered to the resident in co treatment sessions in the last 7 days Enter Number of Days R 4 Days record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days 5 Therapy s
322. nother time TMHP has the right at any time to change or modify the terms of use which will be posted on this website Any use of the website by you after modified terms have baen posted will be deemed to constitute acceptance by you of the modified terms TMHP has the right at any time to change or discontinue any aspect or feature of this website and to terminate any users access to the website TMHP has the right but not che obligation to monitor your use end access ofthis site HIPAA Privacy Vou have requested online access to confidential patient data that is protected by federal and state privacy laws We take very seriously our obligation to protect this confidential patient dats from unauthorized use or disclosure Accordingly we allow only those persons with appropriate authorization to access or provide the confidential patient data through this website Any dissemination or distribution of the confidential patient cata contained in this website to anyone other than the authorized recipient is unauthorized and strictly prohibited by law The privacy and security of confidential patient data is governed by the Health Insurance Portability and Accountability Act of 1996 HIPAA and its O 1 agree to these terms Create Provider Administrator I 1 Note The User Name and Password are used for future log ins to your account Make a copy for your records v 2013 1127 9 LTC
323. ns must be reviewed individually This example will continue with choosing Form 3618 Providers will need to review all the other applicable Type of Forms as well TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR Home Submit Form Form Status Inquiry Current Activity Drafts Vendors Printable Forms Alerts Help Form Status Inquiry Form Select Type of Form 9 3618 Resident Transaction Notice 3619 Medicare SNF patient Transaction Notice 3652 Client Assessment Review and Evaluation CARE PEE Form Status IngMDS 2 0 Minimum Data Set Comprehensive MDSQTR 2 0 Minimum Data Set Quarterly MDS 3 0 Minimum Data Set Comprehensive DLN MDSQTR 3 0 Minimum Data Set Quarterly PASARR PASARR Screening Last Name PE PASRR Evaluation PL1 PASRR Level 1 Screening SSN x LT orm From Date 9 5 9 2010 Bal To Date 40 8 2010 e 3 Enter the From Date and To Date range in the fields allocated 4 Form Status Choose Provider Action Required from the drop down box a TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR Home Submit Form Form Status Inquiry Current Activity Drafts Vendors Printable Forms Alerts Help Form Status Inquiry Form Select Type of Form e 3618 Resident Transaction Notice x Vendor Number for Contract Number sss v Form Status Inquiry DLN Medicaid Number Last Name i First Name SSN H
324. ns of the MDS 3 0 are under separate copyright protections Pfizer Inc holds the copyright for the PHQ 9 and the Annals of Internal Medicine holds the copyright for the CAM Both Pfizer Inc and the Annals of Internal Medicine have granted permission to freely use these instruments in association with the MDS 3 0 MDS 3 0 Nursing Home Quarterly NQ Version 1 11 2 Effective 10 01 2013 Page 35 of 35 Individual Identifier Date Medical Necessity and Level of Care Assessment Version 3 0 RY enuy Identification Information A0310 Type of Assessment Enter A Reason for Assessment 01 Initial assessment 03 Annual assessment 04 Significant change in status assessment Legal Name of Individual A First name Middle initial Social Security and Medicare Numbers A Social Security Number Medicaid Number Enter N if not a Medicaid recipient Gender 1 Male 2 Female Birth Date HKH Month Day Year A1000 Race Ethnicity Check all that apply American Indian or Alaska Native Asian Black or African American E L Cj LJ Hispanic or Latino O Lj Native Hawaiian or Other Pacific Islander White MN and LOC 3 0 V 15 1 of 32 Individual Identifier Date NYa iey Identification Information A1100 Language Enter A Does the individual need
325. nt L 0 No 1 Yes E0800 Rejection of Care Presence amp Frequency Did the individual reject evaluation or care e g bloodwork taking medications ADL assistance that is necessary to achieve the individual s goals for health and well being Do not include behaviors that have already been addressed e g by discussion or care planning with the individual or family and determined to be consistent with individual values preferences or goals Enter Code O Behavior not exhibited L 1 Behavior of this type occurred 1 to 3 days 2 Behavior of this type occurred 4 to 6 days but less than daily 3 Behavior of this type occurred daily MN and LOC 3 0 V 15 8 of 32 Individual Identifier Date Section E E0900 Wandering Presence amp Frequency Has the individual wandered 0 z 3 Behavior not exhibited Skip to E1100 Change in Behavioral or Other Symptoms Behavior of this type occurred 1 to 3 days Behavior of this type occurred 4 to 6 days but less than daily Behavior of this type occurred daily E1000 Wandering Impact Enter A Does the wandering place the individual at significant risk of getting to a potentially dangerous place e g stairs outside of the residence facility L 2 1 No Yes Does the wandering significantly intrude on the privacy or activities of others 0 1 No Yes E1100 Change in Behavior or Other Symptoms
326. nt s Medicaid ID card NPI entered in field A0100A matches the Vendor Contract information on the MESAV for that resident How to Submit Long Term Care Medicaid Information LTCMI Once you have found and opened the assessment set to status Awaiting LTC Medicaid Information using FSI or Current Activity in Click the Section LTCMI tab 4 TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR Home Submit Form Form Status Inquiry Current Activity Drafts endors Printable Forms Alerts Help amp UnLock Form MINIMUM DATA SET MDS Version 3 0 RESIDENT ASSESSMENT AND CARE SCREENING Nursing Home Comprehensive NC item Set Current Status Awaiting LTC Medicaid Information Name DLN RUG PE1 Form Actions Poruate crew Section A Section B F Section C Section D Section E Section F Section G Section H Section I Section J Section K Section L Section M LL Section N Section O la amp ection Box Section Q ROCIO TEES Section X Section Z _ sactlori LTCMI Section LTC Medicaid Information 81 Claims Processing Information S1a DADS Vendor Site ID Number S1b Contract Provider Number am i Sic Service Group S1d Hospice Contract Number Sle Sif r R 2 Enter data into remaining fields not auto populated At this time the provider will have the option to manually enter
327. nt Claim No Recipient s Middle F ZIP Initial Recipient Name Suffix Transaction Information e Service Group e Transaction fe Correct this form Correct this form allows providers to submit a correction The original form or assess ment with status Provider Action Required will be set to status Corrected and will have a parent DLN to the new child form The new form or assessment replaces the original form or assessment Review the cor rectable fields covered in the Form 3618 and 3619 Corrections section of this User Guide to know when to choose correct vs inactivate Remember correcting an LTCMI to include a Purpose Code E or M will void any prior service dates and change the MDS to be valid for the start to end date only If payment has been made recoupment will occur Inactivate Form Inactivate Form will inactivate the form Forms will set to status Form Inactivated and cannot be corrected or re submitted An example of when this Inactivate Form button would be used is when the provider research indicates the form being submitted is a duplicate Resubmit Form Resubmit Form will set the form or assessment status to SAS Request Pending The form or assessment will process during the nightly batch processing Check the status of the form or assessment within two to four days to determine if the form or assessment processed successfully Status will be set to Processed Complete if successfully processed 13 If the provi
328. nt RUG already established the Medicaid admission RUG will not be used unless the resident was out over 30 days or discharged Return Not Anticipated If the RUG is wanted for Medicaid it will require inactivating the assessment at CMS and resubmitting with a different Medicaid reason for assessment Long Term Care Medicaid Information LTCMI LTCMI is the replacement for the federal MDS Section S and contains state specific items for Medicaid payment Providers must access the LTC Online Portal and retrieve their MDS assessments to successfully complete the LTCMI Providers should complete the LTCMI section as soon as possible in order to submit the MDS assessment into TMHP s MN workflow for review within the anticipated quarter time frame The anticipated quarter is within 92 days of the MDS Assessment Complete Date This is known as the 92 day timeless rule Submission of LTCMI To enter the LTCML the provider must log in to the LTC Online Portal and access their assessments set to status Awaiting LTC Medicaid Information using FSI or Current Activity Ihe LTCMI must be completed with all required data and be successfully submitted The assessment is then available for medical necessity determination by TMHP Note Zhe LTC Online Portal allows a 60 day grace period for submission of the LTCMI for Change of Ownership CHOW and new owners Facilities have 60 days from the day the first MDS assessment is submitted with the new contract numb
329. nt is Hospice inactivate the Nursing Facility form Note 3618 3619s should not be submitted on Hospice recipients If the recipient has requested to terminate the Hospice program contact the Hospice provider and request that the provider submit a discharge Form 3071 If the Form 3071 has already been submitted allow 10 days for processing before resubmitting the rejected admission Note f the form rejects again the Hospice provider needs to follow up with DADS Provider Claims Services If the Form 3071 has not yet been submitted allow the time requested by the Hospice provider for processing of the Hospice discharge before resubmitting the rejected admission The recipient has a Service Authorization for a different facility pro cessed admission and discharge for a different provider cover the submitted admission date Contact the prior facility to request that a correcting discharge be submitted for their discharge If the other facility s discharge is incorrect allow seven days for processing time and resubmit the rejected admission If the recipient was in the other provider s facility before and after being in your facility the other facility must submit a retroac tive discharge and admission creating a gap during which the recipient was in your facility An admission and discharge pair will also need to process for your facility to fill the gap Two pairs will need to be processed Coordinate with the other facility
330. number of times per day week or month that each medication is given Record the frequency in column 3 e S9 4 PRN n number of doses as necessary number of times in last 30 days Pro Re Nata PRN means as needed in Latin The PRN n column is only completed for medications that have a frequency as PR Record the number of times in the past 30 days that each medication coded as PR was given Stat medi cations are recorded as a PRN medication Remember if a PRN medication was not given in the past 30 days it should not be listed here Section N on MDS 3 0 assessments reflects the number of medications and section S9 allows for more detailed informa tion to be submitted i e name of medications S10 Comments v 2013 1127 77 LTC Nursing Facility Hospice User Guide LTCMI Fields Optional Enter up to 500 characters if needed It is essential that you include signs and symptoms that present an accurate picture of the resident s condition The comment section can be used for additional qualifying data that indicates the need for skilled nursing care such as Pertinent medical history Ability to understand medication Ability to understand changes in condition Abnormal vital signs Previous attempts at outpatient management of medical condition Results of abnormal lab work S11 Advance Care Planning Advance care planning means planning ahead for how the resident wants to be treated if ill
331. o be resolved before the form can be successfully submitted Once all errors are resolved click the Submit Form button again to submit the form v 2013 1127 59 LTC Nursing Facility Hospice User Guide Actions 3074 Physician Certification of Terminal Illness Provider Information TEST PROVIDER CM2 B c Recipient Information Medicaid Medicare Number SSN i ni Number Last MI First Mame 9 Name 9 Address 9 City 9 State Jj Zip 9 Certification Information Election Start Pe Cert Recert Date T Recertification Date 7 Hospice Information Hospice Provider TEST PROVIDER CM2 Gr act inpoooo000 umber Name Address City a State 9 TX v Zip Num Verbal Verification within two days of election date verbal Verbal Verification Verification Last Name First Name Verbal Verification T Signature on 0 Dat Signad tf File Certification Recertification Physician Signatures Attending Attending Physician Last Physician First Name Name Attending Physician A a Signature on Oo Dateisigned m File License Type State of TX Lic Num v State License Mo 9 Hospice Hospice Physician Last Physi
332. o be sent to the Local Authority using the LTC Online Portal Alerts should be accessed on a daily basis via the LTC Online Portal in order to meet time frames associated with the Alert Accessing Alerts Follow the steps below to access the Alerts screen 1 Go to www tmhp com 2 Click providers on the green bar located at the top of the screen 3 Click Long Term Care on the yellow bar 4 Click the Log In to LTC Online Portal button on the blue bar 5 Enter your User name and Password Click the OK button The Form Status Inquiry FSI page will display by default 122 v 2013 1127 LTC Nursing Facility Hospice User Guide 6 Click the Alerts link located on the blue navigational bar v TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR Home Submit Form Form Status Inquiry Current Activity Drafts endors Printable Forms Alerts Alerts Create Alert Delete Alert Outgoing Alerts o MI Conduct 4 28 2013 PASRR Evaluation Second Notification o Conduct 4 27 2013 IDD Evaluation Second Notification The Alerts screen displays A list of incoming and outgoing alerts are displayed Nursing Facility users will not see incoming alerts The alert list only contains alerts for your Vendor Contract numbers Alerts are only shown for the last 30 days from the current date There is no way to access older alerts Alerts
333. o constitute acceptance by you of the modified terms TMHP has the right at any time to change or discontinue any aspect or feature ofthis website and to terminate any users access to the website TMHP has the right but not the obligation to monitor your use and access of this site HIPAA Privacy you have requested online access to confidential patient data that is protected by federal and state privacy laws We take very seriously our obligation to protect this confidential patient data from unauthorized use or disclosure Accordingly we allow only those persons with appropriate authorization to access or provide the confidential patient data ti dissemination or distribution of the confidential patient cata contained in this website to anyone other than the authorized recipient is unauthorized and strictly prohibited by law The privacy and securi the Health Insurance Portability and Accountability Act of 1996 HIPAA and its LO Ready 5 12 Click the Create Provider Administrator button to create your User Name and Password Home TMHP com My Account TMHP Welcome erick_ext15 Log Off I ferme The provider security information has been verified Enter the provider account information Account Activation User Name 6 20 characters no spaces or Must be a different than your EDI Submitter ID no special characters First Name n
334. o special characters Last Name Business telephone Email TMHP is currently experiencing probl ding Account Activation confirmation emails to MSN and Hotmail accounts In order to receive your Account Activation confirmation which includes your User Name and TMHP ing a different email account If you do not ha parate email account you may set up one fer free with Yahoo To ensure delivery directly to your inbox please add donotreply tmhp com to your address box today s Do not cut and paste Confirm Email ino spaces or special characters New Password e Confirm Password GENERAL TERMS AND CONDITIONS You have entered the secure portion of the Texas Maci employees consultants and subcontractors amp Healthcare Partnership TMH website Throughout the terms herein reference to TMHP means TMHP ACS State Healthcare LLC its parent company affiliates subsidiaries Terms of Use Ev accepting t provided by terms of use you will HP to provide such allowed access to programs reports and information prot swords may enter and access the secure portion of this web ate law contained in the seci ortion of this website Only authorized persons in lawful pos website is subject to the terms of contained harain sion of a password Once you have accepted the terms of use you will not be asked to accept such terms again when you access the site a
335. o store the form for future use but not submit it The form does not have to be complete to save the draft Note f the form is successfully submitted a DLN will be assigned and the LTC Online Portal will show Your form was submitted successfully If there are errors they will be displayed in a box at the top of the screen These errors will need to be resolved before the form will be successfully submitted Once all errors are resolved click the Submit Form button again to submit the form 56 v 2013 1127 LTC Nursing Facility Hospice User Guide Actions 3071 Recipient Election Cancellation Discharge Notice Provider Information TEST PROVIDER CM2 s s Recipient Information Medicaid Number SSN First Last Name MI Name Address City 9 State 9 v Zip DOB v Name of County Facility Code 9 Transaction Information Form Type 9 ii From v To v Setting 9 Medicare Part No v i All Terminal Diagnoses List All Terminal Illnesses Diagnosis Code 9 q Description Diagnosis Code Q Description Diagnosis Code q Description Diagnosis Code Q Description Comments Hospice Information Hospi
336. ocessed because a later discharge Discharge has already been processed This discharge appears to be one of a retroactive pair If an admission after this discharge is missing or re jected resubmit the admission and this discharge on the same day NF 0021 This discharge cannot 3618 be processed because a later Discharge admission to another provider has already been processed This discharge appears to be one of a retroactive pair If an admission prior to this discharge is missing or rejected resubmit the admission and this discharge on the same day NF 0022 This discharge cannotbe 3618 processed because the client does Discharge not have a corresponding Nursing Facility admission missing 3618 Verify that the admission 3618 has been processed NF 0023 This admission cannot be processed because it is effective during a Service Authorization for a different provider Correct the admission date or contact the other provider to determine proper dates 3619 Admit Suggested Action This discharge is part of a retroactive pair Review the facility records to identify the admission prior to this discharge Pull a MESAV and review the Service Authorizations The discharge and admission should split one of the authorizations when these forms process The discharge and admission pair must be submitted at the same time If the form is not part of a pair it should be a correcting discharge not a n
337. ode Bowel continence Select the one category that best describes the resident 0 Always continent 1 Occasionally incontinent one episode of bowel incontinence 2 Frequently incontinent 2 or more episodes of bowel incontinence but at least one continent bowel movement 3 Always incontinent no episodes of continent bowel movements 9 Not rated resident had an ostomy or did not have a bowel movement for the entire 7 days H0500 Bowel Toileting Program Enter Code Is a toileting program currently being used to manage the resident s bowel continence 0 No 1 Yes MDS 3 0 Nursing Home Quarterly NO Version 1 11 2 Effective 10 01 2013 Page 14 of 35 Resident Identifier Date Section __ Active Diagnoses Active Diagnoses in the last 7 days Check all that apply Diagnoses listed in parentheses are provided as examples and should not be considered as all inclusive lists Heart Circulation Anemia e g aplastic iron deficiency pernicious and sickle cell Heart Failure e g congestive heart failure CHF and pulmonary edema Hypertension Orthostatic Hypotension Pariphersi Vascular Disease PVD or Peripheral Arterial Disease PAD 11550 Neurogenic Bladder 11650 Obstructive Uropathy Infections S Multidrug Resistant Organism MDRO Pneumonia Septicemia Tuberculosis Urinary Tract Infection UTI LAST 30 DAYS V
338. of pain e g that hurts ouch stop Facial expressions e g grimaces winces wrinkled forehead furrowed brow clenched teeth or jaw Protective body movements or postures e g bracing guarding rubbing or massaging a body part area clutching or holding a body part during movement None of these signs observed or documented If checked skip to J1100 Shortness of Breath dyspnea J0850 Frequency of Indicator of Pain or Possible Pain in the last 5 days Enter Code Frequency with which individual complains or shows evidence of pain or possible pain 1 Indicators of pain or possible pain observed 1 to 2 days 2 Indicators of pain or possible pain observed 3 to 4 days 3 Indicators of pain or possible pain observed daily J1100 Shortness of Breath dyspnea Check all that apply A Shortness of breath or trouble breathing with exertion e g walking bathing transferring Shortness of breath or trouble breathing when sitting at rest Shortness of breath or trouble breathing when lying flat None of the above J1400 Prognosis Enter Code Does the individual have a condition or chronic disease that may result in a life expectancy of less than 6 months 0 No 1 Yes J1550 Problem Conditions Check all that apply Fever Vomiting Dehydrated L L Internal bleeding Syncope None of the above 17 of 32 MN and LOC 3 0 V 15
339. ollowing day to see changes 128 v 2013 1127 LTC Nursing Facility Hospice User Guide PASRR Level 1 Screening Updates NF Providers must submit PL1 updates directly on the LTC Online Portal Only users with appropriate security permissions can submit updates The PL1 cannot be updated if the status is Form Inactivated or PLI Inactive or if a matching PE with a DLN is found The PL1 can only be updated until an associated PE has been successfully submitted The status of a PL1 does not change upon submission of an update and no parent child form is created The History trail shows the fields that have been updated listing the previous and new values Fields that can be updated on the PASRR Level 1 Screening e A0600 Date of Assessment e B0100A First Name e B0100B Middle Initial e BO100C Last Name e B0100D Suffix e B0200A Social Security No e B0200B Medicare No e B0300 Medicaid No e B0400 Birth Date e B0600 Gender e B0650 Individual is deceased or has been discharged e B0655 Deceased Discharged Date e B0700A Previous Residence Type e B0700B Other Residence Type e B0700C Street Address B0700D City e B0700E State e B0700F ZIP Code e B0700G County of Residence e B0800A Relationship to Individual e B0800B Other Relationship to Individual e B0800C First Name e B0800D Middle Initial e B0800E Last Name B0800F Suffix e B0800G Phone Number e B0800H Stre
340. on __ Active Diagnoses Active Diagnoses in the last 7 days Check all that apply Diagnoses listed in parentheses are provided as examples and should not be considered as all inclusive lists Psychiatric Mood Disorder Anxiety Disorder Depression other than bipolar Manic Depression bipolar disease Psychotic Disorder other than schizophrenia Schizophrenia e g schizoaffective and schizophreniform disorders Post Traumatic Stress Disorder PTSD Pulmonary 16200 Asthma Chronic Obstructive Pulmonary Disease COPD or Chronic Lung Disease e g chronic bronchitis and restrictive lung diseases such as asbestosis 16300 Respiratory Failure 18000 Additional active diagnoses Enter diagnosis on line and ICD code in boxes Include the decimal for the code in the appropriate box MDS 3 0 Nursing Home Quarterly NQ Version 1 11 2 Effective 10 01 2013 Page 16 of 35 Resident Identifier Date Section Health Conditions J0100 Pain Management Complete for all residents regardless of current pain level At any time in the last 5 days has the resident Enter Code A Received scheduled pain medication regimen 0 No 1 Yes Enter Code B Received PRN pain medications OR was offered and declined 0 No 1 Yes EnterCode C Received non medication intervention for pain 0 No 1 Yes J0200 Should P
341. on excludes to from bath toilet C Walk in room how individual walks between locations in room D Walk in home how individual walks in home or community setting E Locomotion in room how individual moves between locations in his her room and adjacent hallway on same floor If in wheelchair self sufficiency once in chair F Locomotion in home how individual moves to and returns from distant areas in his her home or community setting If in wheelchair self sufficiency once in chair G Dressing how individual puts on fastens and takes off all items of clothing including donning removing a prosthesis or TED hose Dressing includes putting on and changing pajamas and housedresses H Eating how individual eats and drinks regardless of skill Do not include eating drinking during medication pass Includes intake of nourishment by other means e g tube feeding total parenteral nutrition IV fluids administered for nutrition or hydration I Toilet use how individual uses the toilet room commode bedpan or urinal transfers on off toilet cleanses self after elimination changes pad manages ostomy or catheter and adjusts clothes Do not include emptying of bedpan urinal bedside commode catheter bag or ostomy bag J Personal hygiene how individual maintains personal hygiene including combing hair brushing teeth shaving applying makeup washing drying face and hands excludes baths and showers L LL LI D UU
342. on A Admitted to information P 3 B Admitted to Other E0600 Specify A Community Program Gommunty Program B Other Community Program E0700 Name of ICF IID Facility E0800 Own Home Family Home Comments E0900 Alternate f Placement Date of Entry 176 v 2013 1127 LTC Nursing Facility Hospice User Guide PASRR Level 1 Screening Section F Sa TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR Home Submit Form Form Status Inquiry Current Activity Drafts Vendors Letters Printable Forms Alerts Help PASRR LEVEL 1 SCREENING Current Status Name DLN O Form Actions Admission Category F0100 9 Exempted Hospital Discharge Has the physician certified that individual is likely to require less than 30 days of NF services For individuals being admitted from acute care in the hospital bes F0200 9 Expedited Admission Does this individual meet any of the following categories for an expedited admission into the nursing facility Please select one category below 0 Not Expedited Admission O 1 Convalescent Care Individual is admitted from an acute care hospital to an NF for convalescent care with an acute physical illness or injury which required hospitalization and is expected to remain in the NF for greater than 30 days O 2 Terminally Il
343. on Required Current Activity is in the blue navigational bar next to Form Status Inquiry Current Activity Received Medicaid Medicare Name Status 4 1 2012 3 21 50 PM Awaiting LTC Medicaid Information 4 1 2012 3 21 50 PM Awaiting LTC Medicaid Information 4 1 2012 3 21 50 PM Awaiting LTC Medicaid Information v 2013 1127 99 LTC Nursing Facility Hospice User Guide Provider Workflow Rejection Messages Below are the rejection messages providers will receive as a result of an error occurring during the nightly batch processing The messages are in order of message number The table contains three columns I 2 Provider Message This is the system message that will be displayed in form and assessment History trail Form Assessment What form and assessment can receive this message Some messages only apply to certain types of assessments When only specific types are affected they are shown Otherwise MDS would indicate all types Admission assessment A0310A 01 Annual assessment A0310A 03 Significant change in status assessment A0310A 04 Significant correction to prior comprehensive assessment A0310A 05 Quarterly review assessment A0310A 02 Significant correction to prior quarterly assessment A0310A 06 Suggested Action The messages and suggested action button is written assuming that the rejected form or assessment is correct in Form Type Transaction and Date o
344. onceptions or beliefs that are firmly held contrary to reality Z None of the above Behavioral Symptoms E0200 Behavioral Symptom Presence amp Frequency Note presence of symptoms and their frequency J Enter Codes in Boxes A Physical behavioral symptoms directed toward others e g hitting Coding kicking pushing scratching grabbing abusing others sexually Behavior not exhibited Behavior of this type occurred 1 to 3 days Behavior of this type occurred 4 to 6 days but less than daily C Other behavioral symptoms not directed toward others e g physical Behavior of this type occurred daily symptoms such as hitting or scratching self pacing rummaging public sexual acts disrobing in public throwing or smearing food or bodily wastes or verbal vocal symptoms like screaming disruptive sounds B Verbal behavioral symptoms directed toward others e g threatening others screaming at others cursing at others E0300 Overall Presence of Behavioral Symptoms Enter Code Were any behavioral symptoms in questions E0200 coded 1 2 or 3 0 No Skip to E0800 Rejection of Care 1 Yes Considering all of E0200 Behavioral Symptoms answer E0500 and E0600 below E0500 Impact on Resident Did any of the identified symptom s Enter Code A Put the resident at significant risk for physical illness or injury 0 No 1 Yes Enter Code B Significantly interfere with the resident s care
345. or faxed request forms are not considered a valid authorization request and are returned as a denial v 2013 1127 147 LTC Nursing Facility Hospice User Guide Nonemergency Prior Authorization and Retroactive Eligibility Ifa resident s Medicaid eligibility is pending a PAN must be requested before a nonemergency transport This request will be initially denied due to Medicaid eligibility When Medicaid eligibility is established the requestor has 95 days from the date that the eligibility was added to TMHP s files to contact the TMHP Ambulance Unit and request that the authorization be reconsidered Once the authorization is approved the requesting NF or other requesting provider contacts the ambulance provider and supplies the PAN and the dates of service that were approved The ambulance provider can then submit a claim to TMHP Prior Authorization Types and Definitions One Time Non repeating 1 day One time prior authorization is a non repeating request for prior authorization and must be submitted on the Nonemergency Ambulance Prior Authorization Request form The authorization period for a one time request is one day The request must be signed and dated by a physician physician assistant PA nurse practitioner NP clinical nurse specialist CNS or discharge planner with knowledge of the client s condition Stamped or computerized signatures and dates are not accepted Without a signature and date the form will be
346. or less than 15 minutes daily Number z Technique A Range of motion passive B Range of motion active C Splint or brace assistance Training and Skill Practice In D Bed mobility E Transfer G Dressing and or grooming H Eating and or swallowing I Amputation prostheses care J Communication O0600 Physician Examinations Enter Days Over the last 14 days on how many days did the physician or authorized assistant or practitioner examine the individual 00700 Physician Orders Enter Days Over the last 14 days on how many days did the physician or authorized assistant or practitioner change the individual s MN and LOC 3 0 V 15 26 of 32 Individual Identifier Date Sime Restraints 1 111 P0100 Physical Restraints Physical restraints are any manual method or physical or mechanical device material or equipment attached or adjacent to the individual s body that the individual cannot remove easily which restricts freedom of movement or normal access to one s body Enter Codes in Boxes Used in Bed A Bedrail B Trunk restraint C Limb restraint Coding O Notused 1 Used less than daily 2 Used daily D Other Used in Chair or Out of Bed E Trunk restraint F Limb restraint G Chair prevents rising Other LILI LLLI Section Q Participation in Assessment and Goal Setting Q0100 Participation in Assessment
347. or quarterly MDS 3 0 assessments that are set to status Awaiting LTC Medicaid Information To delete an assessment 1 Click the Delete link The provider will receive the following message Message from webpage Warning If you delete this MDS assessment from the Portal you will have to submit a correction request to the CMS MDS database to allow the Portal to extract it at a later time Please confirm that you would like to delete this MDS pP assessment from the Portal Press OK to delete this Form 18 v 2013 1127 LTC Nursing Facility Hospice User Guide 2 From here you have two choices a Click the OK button to delete the assessment The following confirmation message will display ttt tt Ee rrr 1 LI MDS assessment was successfully deleted i LI LI Me um uacua ma um um ma nem Um GRO NOU REOR GROS RR UD RES RR UR EO REOR RR GERD GERE ER REOR RS RS GE GROR RS RS GR UR RR RM od Note Use caution when deleting assessments Once deleted the MDS assessment will no longer be available on the LTC Online Portal but the assessment will not be deleted from CMS If an MDS assessment is deleted from the LTC Online Portal TMHP will not re extract the assessment unless it is modified through CMS or b Click the Cancel button if the assessment should not be deleted Current Activity The Current Activity feature allows providers to view document submissions or status changes that have occured w
348. or to this new discharge Rejection of New Discharge for missing Previous Admission New discharge follows a discharge for same contract i e 11 1 2008 discharge no admission 12 1 2008 discharge submitted Submit an admission prior to this discharge Attempting to submit two 3618 discharges in a row missing a 3618 admission Submit the missing admission then submit the 3618 discharge Same contract An admission has already been received for the Date of Above Transaction OR Different contract An admission from another provider has already been received for the Date of Above Transaction Rejection of New Admission for Same Date of Above Transaction New admission has same Date of Above Transaction as an admission already received i e 11 1 2008 admission 11 1 2008 admission Same contract Possibly attempting to submit a duplicate form OR Different contract A different provider has previously submitted an admission for the same Date of Above Transaction date One provider is in error Contact other provider Scenarios 3618 admit exists in Processed Complete status for client A provider A transaction date 10 1 08 3618 admit exists in Processed Complete status for client A provider A transaction date 10 21 08 3618 admit submitted for client A provider A transaction date 10 1 08 Submit not allowed because date already in Processed Complete 3618 admit exists in Processed
349. or want an interpreter to communicate with a doctor or health care staff 0 No 1 Yes Specify in A1100B Preferred language 9 Unable to determine B Preferred language SERRE SRE A1300 Optional Individual Items B Room number iiiI A1550 Conditions Related to IDD Status If the individual is 22 years of age or older complete only if A0310A 01 If the individual is 21 years of age or younger complete always J Check all conditions that are related to IDD status that were manifested before age 22 and are likely to continue indefinitely IDD With Organic Condition A Down syndrome C Epilepsy D Other organic condition related to IDD IDD Without Organic Condition E IDD with no organic condition Z None of the above A2300 Assessment Date Observation end date HH Month Day Year MN and LOC 3 0 V 15 2 of 32 Individual Identifier Date Look back period for all items is 7 days unless another time frame is indicated ST iehi a Hearing Speech and Vision Comatose Persistent vegetative state no discernible consciousness 0 No Continue to B0200 Hearing 1 Yes Skip to G0110 Activities of Daily Living ADL Assistance Hearing Ability to hear with hearing aid or hearing appliances if normally used 0 Adequate no difficulty in normal conversation social interaction listening to TV 1 Minimal difficulty difficulty in some environments e g when
350. ordinator Verifying Assessment Completion A Signature B Date RN Assessment Coordinator signed assessment as complete Af Am ee Month Day Legal Notice Regarding MDS 3 0 Copyright 2011 United States of America and InterRAI This work may be freely used and distributed solely within the United States Portions of the MDS 3 0 are under separate copyright protections Pfizer Inc holds the copyright for the PHQ 9 and the Annals of Internal Medicine holds the copyright for the CAM Both Pfizer Inc and the Annals of Internal Medicine have granted permission to freely use these instruments in association with the MDS 3 0 MDS 3 0 Nursing Home Comprehensive NC Version 1 11 2 Effective 10 01 2013 Page 41 of 41 Resident Identifier Date MINIMUM DATA SET MDS Version 3 0 RESIDENT ASSESSMENT AND CARE SCREENING Nursing Home Quarterly NQ Item Set SectionA Identification Information A0050 Type of Record Enter Code 1 Add new record Continue to A0100 Facility Provider Numbers 2 Modify existing record Continue to A0100 Facility Provider Numbers 3 Inactivate existing record Skip to X0150 Type of Provider A0100 Facility Provider Numbers A National Provider Identifier NPI LI ELE EE B CMS Certification Number CCN C State Provider Number A0200 Type of Provider Enter Code Type of provider 1 Nursing home SNF NF 2 Swing Bed A0310 Type of Assessment mM A Federal OBR
351. ormation or call TMHP at 1 800 626 4117 Option 2 v 2013 1127 151 LTC Nursing Facility Hospice User Guide e Use the TMHP website to access training materials and other resources The TMHP website is available at www tmhp com Pages LTC ltc home aspx e This User Guide can be found under the Help link located on the blue navigational bar within the LTC Online Portal 152 v 2013 1127 LTC Nursing Facility Hospice User Guide Preventing Medicaid Waste Abuse and Fraud Medicaid fraud An intentional deceit or misrepresentation made by a person with the knowledge that deception could result in some unauthorized benefit to himself or some other person It includes any act that constitutes fraud under applicable federal or state law How to Report Waste Abuse and Fraud Reports may be made through the following website https oig hhsc state tx us This website also gives instruc tions on how to submit a report as well as how to submit additional documentation that cannot be transmitted over the Internet The website also provides information on the types of waste abuse and fraud to report to OIG If you are not sure if an action is waste abuse or fraud of Texas Medicaid report it to OIG and let the investigators decide If you are uncomfortable about submitting a report online there is a telephone number for Recipient Fraud and Abuse reporting 1 800 436 6184 v 2013 1127 153 LTC Nursing Facility H
352. orney fees Appellants may request additional time to prepare for their case by contacting the hearing officer Appellants may request an interpreter at no cost However appellants must notify the hearing officer at least two days before the hearing if they are going to require an interpreter Before and during the hearing appellants and their representatives have the right to examine the documents records and evidence that DADS will use To see medical evidence before the hearing the appellant must make a written request to the hearing officer The appellant may bring witnesses and present facts and details about the case The appellant may also question or disagree with any testimony or evidence that is presented by the department Appellants have the right to know all the information the hearing officer examines in making the decision The laws and policies which apply to the appellant s case and the reasons for DADS action will be explained The hearing officer will issue a final written order The decision by the hearing officer is DADS final adminis trative decision If the appellant believes the hearing officer did not follow applicable policy and procedures the appellant can submit a request for administrative review within 30 days of the date of the decision The appellant submits the request for administrative review to the hearing officer who will forward the request to the appropriate legal office for review The appellant
353. orrect contact Provider Claims Services and request that the form be processed manually Confir mation will be made that the Spell of Illness does not exceed 80 days 120 v 2013 1127 LTC Nursing Facility Hospice User Guide Provider Message Form Displayed in History Assessment NF 0080 This admission cannot be 3618 Admit processed because it would cancel the client s Enrollment with a dif ferent provider Verify the effective date and correct it as needed If the date is correct contact Provider Claims Services for assistance NF 0081 This admission cannot 3619 Admit be processed because the client is already admitted into your facility as of the submitted admission date Verify current Service Authoriza tions on file and submit the needed 3618 3619 discharge prior to the submitted admission date to allow this 3619 admission to process Suggested Action This 3618 admission would cancel the previous provider s Service Authorization rather than auto discharge the recipient from the previous provider Review the facility s records to determine the recipient s admission and discharge dates If the 3618 admission s transaction date is correct contact the prior facility and request that they review their admissions and discharges If the prior facility agrees to make adjustments allow processing time and resubmit your rejected admission The recipient has an ongoing Service Authoriz
354. ose three months so the payment could be made at a RUG value rather than the default PC E rate The retroactive Medicaid is shown on the MESAV as a TP 14 Coverage Code P or TP 11 which are retroactive TP13 SSI coverage To fill a period approved by the financial worker for dates prior to the application the provider has two options 1 Submit an off cycle MDS quarterly assessment including the LTCMI by completing The Sle field on the LTCMI completed as the PC M The start date of the approved prior period S1f The end date of the approved prior period S1g 2 Modify an earlier MDS that has not been used for the Medicaid cycle and complete the LTCMI as a PC M by completing The Sle field on the LTCMI completed as the PC M The start date of the approved prior period S1f The end date of the approved prior period S1g Note 70 submit a PC M for one day the Missed Assessment Start Date and the Missed Assessment End Date must be the same PC M Start and End Date Limitations MDS 3 0 Only applicable for MDS 3 0 Admission Quarterly review and Annual assessments e Start date cannot be prior to September 1 2008 The following errors must be fixed before the form will submit e Missed Assessment or Prior Start Date must be on or after 09 01 2008 End date cannot be prior to the Start Date 90 v 2013 1127 LTC Nursing Facility Hospice User Guide Validations Requiring
355. ospice Program Department of Aging and Disability Services Provider Forms PO Box 149030 Mail Code E205 Austin Texas 78714 9030 This form is also located online at www tmhp com Pages LTC Itc forms aspx e fa person is discharged from Hospice for any reason and the person re elects Hospice regardless of the amount of time a new election and a new Physician Certification Form must be completed Note The effective date of Form 3071 is the Hospice election date or the recipient signature date whichever occurs last See the Helpful Telephone Numbers section of this User Guide for contact information on Hospice claims policy and contracting For Hospice forms policy questions should be directed to the state according to policy TMHP only addresses technical questions related to using the LTC Online Portal for Hospice form submission Note Nursing Facilities are reminded that Form 3618 should not be submitted after a recipient is classified as Hospice in the facility If the recipient is classified as Hospice upon admission Form 3618 should not be submitted Hospice providers v 2013 1127 55 LTC Nursing Facility Hospice User Guide should only submit Forms 3071 3074 If the recipient is Medicare for a non related condition and classified as SNF by the Hospice provider Form 3619 is appropriate Nursing facilities should inactivate any Forms 3618 3619 rejected to the Provider Action Required workflow submitted by facilities i
356. ospice User Guide HIPAA Guidelines and Provider Responsibilities Providers must comply with the Health Insurance Portability and Accountability Act HIPAA It is YOUR respon sibility to comply with HIPAA to seek legal representation when needed and to consult the manuals or speak to your TMHP Provider Representative when you have questions 154 v 2013 1127 LTC Nursing Facility Hospice User Guide Resource Information Types of Calls to Refer to TMHP Call TMHP at 1 800 626 4117 Option 1 about the following e NF forms completion including PASRR Level 1 Screening Rejection codes on the forms Management of the Provider Action Required status e f the Medicaid Social Security or Medicare number and the name match the recipients Medicaid ID card and the form is set to status ID Invalid call TMHP to have the form restarted through the system e PASRR Level 1 Screening submission error messages e PASRR Level 1 Screening and PASRR Evaluation status questions Call TMHP at 1 800 626 4117 Option 3 about the following e TMHP LTC Online Portal and TexMedConnect account setup Types of Calls to Refer to DADS PASRR Unit Call DADS PASRR Unit at 1 855 435 7180 Option 1 about the following Assistance or cooperation from a Referring Entity or Local Authority e Assistance with locating information to perform and submit the PL1 Screening e Assistance with locating screenings and evaluations individuals or add
357. ot submit it The form does not have to be complete to save the draft Note f the form is successfully submitted a DLN will be assigned and the LTC Online Portal will show Your form was submitted successfully If there are errors they will be displayed in a box at the top of the screen These errors will need to be resolved before the form can be successfully submitted Once all errors are resolved click the Submit Form button again to submit the form IMPORTANT Validation is performed on the Medicaid SSN Medicare number and the Last Name of the recipient If the Medicaid SSN Medicare number and Last Name do not match processing will not occur The form will be set to status ID Invalid Validations are against the Medicaid Eligibility file Check the recipients Medicaid card or the MESAV and compare to the entry being made If the Medicaid card is incorrect contact the Medicaid Eligibility Worker Corrections are not allowed to the Name or Number fields on the form once submitted thus it is important to submit the correct informa tion Incorrect entries require inactivation and a new submission a TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR Home Submit Form Form Status Inquiry Current Activity Drafts Vendors Printable Forms Alerts Help Your form was submitted successfully You can track this form using the DLN Submit another form Inquiry on a forms Status 50 v 2013 1127 LT
358. other 3 If not resident family or significant other then guardian or legally authorized representative 8 No information source available Q0600 Referral Has a referral been made to the Local Contact Agency Document reasons in resident s clinical record 0 No referral not needed 1 No referral is or may be needed For more information see Appendix C Care Area Assessment Resources 20 2 Yes referral made Enter Code MDS 3 0 Nursing Home Comprehensive NC Version 1 11 2 Effective 10 01 2013 Page 34 of 41 Resident Identifier Date Care Area Assessment CAA Summar V0100 Items From the Most Recent Prior OBRA or Scheduled PPS Assessment Complete only if A0310E 0 and if the following is true for the prior assessment A0310A 01 06 or A0310B 01 06 A Prior Assessment Federal OBRA Reason for Assessment A0310A value from prior assessment 01 Admission assessment required by day 14 02 Quarterly review assessment 03 Annual assessment 04 Significant change in status assessment 05 Significant correction to prior comprehensive assessment 06 Significant correction to prior quarterly assessment 99 None of the above Enter Code Prior Assessment PPS Reason for Assessment A0310B value from prior assessment 01 5 day scheduled assessment 02 14 day scheduled assessment 03 30 day scheduled assessment 04 60 day scheduled assessment 05 90 day scheduled assessment 06 Readmission return assessment 07
359. ove was the person physically restrained prior to the fall is a required field Confusion Disorientation is a required field Assault by Resident or Staff is a required field Resident s Address is a required field Resident s Current Address City is a required field Resident s Current Address State is a required field Resident s Current Address ZIP Code is a required field Medication Certification is a required field Does the resident report having an Out of Hospital Do Not Resuscitate Order is a required field UnLock Form MINIMUM DATA SET MDS Version 3 0 RESIDENT ASSESSMENT AND CARE SCREENING Nursing Home Comprehensive NC Item Set Current Status Awaiting LTC Medicaid Information Name more DEN c7 RUG RAA Form Actions Print Add Note Save LTCMI Populate LTCMI Section A Section B Section C Section D Section E Section F ll Section G Section H Section I ll Section J Section K Section L Section M Section N Section O Section P Section Q Section V Section X Section Z v 2013 1127 67 LTC Nursing Facility Hospice User Guide Circumstances for LTCMI Submission Nursing Facilities are directed to complete the LTCMI when seeking full Medicaid reimbursement when a resident is moving to full Medicaid or continuation of Medicaid payment T
360. pain or possible pain Enter Code 1 Indicators of pain or possible pain observed 1 to 2 days 2 Indicators of pain or possible pain observed 3 to 4 days 3 Indicators of pain or possible pain observed daily Other Health Conditions J1100 Shortness of Breath dyspnea J Check all that apply A Shortness of breath or trouble breathing with exertion e g walking bathing transferring B Shortness of breath or trouble breathing when sitting at rest C Shortness of breath or trouble breathing when lying flat Z None of the above J1400 Prognosis Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months Requires physician Enter Code documentation 0 No 1 Yes J1550 Problem Conditions J Check all that apply MDS 3 0 Nursing Home Quarterly NQ Version 1 11 2 Effective 10 01 2013 Page 18 of 35 Resident Identifier Date Section Health Conditions J1700 Fall History on Admission Entry or Reentry Complete only if A0310A 01 or A0310E 1 Enter Code A Did the resident have a fall any time in the last month prior to admission entry or reentry 0 No 1 Yes 9 Unable to determine Enter Code B Did the resident have a fall any time in the last 2 6 months prior to admission entry or reentry 0 No 1 Yes 9 Unable to determine Enter Code C Did the resident have any fracture related to a fall in the
361. pdates P 129 Form hide reo is PD 130 Fotm 3071 and 3074 Corrections T 133 Counteracting POL zajst etm rete EEE ama EO PEG EE E ETEEN E 134 v 2013 1127 iii LTC Nursing Facility Hospice User Guide hihi teiihr M 135 MDS 3 Oo E U IA 135 THACHHVATIONS d M 137 MDS Assessment nn rere ir p OR TERR E ee A HERR ont OR EO Ferte Re D Wes e ER ORO E EE RE 137 Lornns 2619 and 2619 Dndetbvathol eisoes eiiiai a ig paa bai ce chu ap Cou p db deti an Don 137 Pow t rri Eei 138 PASRR Level d Schiene Inactivato ns tt ccd cd ae reel adeno ix babens d cede NEE cba Du bs E npa cuf Edd 138 Form 3618 and 3619 Submission Validation Rules and Edits see 139 Tam 3618 Resident Transaction Notice Edits 2icsuncoxc oett metes russa EAEE e Lap tob ED Rise Eo aci dM cin bac D 140 Form 3519 Medicate SNP Patient Iransaction Notice Edits uuebeeudzinbeid d cri debct cds te ia 142 Form and Assessment SEIEBSBR coe dedo endian cD ete sa dea unum sn UGG Dicta dubbed Luca DE 144 Nonemergency Ambali ce MT A Y m 146 Prior Authorization Peguir ficyibseteesatoikntengddu i E x uid es UR ne ie EERE RES 146 Dionemergency Dinar Authorization PEOGESS acted ae DO and EI ordei deer ao arua aee Reb Geena a
362. person speaks softly or setting is noisy 2 Moderate difficulty speaker has to increase volume and speak distinctly 3 Highly impaired absence of useful hearing Hearing Aid Hearing aid or other hearing appliance used in completing BO200 Hearing 0 No 1 Yes Speech Clarity Select best description of speech pattern 0 Clear speech distinct intelligible words 1 Unclear speech slurred or mumbled words 2 No speech absence of spoken words Makes Self Understood Ability to express ideas and wants consider both verbal and non verbal expression Enter Dash if unable to assess 0 Understood 1 Usually understood difficulty communicating some words or finishing thoughts but is able if prompted or given time 2 Sometimes understood ability is limited to making concrete requests 3 Rarely never understood B0799 Modes of Expression Check all used by individual to make needs known Speech Writing messages to express or clarify needs American sign language or Braille Signs Gestures Sounds Communication Board Voice Modulator Other None of the above B0800 Ability To Understand Others Understanding verbal content however able with hearing aid or device if used Enter Dash if unable to assess Enten 0 Understands clear comprehension _ 1 Usually understands misses some part intent of message but comprehends most conversation Code 2
363. pient for Medicaid processing A new MDS is not required upon change to Medicaid if the cycle is already established Once the Form 3618 has been submitted the most recent MDS assess ment that meets the necessary criteria will be loaded onto the LTC Online Portal and set to status Awaiting LTC Medicaid Information The facility administrator must sign Form 3618 prior to submission In order for a Medicaid recipient to begin Full Medicaid Provider Payment the following must apply e The recipient must have Medicaid Eligibility Form 3618 will not process until the recipient is determined to be eligible e The MESAV must be updated to reflect the processing of Form 3618 e MDS RUG is authorized Note Zhe MDS should have been submitted to CMS in accordance with the RAI Users Manual whether Medicare Medicaid or private pay status MDS submissions to CMS are not dependent upon the payor source The form must be signed and submitted by the facility administrator within 72 hours of the recipient s Admission to or Discharge from the Medicaid Vendor System to be considered timely A facility administrator may authorize a person to sign the form in their absence The authorization must be in writing and on file at the facility The administrator date signed check box is required for Forms 3618 and 3619 48 v 2013 1127 LTC Nursing Facility Hospice User Guide If the facility is temporarily without an administrator a signature is still re
364. port correct year 0 Missed by gt 5 years or no answer 1 Missed by 2 5 years 2 Missed by 1 year 3 Correct Ask resident What month are we in right now EnterCode B Able to report correct month Enter Code 0 Missed by 1 month or no answer 1 Missed by 6 days to 1 month 2 Accurate within 5 days Ask resident What day of the week is today EnterCode C Able to report correct day of the week 0 Incorrect or no answer 1 Correct C0400 Recall Ask resident Let s go back to an earlier question What were those three words that I asked you to repeat If unable to remember a word give cue something to wear a color a piece of furniture for that word A Able to recall sock 0 No could not recall 1 Yes after cueing something to wear 2 Yes no cue required EnterCode B Able to recall blue 0 No could not recall 1 Yes after cueing a color 2 Yes no cue required EnterCode C Able to recall bed 0 No could not recall 1 Yes after cueing a piece of furniture 2 Yes no cue required C0500 Summary Score LII Add scores for questions C0200 C0400 and fill in total score 00 15 Emersco Enter 99 if the resident was unable to complete the interview Enter Code MDS 3 0 Nursing Home Comprehensive NC Version 1 11 2 Effective 10 01 2013 Page 7 of 41 Resident Identifier Date Cognitive Patterns C0600 Should the Staff Assessment for Mental Status C0700 C1000 be Conducted
365. ption of Forms 3071 and 3074 v 2013 1127 21 LTC Nursing Facility Hospice User Guide 1 Click the Printable Forms link in the blue navigational bar v a TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR Home Submit Form Form Status Inquiry Current Activity Drafts Vendors Alerts Help Printable Forms MDS 2 0 Comprehensive MDS 2 0 Quarterly MDS 2 0 Correction MDS 3 0 Comprehensive MDS 3 0 Quarterly PASRR Level 1 Screening PL1 PASRR Evaluation PE Waiver 3 0 MN and LOC Waiver 3 0 Physician s Signature Page Individual Movement Form 8578 Intellectual Disability Related Condition Assessment ID RC 8578 Assessment 2 Choose a document by clicking the corresponding link A new window and application called Adobe Reader will open and display the blank document in Portable Document Format PDF et Bye Oe D R oomh m remm Resident Identifier Date MINIMUM DATA SET MDS Version 3 0 RESIDENT ASSESSMENT AND CARE SCREENING Nursing Home Comprehensive NC Item Set Section A Identification Information A0100 Facility Provider Numbers A National Provider Identifier NPI B CMS Certification Number CCN C State Provider Number A0200 Type of Provider Enter Code Type of provider 1 Nursing home SNF NF 2 Swing Bed A0310 Type of Assessment A Federal OBRA Reason for Assessment 01 Admission assessment required by day 14 v
366. quired Note in the comment section of Form 3618 that the facility is without an Administrator at this time and enter 999999 in field 13 for the State Board License No Note Nursing Facilities are reminded that Form 3618 should not be submitted after a recipient is classified as Hospice in the facility If the recipient is classified as Hospice upon admission Form 3618 should not be submitted Hospice providers should only submit Forms 3071 3074 If the recipient is Medicare for a non related condition and classified as SNF Skilled Nursing Facility by the Hospice provider Form 3619 is appropriate Nursing Facilities should inactivate any Forms 3618 3619 rejected to the Provider Action Required workflow submitted by facilities in error for full Hospice recipients Repercussions of Submitting Form 3618 Late e Payment to the facility will be delayed e Personal needs allowance for Supplemental Security Income SSI recipients will be delayed e Can delay the Medicaid Eligibility certification for a recipient applying for Medicaid e Failure to submit Form 3618 can restrict the recipient to only having a reduced number of prescriptions e The facility may be subject to sanctions such as vendor hold as a result of contractual noncompliance How to Submit Form 3618 Instructions for completing Form 3618 can be found in Module 3 Form 3618 in the Long Term Care LTC Nursing Facility Hospice CBT found at the following link http learn
367. r Epilepsy 15499 Type of Seizure Check all that apply LJ A Localized partial or focal B Generalized absence myclonic clonic tonic and atonic 15499C Average Frequency of Seizures in the last 7 days No seizures Enter Code 1 Less than 1 seizure week _ 1 6 seizures week 1seizure day 2 5 seizures day 6 12 seizures day More than 12 seizures day 15500 Traumatic Brain Injury TBI 15599 Spina Bifida MN and LOC 3 0 V 15 14 of 32 Individual Identifier Date Section l Active Diagnoses Active Diagnoses in the last 7 days Check all that apply 15600 Malnutrition protein or calorie or at risk for malnutrition n 15699 At risk for dehydration PsyhiticMoodDisoder Anxiety Disorder Depression other than bipolar Manic Depression bipolar disease Psychotic Disorder other than schizophrenia Schizophrenia e g schizoaffective and schizophreniform disorders Post Traumatic Stress Disorder PTSD ADHD Syndrome LI Pulmonary S 16200 Asthma Chronic Obstructive Pulmonary Disease COPD or Chronic Lung Disease e g chronic bronchitis and restrictive lung diseases such as asbestosis 16299 Cystic Fibrosis 16300 Respiratory Failure Msn LL T 16500 Cataracts Glaucoma or Macular Degeneration Ch 17900 None of the above active diagnoses within the last 7 days 18000 Additional
368. r Number of Minutes 3 Group minutes record the total number of minutes this therapy was administered to the resident as part of a group of residents in the last 7 days If the sum of individual concurrent and group minutes is zero skip to O0400B5 Therapy start date Enter Number of Minutes 3A Co treatment minutes record the total number of minutes this therapy was administered to the resident in co treatment sessions in the last 7 days Enter Number of Days R 4 Days record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days 5 Therapy start date record the date the most recent 6 Therapy end date record the date the most recent therapy regimen since the most recent entry started therapy regimen since the most recent entry ended enter dashes if therapy is ongoing Month O0400 continued on next page MDS 3 0 Nursing Home Comprehensive NC Version 1 11 2 Effective 10 01 2013 Page 30 of 41 Resident Identifier Date SectionO Special Treatments Procedures and Programs 00400 Therapies Continued C Physical Therapy Enter Number of Minutes 1 Individual minutes record the total number of minutes this therapy was administered to the resident individually in the last 7 days Enter Number of Minutes 2 Concurrent minutes record the total number of minutes this therapy was administered to the resident concurrently with one other resident in the
369. r to a NF admission PASRR Evaluation The PASRR Evaluation is an in depth evaluation to determine if an individual has a PASRR eligible diagnosis of mental illness intellectual disability or developmental disability has an interest in alternate placement meets the NF level of care and whether or not the individual would benefit from specialized services The PASRR Evaluation must be completed and submitted in the Long Term Care Portal before a NF can certify whether or not the individual can be served in their facility e Long Term Care Community Services Waiver Programs Workshop User Guide The Long Term Care LTC Community Services Waiver Programs Workshop User Guide provides step by step instructions for how to use the various features of the portal information regarding the purpose of the Medical Necessity and Level of Care MN LOC Assessment how to submit the MN LOC Assessment and managing assessments set to status Provider Action Required Yellow Form Actions Bar Options found in the yellow Form Actions bar may include Print Use as template Correct this form Update Form Add Note and Inactivate Form Options will vary depending on your security the type of document e g PL1 PE MDS assessment or Form 3618 3619 3071 or 3074 as well as document status The yellow Form Actions bar is available when an individual document is being viewed in detail Form Actions Use as template Update Form Add
370. rds up to two more times C0300 Temporal Orientation orientation to year month and day Ask resident Please tell me what year it is right now Enter Code A Able to report correct year 0 Missed by gt 5 years or no answer 1 Missed by 2 5 years 2 Missed by 1 year 3 Correct Ask resident What month are we in right now EnterCode B Able to report correct month Enter Code 0 Missed by 1 month or no answer 1 Missed by 6 days to 1 month 2 Accurate within 5 days Ask resident What day of the week is today EnterCode C Able to report correct day of the week 0 Incorrect or no answer 1 Correct C0400 Recall Ask resident Let s go back to an earlier question What were those three words that asked you to repeat If unable to remember a word give cue something to wear a color a piece of furniture for that word A Able to recall sock 0 No could not recall 1 Yes after cueing something to wear 2 Yes no cue required Enter Code B Able to recall blue 0 No could not recall 1 Yes after cueing a color 2 Yes no cue required Enter Code C Able to recall bed 0 No could not recall 1 Yes after cueing a piece of furniture 2 Yes no cue required C0500 Summary Score LII Add scores for questions C0200 C0400 and fill in total score 00 15 Enerscos Enter 99 if the resident was unable to complete the interview Enter Code MDS 3 0 Nursing Home Quarterly NO Version 1
371. rint but not regular print in newspapers books Moderately impaired limited vision not able to see newspaper headlines but can identify objects Highly impaired object identification in question but eyes appear to follow objects Severely impaired no vision or sees only light colors or shapes eyes do not appear to follow objects Enter Code Enter Code B1200 Corrective Lenses Enter Code Corrective lenses contacts glasses or magnifying glass used in completing B1000 Vision 0 No 1 Yes MDS 3 0 Nursing Home Quarterly NO Version 1 11 2 Effective 10 01 2013 Page 6 of 35 Resident Identifier Date Section C Cognitive Patterns C0100 Should Brief Interview for Mental Status C0200 C0500 be Conducted Attempt to conduct interview with all residents 0 No resident is rarely never understood Skip to and complete C0700 C1000 Staff Assessment for Mental Status 1 Yes Continue to C0200 Repetition of Three Words Brief Interview for Mental Status BIMS C0200 Repetition of Three Words Ask resident am going to say three words for you to remember Please repeat the words after I have said all three The words are sock blue and bed Now tell me the three words Number of words repeated after first attempt 0 None 1 One 2 Two 3 Three After the resident s first attempt repeat the words using cues sock something to wear blue a color bed a piece of furniture You may repeat the wo
372. rior provider and request that they submit the missing discharge 9 Find Provider Action Required status on the far left It should be the last line in the History trail 10 Find the rejection message in the white line just below the Provider Action Required 96 v 2013 1127 LTC Nursing Facility Hospice User Guide 11 12 Perform the necessary research to resolve the error See the provider workflow rejection messages in the Provider Workflow Rejection Messages section of this User Guide for more information Depending on the provider research providers have one of three options to move the form or assessment out of the provider workflow There are situations where the Provider Action is to contact DADS Provider Claims Services TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR Home Submit Form Form Status Inquiry Current Activity Drafts Vendors Printable Forms Alerts Help UnLock Form 3618 RESIDENT TRANSACTION NOTICE Current Status Provider Action Required Name 2A w Form Actions Print Use as template n a Provider Information Resubmit Form L LLEEEEEeEE Vendor Number Contract Number NPI Number Recipient Information 1 Medicaid Recipient No 4 e Recipient s Last 5 Address Address 2 Social Security No Name i RENE City 3 Medicare or RR Realin REIS State Retireme
373. rn Anticipated was selected Complete MDS 3 0 A0310A 04 Significant Submit next MDS as change in status scheduled assessment An MDS is not required until the current assessment expires v 2013 1127 85 LTC Nursing Facility Hospice User Guide MDS Purpose Code E Missed Assessment Purpose Code E should be used for a missed assessment According to 40 Texas Administrative Code TAC 19 2413 3 Missed MDS assessment An MDS assessment that is received by the state Medicaid claims administrator outside the time period that the MDS assessment covers g Missed MDS assessments When the state Medicaid claims administrator receives a missed MDS assess ment DADS pays the Nursing Facility a default RUG rate for the entire period of the missed MDS assessment if the recipient meets financial eligibility for Medicaid except as provided in paragraph 2 of this TAC subsection Note An On Time MDS assessment is an MDS assessment that is submitted in accordance with the federal MDS submis sion schedule and the state Medicaid claims administrator within 31 days of the completion date A Late MDS assessment is an assessment with a Z0500B MDS 3 0 date after the 31 day submission period but within the 92 days the assess ment represents If a new resident is admitted to the facility and the Admission assessment is submitted more than 91 days after Z0500B MDS 3 0 of that Admission assessment the Admission assessment will ha
374. rsing Home Comprehensive NC Version 1 11 2 Effective 10 01 2013 Page 33 of 41 Resident Identifier Date SectionQ Participation in Assessment and Goal Setting Q0490 Resident s Preference to Avoid Being Asked Question Q0500B Complete only if A0310A 02 06 or 99 EnterCode Does the resident s clinical record document a request that this question be asked only on comprehensive assessments 0 No 1 Yes Skip to Q0600 Referral 8 Information not available Q0500 Return to Community Enter Code B Ask the resident or family or significant other or guardian or legally authorized representative if resident is unable to understand or respond Do you want to talk to someone about the possibility of leaving this facility and returning to live and receive services in the community 0 No 1 Yes 9 Unknown or uncertain Q0550 Resident s Preference to Avoid Being Asked Question Q0500B Again Enter Code A Does the resident or family or significant other or guardian or legally authorized representative if resident is unable to understand or respond want to be asked about returning to the community on all assessments Rather than only on comprehensive assessments 0 No then document in resident s clinical record and ask again only on the next comprehensive assessment 1 Yes 8 Information not available Enter Code B Indicate information source for Q0550A 1 Resident 2 If not resident then family or significant
375. s Entel ays Record the number of days that injections of any type were received during the last 7 days or since admission entry or reentry if less than 7 days If 0 Skip to N0410 Medications Received Enkar Des Insulin injections Record the number of days that insulin injections were received during the last 7 days or since admission entry or reentry if less than 7 days Enter Days B Orders for insulin Record the number of days the physician or authorized assistant or practitioner changed the resident s insulin orders during the last 7 days or since admission entry or reentry if less than 7 days N0410 Medications Received Indicate the number of DAYS the resident received the following medications during the last 7 days or since admission entry or reentry if less than 7 days Enter 0 if medication was not received by the resident during the last 7 days Enter Days A Antipsychotic L BL Enter Days B Antianxiety C Antidepressant E Anticoagulant warfarin heparin or low molecular weight heparin F Antibiotic LI MDS 3 0 Nursing Home Quarterly NQ Version 1 11 2 Effective 10 01 2013 Page 24 of 35 Resident Identifier Date SectionO Special Treatments Procedures and Programs 00100 Special Treatments Procedures and Programs Check all of the following treatments procedures and programs that were performed during the last 14 days 1 While NOT a Resident Performed while NOT a resident of this
376. s choose NF Waiver Programs Option 4 If you are attempting to become a Texas Medicaid or CSHCN Services Program provider and currently do not have a TPI NPI choose Provider Enrollment Provider Type NF Waiver Programs Provide ai of the following information Provider Number Format 123456789 More Info Formerly known as Contract Number Format 0123456741 More Info Vendor Number Vendor Password More Info Formerly known as MicroECS password Option 2 If you are a provider enrolled by DADS and would like to view R amp S reports and submit Log OFF v 2013 1127 LTC Nursing Facility Hospice User Guide 10 Click the Next button 11 Check the I agree to these terms box at the bottom of the screen to indicate agreement Home TMHP com My Account TMHP Welcome erick_ext15 Log Off a f rme The provider security information has been verified Enter the provider account information Account Activation User Name 6 20 characters no spaces or special characte Must be a different than your EDI Submitter ID haracters e First Name no special Last Name Business telephone Email TMHP is currently experiencing problems sending Account Activation confirmation emails to MSN and Hotmail accounts In order to receive your Account on confirmation email which includes your User Name and P
377. s Hospice and every six months recertification there after Physician certification statements are valid for six months and must be renewed with a new certification statement A Hospice recipients terminal condition can be verified within two days of the Hospice election date as evidenced by verbal verification by the Hospice staff The physician is allowed to sign and date the certification recertification within the six month terminal illness time frame the physician is certifying if a verbal verification is obtained If no verbal verification is obtained the physicians signature must be obtained within two days of the election Note Recertification forms must be signed no earlier than 30 calendar days before the recertification date or anytime during the six month recertification period e Ifa person is discharged off of Hospice for any reason and the person re elects Hospice regardless of the amount of time a new election and new Physician Certification Form must be completed Note All eligibility forms must be successfully submitted prior to receipt of payment e Ifthe initial certification statement is signed by the physician after the six month time frame the effective date will be the date the document was signed by the physician Medicaid payment will not be made prior to that date e The two day verbal verification period does not apply to recertification The recertification statements must be signed and dated by the physician pr
378. s administrator for user access An administrator account is required for LTC Online Portal access but it is strongly recommended to have multiple administrator accounts in case one administrator is unavailable The administrator account is the primary user account for a provider contract number The administrator account provides the ability to add remove permissions access to LTC Online Portal features for other user accounts on the same provider contract number A user account can be created by an administrator User account permissions and limitations are set by the holder of an administrator account This allows administrators to set the level of access according to employees responsibilities If you already have either an administrator or user account go to www tmhp com Pages LTC ltc home aspx Click the Log In to LTC Online Portal button v 2013 1127 LTC Nursing Facility Hospice User Guide Third party vendors are allowed to submit the LTCMI section of an MDS assessment directly on the LTC Online Portal on behalf of a provider Providers using a third party software vendor are still required to obtain LTC Online Portal access for rights to submit the LTCMI section of the assessment For questions related to this functionality providers are directed to contact their third party software vendors If you do not have an account you can create one by following the steps below In order to do so you will need to
379. s already estab lished in your facility you may monitor the MESAV for updated Applied Income If the MESAV does show an Applied Income for the dates of the form or assessment resubmit the rejected form or assessment There is no gap in Level records for the resident during the Purpose Code timeframe Pull a MESAV for the Purpose Code timeframe requested on this assessment and determine if the dates are reflected in the Level section of the resident s MESAV Validate whether a gap in coverage exists If there is a Level record with valid continuous coverage on file a Purpose Code is not needed Inactivate the assessment on the federal CMS database If the expected gap is not reflected on the Level record contact DADS Provider Claims Services at 512 438 2200 Option 1 for assistance If the Purpose Code dates are wrong modify the Purpose Code dates on the LTCMI and resubmit the rejected assessment There is no 3 month prior Nursing Facility or prior month SSI eligibility for the resident during the Purpose Code timeframe One of these two specific flavors of eligibility is required to process an assessment with Purpose Code M Pull a MESAV for the Purpose Code timeframe requested on this assessment and determine if a Level record is needed for the dates requested on the LTCMI If a Level record is needed continue with the steps below If not inactivate the MDS Determine if the MESAV reflects either Prior Coverage P
380. s due Submit a new 3619 based the cli ent s Medicare remittance Suggested Action For each Medicare Spell of Illness 20 days of Full Medicare coverage are required between one or more providers The recipient has not yet met the 20 day requirement so a Medicare Part A Coinsurance Service Authorization was not created Review the recipient s Medicare remittance to determine the Full Medicare Qualifying Stay dates for this Spell of Illness Check the Dates of Qualifying Stay on the form The dates entered must add up to the 20 day requirement or an additional form must document the remainder of the 20 days of Qualifying Stay Some Full Medicare dates may have already been recorded from previous 3619 admissions If the Dates of Qualifying Stay on the form are wrong correct the admission and resubmit If the Dates of Qualifying Stay on the form are correct submit another form to document the remaining days of Qualifying Stay once that information becomes available To determine if the Qualifying Stay dates from the Medicare remittance advice are on file contact DADS Provider Claims Services at 512 438 2200 Option 1 for assistance If a different 3619 admission was submitted with incorrect Dates of Qualifying Stay submit a correction for that form prior to resubmitting this rejected admission If this form cannot be corrected inactivate the form Note f this is not traditional Medicare document this in the comment section an
381. s gov NursingHomeQualityInits 25 NHQIMDS30 asp v 2013 1127 135 LTC Nursing Facility Hospice User Guide New Assessment Modifications will be considered incomplete until a new LTCMI is successfully submitted TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR Home Submit Form Form Status Inquit Current Activity Drafts Vendors Printable Forms Alerts Help amp MINIMUM DATA SET MDS VERSION 3 0 RESIDENT ASSESSMENT AND CARE SCREENING Nursing Home Comprehensive NC Item Set Current Status Awaiting LTC Medicaid Information Name wee DLN RUG RAA Save LTCMI Section A _ Se Section C Section D Section E Section F Section G Section H Section I I Section J Section K Section L Section M Section N Section O Section P s n ection Q Section V Section Z Section LTCMI Section X Correction Request In this X0150 Pme of Provider Ty Parent Assessment 4 E TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP A STATE MEDICAID CONTRACTOR Home Submit Form Form Status Inquiry Current Activity Drafts Vendors Printable Forms Alerts Help E MINIMUM DATA SET MDS VERSION 3 0 RESIDENT ASSESSMENT AND CARE SCREENING Nursing Home Comprehensive NC Item Set Current Status Corrected Jame AEP Tao eM DLN eee RUG RAA Print ENT I Section B Section C Section D Section E Section F S
382. s of Qualifying Stay and submit corrections as needed Verify the begin date of Medicare Part A Coinsurance and submit a correction as needed If the dates are correct and the Medicare remittance advice validates that Coinsurance is due for the time period that your 3619s indicate fax the remittance advice with a copy of the 3619s to 512 438 3400 attention ECF Form Processing or call 512 438 3400 Option 3 f the Medicare remittance Advice does not correspond to the 3619s submitted the forms will not be processed The additional days of Medicare Part A Coinsurance on this correc tion would create an overlap with Full Medicare dates already on the recipient s file if this correction is processed as submitted Review the Medicare Remittances for this Spell of Illness to determine the Full Medicare and Coinsurance dates Pull a MESAV and compare the Service Authorizations on file and the additional Coinsurance to the remittance dates The system has determined that the additional Coinsurance dates would create an overlap with existing Service Authorizations Also consider the Qualifying Stays reported on the processed 3619s These dates create Full Medicare periods which do not appear on the MESAV Submit any additional 3619 corrections to adjust begin or end dates to allow this discharge correction to process The effective date of this form is outside the provider s contract dates Note The effective date of a discharge is the Dat
383. s of whether the resident is private pay Medicare or Medicaid the provider should complete an Admission assessment for a first physical Omnibus Budget Reconciliation Act OBRA admission within 14 calendar days of admission to v 2013 1127 61 LTC Nursing Facility Hospice User Guide the NE For Texas Medicaid if a resident is active in a NF and discharges to another NF for even one day then returns to the original Nursing Facility the readmission to the original NF is considered a first physical admis sion As soon as another provider is introduced the prior NF s MDS cycle for the resident is ended and must be restarted if the resident returns to the original NE Discharging to the residents home to Hospice or to the hospital is not discharging to another NF 2 If the resident discharges from a NF and the Form 3618 discharge type indicates Return Not Anticipated a new Admission assessment is required if the resident readmits to the NF Remember that the Form 3618 is expected to match the MDS discharge tracking form also submitted for this resident The MDS discharge tracking form would indicate Discharge Return Not Anticipated Although CMS rules allow the use of the Reason for Assess ment on the discharge tracking form for any resident whose first physical admission to the NF is less than 14 days a provider should NOT use this reason for assessment if the residents stay is being paid for by Texas Medicaid This is because if the
384. s said 0 Behavior not present 1 Behavior continuously present does not fluctuate C Altered level of consciousness Did the resident have altered level of consciousness e g vigilant 2 Behavior present startled easily to any sound or touch lethargic repeatedly dozed off when being asked questions but fluctuates comes and responded to voice or touch stuporous very difficult to arouse and keep aroused for the interview goes changes in severity comatose could not be aroused Disorganized thinking Was the resident s thinking disorganized or incoherent rambling or irrelevant conversation unclear or illogical flow of ideas or unpredictable switching from subject to subject D Psychomotor retardation Did the resident have an unusually decreased level of activity such as sluggishness staring into space staying in one position moving very slowly C1600 Acute Onset Mental Status Change Enter Code Is there evidence of an acute change in mental status from the resident s baseline 0 No 1 Yes Copyright 1990 Annals of Internal Medicine All rights reserved Adapted with permission MDS 3 0 Nursing Home Comprehensive NC Version 1 11 2 Effective 10 01 2013 Page 8 of 41 Resident Identifier Date D0100 Should Resident Mood Interview be Conducted Attempt to conduct interview with all residents Enten ode 0 No resident is rarely never understood gt Skip to and complete D0500 D0600 St
385. scale Enter two digit response Enter 99 if unable to answer Verbal Descriptor Scale Ask resident Please rate the intensity of your worst pain over the last 5 days Show resident verbal scale Mild Moderate Severe Very severe horrible Unable to answer Enter Rating Enter Code MDS 3 0 Nursing Home Quarterly NO Version 1 11 2 Effective 10 01 2013 Page 17 of 35 Resident Identifier Date Section Health Conditions J0700 Should the Staff Assessment for Pain be Conducted Enter Code No J0400 1 thru 4 gt Skip to J1100 Shortness of Breath dyspnea LI 1 Yes J0400 9 Continue to J0800 Indicators of Pain or Possible Pain Staff Assessment for Pain J0800 Indicators of Pain or Possible Pain in the last 5 days J Check all that apply A Non verbal sounds e g crying whining gasping moaning or groaning B Vocal complaints of pain e g that hurts ouch stop C Facial expressions e g grimaces winces wrinkled forehead furrowed brow clenched teeth or jaw E D Protective body movements or postures e g bracing guarding rubbing or massaging a body part area clutching or holding a L body part during movement Z None of these signs observed or documented If checked skip to J1100 Shortness of Breath dyspnea J0850 Frequency of Indicator of Pain or Possible Pain in the last 5 days Frequency with which resident complains or shows evidence of
386. sed by DADS Please allow 2 4 business days for the next status change Processed Complete 6 2 2010 10 00 02 AM 6 2 2010 10 00 02 AM The example below shows status JD Invalid indicating that the assessment failed Medicaid ID validtion ID Invalid 6 1 2010 12 55 02 PM TMHP Applied Income confirmed 6 2 2010 9 58 39 AM TMHP SAS Change Request successful 6 1 2010 12 55 02 PM TMHP Medicaid ID is not valid v 2013 1127 93 LTC Nursing Facility Hospice User Guide Provider Workflow Process Provider workflow allows providers to independently manage their forms and assessments when errors in the system s processing occur The system sends the form and assessment information to DADS and updates the MESAV The functionality of provider workflow allows providers to directly manage their rejections which occurred during the nightly processing The benefit to this process is shorter time in resolution In summary forms and assessments are sent to the provider workflow if they are set to status Provider Action Required Forms and assessments reach this status if e The form or assessment has not been successfully processed e An error occurred during the nightly batch processing Note Rejection error message can be found within the form and assessment History trail Ownership for resolution belongs to the provider The provider workflow is the responsibility of the provider to monitor and manage Forms and ass
387. sed nurses in an institutional setting to carry out the physicians planned regimen for total care A recipient s need for custodial care in a 24 hour institutional setting does not constitute a medical need A group of health care professionals employed or contracted by the Medicaid claims administrator contracted with HHSC makes individual determinations of medical necessity regarding nursing facility care These health care professionals consist of physicians and registered nurses 40 TAC 19 2403 e states A recipient may establish permanent medical necessity status after completion date of any MDS assessment is approved for medical necessity no less than 184 calendar days after the recipients admission to the Texas Medicaid Nursing Facility Program v 2013 1127 43 LTC Nursing Facility Hospice User Guide General Qualifications for Medical Necessity Determinations 40 TAC 19 2401 states Medical necessity is the prerequisite for participation in the Medicaid Title XIX Long term Care program This section contains the general qualifications for a medical necessity determination To verify that medical necessity exists an individual must meet the conditions described in paragraphs 1 and 2 of this section 1 The individual must demonstrate a medical condition that A is of sufficient seriousness that the individual s needs exceed the routine care which may be given by an untrained person and B requires license
388. sident Identifier Date SectionX Correction Request X1100 RN Assessment Coordinator Attestation of Completion A Attesting individual s first name TTP TTT ETT tty B Attesting individual s last name LL IIIDIILILLLLILLLILI C Attesting individual s title E Attestation date LL LT JLT I Month Day MDS 3 0 Nursing Home Quarterly NQ Version 1 11 2 Effective 10 01 2013 Page 33 of 35 Resident Identifier Date SectionZ Assessment Administration Z0100 Medicare Part A Billing A Medicare Part A HIPPS code RUG group followed by assessment type indicator TT tT TI B RUG version code LIT LT T T4 1j EnterCode C Is this a Medicare Short Stay assessment 0 No 1 Yes Z0150 Medicare Part A Non Therapy Billing A Medicare Part A non therapy HIPPS code RUG group followed by assessment type indicator B RUG version code TT TET TI Z0200 State Medicaid Billing if required by the state A RUG Case Mix group TT TTT ty B RUG version code ITIITI Z0250 Alternate State Medicaid Billing if required by the state A RUG Case Mix group TTT TTT tty B RUG version code TT EET Z0300 Insurance Billing A RUG billing code TTT TTT tty B RUG billing version TT ETT Ty MDS 3 0 Nursing Home Quarterly NQ Version 1 11 2 Effective 10 01 2013 Page 34 of 35 Resident Identifier Date SectionZ Assessment Administration Z0400 Signature o
389. sing Facility Hospice User Guide UOYNq WO ayeANIeay 24 uo Bu Aq JUauussasse a eAI Dea1 ue JN SUJUOW 9 Jae peus JW S 3uepiseJ JI g f S9jeAn2eaH JapiAold ee r 1 V oAn eu xau Iv IV Duipuag Iy buipuad pe y aq 01 spaau p I p4 E qe MMOL 23u awody perjddy uone ijdde mau ou J S9jeA2eay JepiAOJd abe1aA02 JN 12234102 peuuguo JW aaey jou Aew jUapisad dimi a ae a r eee CCC CeCe CCT eee Lo p failiqi6i3 pre ipaw 9AIl2eu 29U AW 4 3 JW bulpuad I E RISE Ree JW UPUA X Mich E j paeuuyuo ql put c m um um um M eas Rae eee ee TM 9An eu 23u I I gt i I pre ipelw QI presipay 4 3 Suipu d AI P e2IP W a Py X aiepljea isanbay V uusvyg o1 Ajddb jou saoq Kypiqibij3 pre ipaw uM juapisay uone yueA LAGI pre ipew 1 Bulpuegq pe ouddy NW pH NW aisse aN e2ipaw JO pamalAay 1uauissessy p eyepijeAsenbay gt peuuguo y Bulpuad 1sanbeg SYS UOMO sjluugns JN OU J 0 1Je15s21 01 dHIALL1201u02 sak J yaeu aweu sej Jo S12319 JNO S44 pue sg e1e ipaw pre ipaW NSS SUJJJUO2 JN PIeAU CI 165 LTC Nursing Facility Hospice User Guide Appendix B Medicaid Eligibility Verification Resident with Pending Medicaid Eligibility 166 LTC Nursing Facility Hospice User Guide uoyNng U0J ayeAIDeaY eu
390. sing Home Quarterly NO Version 1 11 2 Effective 10 01 2013 Page 29 of 35 Resident Identifier Date SectionQ Participation in Assessment and Goal Setting Q0490 Resident s Preference to Avoid Being Asked Question Q0500B Complete only if A0310A 02 06 or 99 Does the resident s clinical record document a request that this question be asked only on comprehensive assessments 0 No 1 Yes Skip to Q0600 Referral 8 Information not available Enter Code Q0500 Return to Community Enter Code B Ask the resident or family or significant other or guardian or legally authorized representative if resident is unable to understand or respond Do you want to talk to someone about the possibility of leaving this facility and returning to live and receive services in the community 0 No 1 Yes 9 Unknown or uncertain Q0550 Resident s Preference to Avoid Being Asked Question Q0500B Again Enter Code A Does the resident or family or significant other or guardian or legally authorized representative if resident is unable to understand or respond want to be asked about returning to the community on all assessments Rather than only on comprehensive assessments 0 No then document in resident s clinical record and ask again only on the next comprehensive assessment 1 Yes 8 Information not available Enter Code B Indicate information source for Q0550A 1 Resident 2 If not resident then family or significant o
391. sion 1 11 2 Effective 10 01 2013 Page 16 of 41 Resident Identifier Date SectionH Bladder and Bowel H0100 Appliances i Check all that apply A Indwelling catheter including suprapubic catheter and nephrostomy tube B External catheter C Ostomy including urostomy ileostomy and colostomy D Intermittent catheterization Z None of the above H0200 Urinary Toileting Program Has atrial of a toileting program e g scheduled toileting prompted voiding or bladder training been attempted on admission entry or reentry or since urinary incontinence was noted in this facility 0 No Skip to H0300 Urinary Continence 1 Yes Continue to H0200B Response 9 Unable to determine Skip to HO200C Current toileting program or trial Response What was the resident s response to the trial program 0 Noimprovement 1 Decreased wetness 2 Completely dry continent 9 Unable to determine or trial in progress Current toileting program or trial Is a toileting program e g scheduled toileting prompted voiding or bladder training currently being used to manage the resident s urinary continence 0 No 1 Yes H0300 Urinary Continence Enter Code Urinary continence Select the one category that best describes the resident 0 Always continent L 1 Occasionally incontinent less than 7 episodes of incontinence 2 Frequently incontinent 7 or more episodes of
392. sk of Pressure Ulcers Enter Code E Is this individual at risk of developing pressure ulcers 0 1 No Yes M0210 Unhealed Pressure Ulcer s Enter Code Ll Does this individual have one or more unhealed pressure ulcer s at Stage 1 or higher 0 No gt skip to M1030 Number of Venous and Arterial Ulcers 1 Yes Continue to M0300 Current Number of Unhealed Pressure Ulcers at Each Stage M0300 Current Number of Unhealed Pressure Ulcers at Each Stage Enter Number E Enter Number L Enter Number L Enter Number L Enter Number L Enter Number L Enter Number L MN and LOC 3 0 V 15 A Number of Stage 1 pressure ulcers Stage 1 Intact skin with non blanchable redness of a localized area usually over a bony prominence Darkly pigmented skin may not have a visible blanching in dark skin tones only it may appear with persistent blue or purple hues B Stage 2 Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed without slough May also present as an intact or open ruptured blister 1 Number of Stage 2 pressure ulcers If0 Skip to MO300C Stage 3 3 Date of oldest Stage 2 pressure ulcer Enter dashes if date is unknown Month Day Year C Stage 3 Full thickness tissue loss Subcutaneous fat may be visible but bone tendon or muscle is not exposed Slough may be present but does not obscure the depth of tissue loss
393. sment is the appropriate reason for assessment If the Entry Date is two years prior to the completion date this assessment probably should not be an Admission assessment If the Admission assessment is needed because the resident had a Form 3618 discharge indicating Return Not Anticipated the Entry Date should be the new readmission date not an admission prior to the discharge If the provider already submitted the assessment with the Entry Date prior to the discharge date a modification must be transmitted to the state MDS database to adjust the Entry Date to the readmission date following the discharge Swing bed providers are required to submit MDS 3 0 assessments A0200 Type of Provider coded as 2 Swing Bed MDS 3 0 assessments for swing bed providers include assessments listed in items A0310B A0310C A0310D and A0310E These assessments are submitted to CMS however they are not retrieved by TMHP Swing bed provid ers must complete the appropriate MDS 3 0 OBRA required Comprehensive or Quarterly assessments listed in item A0310A in accordance with the MDS 3 0 RAI Users Manual if services provided are eligible for Medicaid reim bursement OBRA required assessments listed in A0310A that meet TMHP guidelines are retrieved by TMHP and the associated LTCMI will have field S1c Service Group auto populated to equal ten 10 based on the vendor contract number provided upon log in MDS Discharge Tracking and Re Entry Tracking forms 3 0
394. sment will not be considered successfully submit ted until all errors are resolved S4c RN Coordinator License State Required Choose the license state in which the RN Coordinator is licensed from the drop down box S5 Primary Diagnosis S5a Primary Diagnosis ICD 9 Code Required Enter a valid ICD 9 code for the recipient s primary diagnosis Use your best clinical judgment S5b Primary Diagnosis ICD Description Optional Click the magnifying glass and the description will be auto populated based on the primary diagnosis ICD Code S6 Additional MN Information S6a Tracheostomy Care Conditional Choose from the drop down box 1 Less than once a week 2 1to6times a week 3 Once a day 4 Twice a day 5 3 11 times a day 6 Every 2 hours 7 24 hour continuous gt This field is only required and available for data entry if O0100E Tracheostomy care column 2 While a Resident is checked AND the resident is 21 years of age or younger ENTRY TIP This field will be disabled if field O0100E2 Tracheostomy Care is not checked on the MDS The Provider must submit an MDS Modification if field O0100E2 is not checked and S6a is to be claimed for the add on rate 74 v 2013 1127 LTC Nursing Facility Hospice User Guide LTCMI Fields S6b Ventilator Respirator Conditional Choose from the drop down box 1 Less than once a week 2 1 to 6 times a week 3 Once a day 4 Tw
395. spital Discharge criteria then the RE follows the Preadmission or Expedited Admission process described in a subsequent diagrams 3 If the individual does meet Exempted Hospital Discharge criteria then a The RE sends the PL1 to the admitting NF with the individual b The NF submits the PL1 on the Portal immediately on receipt If the individual is discharged from the NF prior to 30 days from the admission date the NF indicates the discharge on the PL1 a Ifthe individual is still in residence at the NF after 30 days from the admission date then the Portal alerts the Local Authority to perform a PE b The Local Authority performs the PE within 72 hours of notification 5 he Local Authority submits the PE on the LTC Online Portal within seven calendar days of notification by the Nursing Facility 6 The NF reviews the PE including recommended specialized services and certifies if they are able or unable to serve the individual If the NF is unable to serve the individual the LA coordinates placement into another NF or an alternate setting 36 v 2013 1127 LTC Nursing Facility Hospice User Guide Expedited Admission Process Does individual fit into a Category for Expedited Admission RE performs PLI gt RE sends PL1 to NF with individual on receipt NF submits PL1 on Portal immediately No Y RE follows Preadmission or Exempted Hospital Disc
396. ssant E Anticoagulant warfarin heparin or low molecular weight heparin F Antibiotic LI MDS 3 0 Nursing Home Comprehensive NC Version 1 11 2 Effective 10 01 2013 Page 28 of 41 Resident Identifier Date SectionO Special Treatments Procedures and Programs 00100 Special Treatments Procedures and Programs Check all of the following treatments procedures and programs that were performed during the last 14 days 1 While NOT a Resident Performed while NOT a resident of this facility and within the last 14 days Only check column 1 if 1 2 resident entered admission or reentry IN THE LAST 14 DAYS If resident last entered 14 or more days While NOT a While a ago leave column 1 blank Resident Resident 2 While a Resident Performed while a resident of this facility and within the last 14 days J Check all that apply J Cancer Treatments A Chemotherapy LIL B8 a E a E HEE HN B Radiation Respiratory Treatments C Oxygen therapy D Suctioning E Tracheostomy care F Ventilator or respirator G BiPAP CPAP E E NN H IV medications l Transfusions J Dialysis K Hospice care L Respite care M Isolation or quarantine for active infectious disease does not include standard body fluid precautions None of the Above es 86 a es INE ER e a Z None of the above 00250 Influenza Vaccine Refer to current version of RAI manual for current flu season and repor
397. ssibility of individual self harm Was responsible caregiver provider or appropriate entity informed that there is a potential for individual self harm 0 No 1 Yes Copyright Pfizer Inc All rights reserved Reproduced with permission MN and LOC 3 0 V 15 6 of 32 Individual Identifier Date SectionD MYY D0500 Caregiver Assessment of Individual Mood PHQ 9 OV Do not conduct if Individual Mood Interview D0200 D0300 was completed Over the last 2 weeks did the individual have any of the following problems or behaviors If symptom is present enter 1 yes in column 1 Symptom Presence Then move to column 2 Symptom Frequency and indicate symptom frequency 1 Symptom Presence 2 Symptom Frequency 1 2 0 No enter 0 in column 2 0 Never or 1 day Symptom Symptom 1 Yes enter 0 3 in column 2 2 6 days several days Presence Frequency 7 11 days half or more of the days 12 14 days nearly every day Enter Scores in Boxes Little interest or pleasure in doing things Feeling or appearing down depressed or hopeless Trouble falling or staying asleep or sleeping too much Feeling tired or having little energy Poor appetite or overeating Indicating that s he feels bad about self is a failure or has let self or family down Trouble concentrating on things such as reading the newspaper or watching television Moving or speaking so slowly that ot
398. ssment A0700 Screener 9 A First Name B Middle Initial 9 C Last Name D Suffix A0800 Position Title A0900 Type of Entity 9 A Type of Entity B Other Type of Entity vv C Physician First Name D Physician Middle Initial E Physician Last Name F Physician Suffix A1000 Current Location A Name B Street Address C City D State E ZIP Code F Phone Number A1100 Date of Last Physical Examination M A1200 9 Signature and accurate o I certify that to the best of my knowledge this information is true A Certification of Signature 172 v 2013 1127 LTC Nursing Facility Hospice User Guide PASRR Level 1 Screening Section B Fa TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR Home Submit Form Form Status Inquiry Current Activity Drafts Vendors Letters Printable Forms Alerts Help PASRR LEVEL 1 SCREENING Section A Section B Section C Section D Section F Personal Information B0100 Individua
399. ssment contact the HHSC Eligibility Worker or Supplemental Security Income SSI office to update the Financial Eligibility records Once the Financial Eligibility has been updated resubmit the rejected form or assessment If the recipient is already estab lished in your facility you may monitor the MESAV for updated Financial Eligibility If the MESAV does show Financial Eligibility for the dates of the form or assessment resubmit the rejected form or assessment The submitted Primary Diagnosis International Classification of Diseases ICD Code is not valid Modify the Primary Diagnosis Code on the LTCMI section as needed and resubmit the rejected assessment If the Primary Diagnosis Code on the LTCMI section is valid contact DADS Provider Claims Services at 512 438 2200 Option 1 for assistance The provider s contract is either not in effect as of the effective date of the form or assessment or the provider is not authorized to bill for the type of services covered by the form or assessment Review the facility contract to determine if the contract is in effect and authorizes the type of services covered by the form or assessment If the effective date of the form or assessment is wrong modify the form or assessment and resubmit the rejected form or assessment If the contract is not yet in effect resubmit the rejected form or assessment once the service code is effective in the system For 3619 admissions resubm
400. surance is authorized for your facility If so submit a 3619 discharge to close the Coinsurance Review the LTC Online Portal to determine the status of the prior 3618 admission If it is rejected verify if the issue still exists and take the necessary actions to process the admission Once the admission has been processed resubmit the rejected discharge If the rejected discharge is reflected on the recipient s MESAV contact DADS Provider Claims Services at 512 438 2200 Option 1 for assistance This admission and discharge pair is either retroactive to the current authorizations or the recipient is currently authorized at a prior facility Review the facility records to identify the admission prior to this discharge If the pair is retroactive the admission and discharge must be submitted at the same time A gap in the Service Authorizations must exist for this time period to fill If the recipient has been in your facility previously you may be able confirm this gap by pulling a MESAV and verifying dates If the prior admission form was rejected correct that form and resubmit The admission must be processed before the discharge can process If the prior admission form is missing submit that missing form then resubmit the rejected discharge v 2013 1127 105 LTC Nursing Facility Hospice User Guide Form Assessment Provider Message Displayed in History NF 0020 This discharge cannotbe 3618 pr
401. t 7 days Only check column 1 if 1 2 resident entered admission or reentry IN THE LAST 7 DAYS If resident last entered 7 or more days While NOT a While a ago leave column 1 blank Resident Resident 2 While a Resident Performed while a resident of this facility and within the last 7 days J Check all that apply J A Parenteral IV feeding L B Feeding tube nasogastric or abdominal PEG C Mechanically altered diet require change in texture of food or liquids e g pureed food thickened liquids D Therapeutic diet e 9 low salt diabetic low cholesterol Z None of the above MDS 3 0 Nursing Home Comprehensive NC Version 1 11 2 Effective 10 01 2013 Page 23 of 41 Resident Identifier Date SecionK Swallowing Nutritional Status K0710 Percent Intake by Artificial Route Complete K0710 only if Column 1 and or Column 2 are checked for K0510A and or K0510B 1 While NOT a Resident Performed while NOT a resident of this facility and within the last 7 days Only enter a code in column 1 if resident entered admission or reentry IN THE LAST 7 DAYS If resident last entered 7 or more days ago leave column 1 blank 1 2 3 2 While a Resident While NOT a While a During Entire Performed while a resident of this facility and within the last 7 days Resident Resident 7 Days 3 During Entire 7 Days Performed during the entire last 7 days i Enter Codes J A Proportion of total calories the resident receive
402. t at all Important but can t do or no choice Noresponse or non responsive LILILILILICIELIL Indicate primary respondent for Daily and Activity Preferences F0400 and F0500 EnienCods 1 Resident 2 Family or significant other close friend or other representative 9 Interview could not be completed by resident or family significant other No response to 3 or more items MDS 3 0 Nursing Home Comprehensive NC Version 1 11 2 Effective 10 01 2013 Page 13 of 41 Resident Identifier Date SectionF Preferences for Customary Routine and Activities F0700 Should the Staff Assessment of Daily and Activity Preferences be Conducted Enter Code No because Interview for Daily and Activity Preferences F0400 and F0500 was completed by resident or family significant other Skip to and complete GO110 Activities of Daily Living ADL Assistance Yes because 3 or more items in Interview for Daily and Activity Preferences F0400 and F0500 were not completed by resident or family significant other Continue to F0800 Staff Assessment of Daily and Activity Preferences F0800 Staff Assessment of Daily and Activity Preferences Do not conduct if Interview for Daily and Activity Preferences F0400 F0500 was completed Resident Prefers J Check all that apply A Choosing clothes to wear B Caring for personal belongings C Receiving tub bath D Receiving shower E Receiving bed bath F Receiving sponge bath
403. t can be resubmitted If the 3618 discharge is correct there are quite a few 3618 3619s that need to process between the begin and end dates of the Service Authorization Verify all dates and submit the needed forms If the recipient does not have Service Authorizations on the MESAV use the statuses on the LTC Online Portal to determine the forms that have processed Remember authorizations will only display if the MDS has also processed If the most recent processed form is a 3618 admission prior to the rejected 3619 admission a 3618 discharge must be processed prior to resubmitting the rejected 3619 admission If the most recent processed form is a 3618 discharge after the rejected 3619 admission verify that the 3618 discharge was submitted for the correct date If the date is wrong correct the 3618 discharge and resubmit If the 3618 discharge is now prior to the rejected 3619 admission resubmit the rejected 3619 admission For each Medicare Spell of Illness only 20 days of Full Medicare cov erage are allowed between one or more providers The recipient will exceed the 20 day limit if the form is processed as submitted e Review the recipient s Medicare remittance to determine the Full Medicare Qualifying Stay dates for this Spell of Illness Check the Dates of Qualifying Stay on the form The number of days on the form plus any Full Medicare days already documented for that Spell of Illness cannot exceed 20 days I
404. tart date record the date the most recent 6 Therapy end date record the date the most recent therapy regimen since the most recent entry started therapy regimen since the most recent entry ended enter dashes if therapy is ongoing Month O0400 continued on next page MDS 3 0 Nursing Home Quarterly NO Version 1 11 2 Effective 10 01 2013 Page 26 of 35 Resident Identifier Date SectionO Special Treatments Procedures and Programs 00400 Therapies Continued C Physical Therapy Enter Number of Minutes 1 Individual minutes record the total number of minutes this therapy was administered to the resident individually in the last 7 days Enter Number of Minutes 2 Concurrent minutes record the total number of minutes this therapy was administered to the resident concurrently with one other resident in the last 7 days Enter Number of Minutes 3 Group minutes record the total number of minutes this therapy was administered to the resident as part of a group of residents in the last 7 days If the sum of individual concurrent and group minutes is zero skip to O0400C5 Therapy start date Enter Number of Minutes 3A Co treatment minutes record the total number of minutes this therapy was administered to the resident in co treatment sessions in the last 7 days Enter Number of Days x E i 4 Days record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days
405. te K0710 only if K0510A or K0510B is checked Enter A Proportion of total calories the individual received through parenteral or tube feeding during entire 7 days 1 25 or less 2 26 50 3 51 or more B Average fluid intake per day by IV or tube feeding during entire 7 days 1 500 cc day or less 2 501 cc day or more S a 0n ME Oral Dental Status L0200 Dental Check all that apply Broken or loosely fitting full or partial denture chipped cracked uncleanable or loose No natural teeth or tooth fragment s edentulous Abnormal mouth tissue ulcers masses oral lesions including under denture or partial if one is worn Obvious or likely cavity or broken natural teeth Mouth or facial pain discomfort or difficulty with chewing Unable to examine Ly E O L Inflamed or bleeding gums or loose natural teeth CJ i O Li None of the above were present MN and LOC 3 0 V 15 19 of 32 Individual Identifier Date Section M Skin Conditions Report based on highest stage of existing ulcer s at its worst do not reverse stage M0100 Determination of Pressure Ulcer Risk Check all that apply A Individual has a stage 1 or greater a scar over bony prominence or a non removable dressing device B Formal assessment instrument tool e g Braden Norton or other C Clinical assessment Z None of the above M0150 Ri
406. te as well as the Qualifying Stay date ranges and correct them as needed 3619 Admit NF 0073 This discharge modifica tion cannot be processed because the new discharge would create an overlap with an existing Full Medi care period Verify the Full Medicare periods and Service Authorizations already established and submit any additional modifications 3619 Discharge Mod NF 0074 This form cannot be processed because the submitted Contract Number is not valid as of the form effective date Adjust the effective date or resubmit with the correct Contract Number 3618 3619 Suggested Action The recipient has a Service Authorization with a different provider as of the submitted discharge date Review the facility s records to verify that the transaction date on the rejected discharge is correct Determine if the 3618 admission prior to this discharge has been submitted If not submit that 3618 admission If it was rejected resolve the issue and resubmit that 3618 admission Resubmit the rejected 3618 discharge after the missing or corrected admission has been processed The Qualifying Stay dates or transaction date on this admission would cancel the previous provider s Service Authorization rather than auto discharge the recipient from the previous provider Review the facility s records to determine the recipient s admission and discharge dates and identify the Spell of Illness Verify the begin and end date
407. tem Set Current Status Name 1 RUG RAA Parent DLN TE a Form Actions Section A Section B Section C Section D Section E Section F Section G Section H Section I Section J Section K Section L al Section M Section N Section O Section P Section Q Section V Section X Section Z Section LTC Medicaid Information S1 Claims Processing Information Sla DADS Vendor Site ID Number 1 S1b Contract Provider Number Sic e Service Group 1 Nursing Facilit Sid ospice Contract Number Sle Purpose Code v Sif Missed Asse ant or Sig Missed Ass nent o S2 PASARR Information S2a To your knowledge does the resident have an intellectual 0 No vj disability S2b To your knowledge does the resident have a developmental 0 No v disability S2c To your knowledge does the resident have a condition of mental a No dina ta the DAGARR an 5 Click the Submit Form button 6 The original assessment parent is set to status Corrected and the new assessment child DLN is assigned creating a parent child DLN relationship The new child assessment replaces the parent assessment Form Submitted 10 8 2010 10 59 57 AM 10 8 2010 10 59 TMHP This form was submitted as a correction for DLN Mi Note Corrections are processed overnight Providers must wait until the f
408. that the individual received Speech Language Pathology and Audiology Services Occupational Therapy or Physical Therapy for at least 15 minutes in the past 7 days e Modified O0400F1 instructions must read Total minutes record the total number of minutes this therapy was administered to the individual in the last 7 days If zero skip to O0420 Distinct Calendar Days of Therapy For questions about these modifications to the LTC Online Portal contact the LTC Helpdesk at 1 800 626 4117 Option 1 2 v 2013 1002 Resident Identifier Date MINIMUM DATA SET MDS Version 3 0 RESIDENT ASSESSMENT AND CARE SCREENING Nursing Home Comprehensive NC Item Set SectionA Identification Information A0050 Type of Record Enter Code 1 Add new record Continue to A0100 Facility Provider Numbers 2 Modify existing record Continue to A0100 Facility Provider Numbers 3 Inactivate existing record Skip to X0150 Type of Provider A0100 Facility Provider Numbers A National Provider Identifier NPI LI ELE EE B CMS Certification Number CCN C State Provider Number A0200 Type of Provider Enter Code Type of provider 1 Nursing home SNF NF 2 Swing Bed A0310 Type of Assessment mM A Federal OBRA Reason for Assessment 01 Admission assessment required by day 14 LII 02 Quarterly review assessment 03 Annual assessment 04 Significant change in status assessment 05 Signifi
409. the recipient s MESAV contact DADS Provider Claims Services at 512 438 2200 Option 1 for assistance The recipient has a Service Authorization for a different facility pro cessed admission and discharge for a different provider cover the submitted admission date Contact the prior facility to request that a correcting discharge be submitted for their discharge If the other facility s discharge is incorrect allow seven days for processing time and resubmit the rejected admission If the recipient was in the other provider s facility before and after being in your facility the other facility must submit a retroac tive discharge and admission creating a gap during which the recipient was in your facility An admission and discharge pair will also need to process for your facility to fill the gap Two pairs will need to be processed Coordinate with the other facility 106 v 2013 1127 LTC Nursing Facility Hospice User Guide Provider Message Form Displayed in History Assessment NF 0024 This admission cannot 3619 Admit be processed alone because a later admission has already been processed This admission is part of a retroactive pair Identify the discharge following this admission and submit as a pair Suggested Action The recipient has an existing Service Authorization for your facility processed admission and discharge for your facility cover the sub mitted admission date This admission is
410. ther 3 If not resident family or significant other then guardian or legally authorized representative 8 No information source available Q0600 Referral Has a referral been made to the Local Contact Agency Document reasons in resident s clinical record 0 No referral not needed 1 No referral is or may be needed For more information see Appendix C Care Area Assessment Resources 20 2 Yes referral made Enter Code MDS 3 0 Nursing Home Quarterly NO Version 1 11 2 Effective 10 01 2013 Page 30 of 35 Resident Identifier Date SectionX Correction Request Complete Section X only if A0050 2 or 3 Identification of Record to be Modified Inactivated The following items identify the existing assessment record that is in error In this section reproduce the information EXACTLY as it appeared on the existing erroneous record even if the information is incorrect This information is necessary to locate the existing record in the National MDS Database X0150 Type of Provider Enter Code Type of provider 1 Nursing home SNF NF 2 Swing Bed X0200 Name of Resident on existing record to be modified inactivated A First name TT ETT TET tt C Last name X0300 Gender on existing record to be modified inactivated Enter Code 1 Male LI 2 Female X0400 Birth Date on existing record to be modified inactivated LL TE TARNE Month Day Year X0500 Social Security Number on existing record to be mo
411. thorization Verify the Full Medicare periods and Service Authorizations already established and submit any additional modifi cations NF 0078 This admission cannot 3619 Admit be processed because the earli est Qualifying Stay date is too old compared to the transaction date Verify the Qualifying Stay dates and correct them as needed If the Qualifying Stay dates are correct contact Provider Claims Services for assistance Suggested Action This discharge has been submitted using the incorrect Contract Number The facility has had a Change of Ownership and the dis charge needs to be submitted using the Contract Number that was active on the effective date of the discharge Note The effective date of a discharge is the Date of Above Transaction minus one day Exception For a 3618 discharge marked Deceased use Date of Above Transaction instead because DADS pays for the date of death Confirm the transaction date for the rejected form and submit a correction of the date as needed If the date is correct but the form is under the incorrect contract inactivate the form and resubmit with the proper contract If there is not an active contract for the transaction date the submission will have to be held until the contract has been approved The submitted MDS admission Entry Date is earlier than the Service Authorization begin date on the recipient s file e Verify the Entry Date and submit a modification to the fed
412. tient rehabilitation facility ID DD facility Hospice Deceased Long Term Care Hospital LTCH Other MDS 3 0 Nursing Home Quarterly NO Version 1 11 2 Effective 10 01 2013 Page 4 of 35 Resident Identifier Date SectionA Identification Information A2200 Previous Assessment Reference Date for Significant Correction Complete only if A0310A 05 or 06 A2300 Assessment Reference Date Observation end date Month Day Year A2400 Medicare Stay Enter Code A Has the resident had a Medicare covered stay since the most recent entry 0 No gt Skip to B0100 Comatose 1 Yes Continue to A2400B Start date of most recent Medicare stay B Start date of most recent Medicare stay Month Day Year C End date of most recent Medicare stay Enter dashes if stay is ongoing Month Year MDS 3 0 Nursing Home Quarterly NO Version 1 11 2 Effective 10 01 2013 Page 5 of 35 Resident Identifier Date Look back period for all items is 7 days unless another time frame is indicated Hearing Speech and Vision B0100 Comatose Enter Code Persistent vegetative state no discernible consciousness 0 No Continue to B0200 Hearing 1 Yes Skip to G0110 Activities of Daily Living ADL Assistance B0200 Hearing Ability to hear with hearing aid or hearing appliances if normally used 0 Adequate no difficulty in normal conversation social interaction listening to TV 1 Minimal di
413. ting period Enter Code A Did the resident receive the Influenza vaccine in this facility for this year s Influenza season 0 No Skip to 00250C If Influenza vaccine not received state reason 1 Yes Continue to O0250B Date vaccine received B Date vaccine received Complete date and skip to 00300A Is the resident s Pneumococcal vaccination up to date C If Influenza vaccine not received state reason 1 Resident not in facility during this year s flu season Received outside of this facility Noteligible medical contraindication Offered and declined Not offered Inability to obtain vaccine due to a declared shortage None of the above Enter Code 00300 Pneumococcal Vaccine Enter Code A Is the resident s Pneumococcal vaccination up to date 0 No Continue to O0300B If Pneumococcal vaccine not received state reason 1 Yes gt Skip to 00400 Therapies Enter Code B If Pneumococcal vaccine not received state reason 1 Not eligible medical contraindication 2 Offered and declined 3 Not offered MDS 3 0 Nursing Home Comprehensive NC Version 1 11 2 Effective 10 01 2013 Page 29 of 41 Resident Identifier Date SectionO Special Treatments Procedures and Programs 00400 Therapies A Speech Language Pathology and Audiology Services Enter Number of Minutes 1 Individual minutes record the total number of minutes this therapy was administered to the resident individua
414. tion TheLocal Authority responsible for the IDD Section of the PASRR Evaluation should com plete the IDD Section Complete the MI Section on The MI Section of the PASRR Evaluation has not been submitted on the LTC Online Portal the PASRR Evaluation TheLocal Authority responsible for the MI Section of the PASRR Evaluation should com plete the MI Section 168 v 2013 1127 LTC Nursing Facility Hospice User Guide Appendix D LTC Online Portal Review Answer the following questions 1 Name 3 benefits of using the LTC Online Portal 1 2 3 2 In order to access the LTC Online Portal what is the first step that you must take 3 Under what condition would you see the yellow Form Actions bar 4 How can you tell if a field is required v 2013 1127 169 LTC Nursing Facility Hospice User Guide Review Answers 1 Name 3 benefits of using the LTC Online Portal The LTC Online Portal is a web based application that is available 24 hours a day 7 days a week TMHP provides LTC Online Portal technical support by phone 7 00 a m 7 00 p m Central Time Monday through Friday excluding holidays The LTC Online Portal provides error messages that must be resolved before submission Providers have the ability to monitor the status of their forms and assessments and to submit additional information when needed 2 In order to access the LTC Online Portal what is the first step that you must
415. tion to indicating Hospice Care on the assessment the Hospice contract number on the LTCMI will be required to allow the Hospice provider to view assessments submitted with their contract numbers The Hospice contract number entered on the LTCMI will be validated and must contain a valid Hospice provider number to be accepted onto the LTC Online Portal Hospice providers can view on the LTC Online Portal MDS assessments submitted on their behalf based on the Hospice contract number that is indicated in the LTCMI S1d Hospice Contract Number S1d must be completed correctly in order to view those assessments Hospice nurses are not required to sign off on the assessment for the Hospice recipients Providers can print and sign their assessment prior to submitting The assessment should be signed by the MDS RN Assessment Coordinator v 2013 1127 83 LTC Nursing Facility Hospice User Guide Resident Returns Prior Discharge Return Not Anticipated e Refer to Preadmission process for steps associated with PL1 and PE e Submit a 3618 Admission by day three admitting to full Medicaid e Complete an Admission MDS assessment by day 14 e Complete a quarterly assessment within 92 days of the Admission MDS unless a SCSA was completed prior to this Refer to Preadmission process for steps associated with PL1 and PE Form 3618 must be signed and electronically submitted within 72 hours of admission Submit MDS 3 0 A0310A 01 Adm
416. tive date Suggested Action This admission modification is later than the end date of the Service Authorization it is trying to change Review the facility s records to determine the recipient s admission and discharge dates Pull a MESAV and review the Service Authorizations on file If the correction was not done on the right admission adjust the admission date on this correction back to the original admission date and resubmit Then correct the admission date on the appro priate admission form and submit If the end date of the Service Authorization being modified is not correct submit a discharge correction to adjust the end date and resubmit the rejected admission correction the next day If the Service Authorization being changed should be canceled inactivate this correction and submit a correction to the corre sponding discharge making it a counteracting form to the admission form This is a modification of a processed MDS assessment that had a Purpose Code on the LTCMI Once an MDS has been processed as either a PC E or M the form must continue to have a Purpose Code on the LTCMI A modification can change a PC M toa PCE but a PCE cannot be changed to a PC M and a PC E or M cannot be changed to no Purpose Code Review the LTCMI on the prior submission parent form noting the Purpose Code and the dates requested Modify the rejected assessment entering the appropriate Purpose Code and proper dates then resubm
417. to 2 days 2 Indicators of pain or possible pain observed 3 to 4 days 3 Indicators of pain or possible pain observed daily Other Health Conditions J1100 Shortness of Breath dyspnea l Check all that apply A Shortness of breath or trouble breathing with exertion e g walking bathing transferring B Shortness of breath or trouble breathing when sitting at rest C Shortness of breath or trouble breathing when lying flat Z None of the above J1300 Current Tobacco Use Enter Code Tobacco use 0 No 1 Yes J1400 Prognosis Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months Requires physician Enter Code documentation 0 No 1 Yes J1550 Problem Conditions J Check all that apply MDS 3 0 Nursing Home Comprehensive NC Version 1 11 2 Effective 10 01 2013 Page 21 of 41 Resident Identifier Date Section Health Conditions J1700 Fall History on Admission Entry or Reentry Complete only if A0310A 01 or A0310E 1 Enter Code A Did the resident have a fall any time in the last month prior to admission entry or reentry 0 No 1 Yes 9 Unable to determine Enter Code B Did the resident have a fall any time in the last 2 6 months prior to admission entry or reentry 0 No 1 Yes 9 Unable to determine Enter Code C Did the resident have any fracture related to
418. to pass validations The provider has two options regarding the submissions e Ifa submission displays a message that a form is missing the provider can save the form as a draft Submit the missing form and then retrieve the draft and submit to complete both transactions v 2013 1127 139 LTC Nursing Facility Hospice User Guide e If the submission displays that a form is missing that form can be adjusted to submit the missing form and then using Use as template the original form can be submitted now that the edit has been resolved The submission of the missing form and the erroring form can occur the same day The missing form will need to be submitted and then the erroring form Providers do not need to wait for the missing form to process overnight Form 3618 Resident Transaction Notice Edits Edit Description System Message displayed at time of submission System Message Clarification System Message Resolution assistance for resolving error Last form submitted was an admission Please supply discharge form prior to this admission Rejection of New Admission for missing Previous Discharge New admission follows an admission for same contract i e 11 12 2008 admission no discharge 12 16 2008 admission submitted Submit a discharge prior to this admission Attempting to submit two 3618 admissions in a row missing a 3618 discharge Submit the missing discharge then submit the 3618
419. tomy or catheter and adjusts clothes Do not include emptying of bedpan urinal bedside commode catheter bag or ostomy bag J Personal hygiene how resident maintains personal hygiene including combing hair brushing teeth shaving applying makeup washing drying face and hands excludes baths and showers MDS 3 0 Nursing Home Comprehensive NC Version 1 11 2 Effective 10 01 2013 2 ADL Support Provided Code for most support provided over all shifts code regardless of resident s self performance classification Coding 0 No setup or physical help from staff Setup help only One person physical assist Two persons physical assist ADL activity itself did not occur or family and or non facility staff provided care 100 of the time for that activity over the entire 7 day period 1 TUTO UNE J Enter Codes in Boxes Page 15 of 41 Resident Identifier Date SectionG _ Functional Status G0120 Bathing How resident takes full body bath shower sponge bath and transfers in out of tub shower excludes washing of back and hair Code for most dependent in self performance and support Enter Code A Self performance 0 Independent no help provided Supervision oversight help only Physical help limited to transfer only Physical help in part of bathing activity Total dependence Activity itself did not occur or family and or non facility staff provided care 10096 of the time for that activity ov
420. tral venous catheter CVC This includes epidural intrathecal or venous access or Peripherally Inserted Central Catheter PICC devices This does NOT include hemodialysis or peritoneal dialysis access devices v 2013 1127 75 LTC Nursing Facility Hospice User Guide LTCMI Fields S6g At what developmental level is the resident functioning Conditional Choose from the drop down box Unknown or unable to assess 1 1 Infant 2 1 2 Toddler 3 3 5 Pre School 4 6 10 School age 5 11 15 Young Adolescence 6 16 20 Older Adolescence Thisis a required field for all assessments on residents who are 20 years of age or younger based on birth date minus date of submission TMHP Received date This field is not available for data entry if the resident is 21 years of age or older S6h Enter the number of times this resident has fallen in the last 90 days Required Record the number of times the resident has fallen in the last 90 days Enter 0 zero if no falls Each fall should be counted separately If the resident has fallen multiple times in one day count each fall individually Valid range includes 0 zero 999 Leading zeroes may be included or omitted from the submitted value A decimal point and decimal values may not be included on the LTC Online Portal S6i In how many of the falls listed above was the person physically restrained prior to the fall Conditional This is a required
421. ts 25 NHQIMDS30 asp v 2013 1127 159 LTC Nursing Facility Hospice User Guide Minimum Data Set MDS Quick Reference Guide MDS Telephone Numbers CMS Net Remote User Support Helpdesk Verizon oi icccssancatasercencntanstcntoneseainncaccatanextaiemeraniverianionls 1 888 238 2122 MDS Technical Benott C wise tS fa ow aes Dicta oue DJ T EE RE ob biden suas 512 438 2396 MDS Glinieal A Dearest S T tb sisisi cirea a an a decane pupsinin Siia ii rine 210 619 8010 MDS RAP Care Plan Trining agossen n a aa iaae 512 458 1257 512 467 2242 CASPER QOM OI Clinical QwestiOnsys iiec rita tue ee Ee R aE aee URL ER EY EEE 210 619 8010 CASPER OQM QI Report QUestiOnS eseis isse PRSE MN ME pH ep UM GR aia a iiaii aiies eiiis 512 438 2396 IRAVEN Help Desk ssiri R TEE aces E REE REEE EEEE 1 800 339 9313 Swing Bed Automation Technical iussisset a EENE 1 800 339 9313 Swing Bed Clinical MDS acca e cute espace scernaerie caves eiie DG ese esl esa pc bcd bap esnn do EUR pANEUUDAME EA 210 619 8010 MDS Informational Websites e QIES Technical Support Office QTSO www qtso com e For validation report messages and descriptions see MDS Federal MDS 3 0 site www cms gov NursingHomeQualityInits 25 NHQIMDS30 asp e MDS Software Specifications www cms gov MDS20SW Specs e MDS RAP Care Planning Training www tahsa org e MDS RAP Care Planning Training www txhca org e jRAVEN see Federal MDS 3 0 e Resident Assessment Instrument RAT
422. u may enter in the date using the mm dd yyyy format Date of Birth R2 E May 2012 v Sun Mon Tue Wed Thu Fri Sat 6 27 28 29 30 T 3 4 5 7 10 11 12 14 17 24 31 v 2013 1127 33 LTC Nursing Facility Hospice User Guide Timeout The LTC Online Portal will timeout after 20 minutes of no activity Any information that has been entered will be lost To prevent this timeout from occurring when completing the Section LTCMI tab of an MDS assessment complete and submit within 20 minutes or click on a different tab e g Section A to reset the timer then click the Section LTCMT tab to return to and complete the LTCMI RUG Value The Resource Utilization Group RUG is used for MDS 3 0 to classify relative direct care resource requirements for Nursing Facility residents and to determine the rate of payment for Nursing Facility Daily Care and Hospice room and boarding fees Once an individual assessment is open the RUG value can be found next to the DLN UnLock Form MINIMUM DATA SET MDS Version 3 0 RESIDENT ASSESSMENT AND CARE SCREENING Nursing Home Comprehensive NC Item Set Current Status Awaiting LTC Medicaid Information Name f DLN __ Form Actions Print Save LrcMr Populate LTCMI J Section A Section B Section C Section D Section E Section F Section G Section H Section I Section J Sect
423. ubmitted information for previous service dates submit a Correction More information about Corrections to Form 3071 can be found in the Corrections section of this User Guide If the form is intended to terminate a recipient from the Hospice program check the CANCEL box and include only the TO Date An Individual or Responsible Party signature is required if the cancellation code is 14 Individ ual Transferred to Another Service Other Than Hospice or 77 Individual Withdrew Was Dissatisfied Or Refused Service The Setting field indicates where the client is receiving services The setting determines which Hospice services are authorized Community type settings are not authorized for Room and Board services A client who resides in an assisted living facility is considered to be in the Community and the setting should be Home Verify the classifi cation of the facility before indicating the client is in a Nursing Facility or an Intermediate Care Facility for Individ uals with Intellectual Disabilities ICF IID facility Nursing Facility and ICF IID facilities must have an associated Level of Service record per facility type e The Hospice staff must complete Form 3071 e The provider must maintain an original Form 3071 on file for reproduction Submission of the form is outlined in the How to Submit Form 3071 section of this User Guide An original can be obtained by submitting a written request to Medicaid H
424. ucinous 4 Eschar black brown or tan tissue that adheres firmly to the wound bed or ulcer edges may be softer or harder than surrounding skin None of the above M0800 Worsening in Pressure Ulcer Status Since Prior Assessment OBRA or Scheduled PPS or Last Admission Entry or Reentry Complete only if A0310E 0 Indicate the number of current pressure ulcers that were not present or were at a lesser stage on prior assessment OBRA or scheduled PPS or last admission entry or reentry If no current pressure ulcer at a given stage enter 0 Enter Number LI A Stage2 Enter Number LI B Stage 3 Enter Number LI C Stage4 MDS 3 0 Nursing Home Quarterly NO Version 1 11 2 Effective 10 01 2013 Page 22 of 35 Resident Identifier Date SectionM _ Skin Conditions M0900 Healed Pressure Ulcers Complete only if A0310E 0 Enter Code A Were pressure ulcers present on the prior assessment OBRA or scheduled PPS 0 No Skip to M1030 Number of Venous and Arterial Ulcers 1 Yes Continue to M0900B Stage 2 Indicate the number of pressure ulcers that were noted on the prior assessment OBRA or scheduled PPS that have completely closed resurfaced with epithelium If no healed pressure ulcer at a given stage since the prior assessment OBRA or scheduled PPS enter 0 Enter Number B Stage2 Enter Number C Stage 3 Enter Number D Stage4 M1030 Number of Venous and Arterial Ulcers Enter Number
425. ull staff performance and extensive assistance code extensive ass istance o When there is a combination of full staff performance weight bearing assistance and or non weight bearing assistance code limited assistance 2 If none of the above are met code supervision 1 ADL Self Performance Code for resident s performance over all shifts not including setup If the ADL activity occurred 3 or more times at various levels of assistance code the most dependent except for total dependence which requires full staff performance every time Coding Activity Occurred 3 or More Times Independent no help or staff oversight at any time Supervision oversight encouragement or cueing Limited assistance resident highly involved in activity staff provide guided maneuvering of limbs or other non weight bearing assistance Extensive assistance resident involved in activity staff provide weight bearing support Total dependence full staff performance every time during entire 7 day period Activity Occurred 2 or Fewer Times Activity occurred only once or twice activity did occur but only once or twice Activity did not occur activity did not occur or family and or non facility staff provided care 10096 of the time for that activity over the entire 7 day period A Bed mobility how resident moves to and from lying position turns side to side and positions body while in bed or alternate sleep furniture B Transfer
426. urinary incontinence but at least one episode of continent voiding 3 Always incontinent no episodes of continent voiding 9 Notrated resident had a catheter indwelling condom urinary ostomy or no urine output for the entire 7 days H0400 Bowel Continence Enter Code Bowel continence Select the one category that best describes the resident 0 Always continent L 1 Occasionally incontinent one episode of bowel incontinence 2 Frequently incontinent 2 or more episodes of bowel incontinence but at least one continent bowel movement 3 Always incontinent no episodes of continent bowel movements 9 Not rated resident had an ostomy or did not have a bowel movement for the entire 7 days H0500 Bowel Toileting Program Enter Code Is a toileting program currently being used to manage the resident s bowel continence LI 0 No 1 Yes H0600 Bowel Patterns Enter Code Constipation present 0 No 1 Yes MDS 3 0 Nursing Home Comprehensive NC Version 1 11 2 Effective 10 01 2013 Page 17 of 41 Resident Identifier Date Section __ Active Diagnoses Active Diagnoses in the last 7 days Check all that apply Diagnoses listed in parentheses are provided as examples and should not be considered as all inclusive lists 10100 Cancer with or without metastasis Heart Circulation Anemia e g aplastic iron deficiency pernicious and sickle cell Atrial Fibrillation or Other Dysrhythm
427. ust choose another page from the Select a page drop down box You may also export the search results to Microsoft Excel 6 Click the View Detail link at the left of the DLN to display the details of the assessment Form Status Inquiry DLN Medicaid Number Last Name First Name Form Status v SSN dH H From Date e anms Tw To Date e monos wr Mental Illness Oo Intellectual Disability o Developmental Disability 7 PASRR Eligibility v Discharged Deceased v 2 record s returned Export Data to Excel 3 21 2013 Individual Placed Lt in NF PE Confirmed View 3 26 2013 N Pending Placement in NF PE Confirmed v 2013 1127 17 LTC Nursing Facility Hospice User Guide Descriptions of the column headings seen above are for results for Type of Forms MDS and MDSQTR assessments View Detail The hyperlink used to open the document DLN The unique document locator number assigned to each successful submission TMHP Received Date The actual date the assessment was successfully submitted on the LTC Online Portal Exception f your MDS assessment is set to status Awaiting LTC Medicaid Information the date shown in the TMHP received date column is the date that the MDS was loaded onto the LTC Online Portal Once the LTCMI is successfully submitted the date will change to the submission date SSN MDS 3 0 A0600A Me
428. utes a day in the last 7 days E Psychological Therapy by any licensed mental health professional Enter Number of Minutes 1 Total minutes record the total number of minutes this therapy was administered to the individual in the last 7 days If zero skip to O0400F Recreational Therapy Enter Number of Days 2 Days record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days F Recreational Therapy includes recreational and music therapy Enter Number of Minutes 1 Total minutes record the total number of minutes this therapy was administered to the individual in the last 7 days If zero skip to 00420 Distinct Calendar Days of Therapy nter Number of Days 2 Days record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days MN and LOC 3 0 V 15 25 of 32 Individual Identifier Date Section O Special Treatments Procedures and Programs 00420 Distinct Calendar Days of Therapy Enter Number of Days Record the number of calendar days that the individual received Speech Language Pathology and Audiology L Services Occupational Therapy or Physical Therapy for at least 15 minutes in the past 7 days 00500 Restorative Nursing Programs Record the number of days each of the following restorative programs was performed for at least 15 minutes a dayin the last 7 calendar days enter 0 if none
429. v Developmental Disability 9 Is there evidence or indicators that this is an individual that has a Developmental isability Related Condition other than an Intellectual Disability e g Autism Cerebral alsy Spina Bifida b See DADS related condition list Click Here Local Authority Information C0400 LA MI Contract No C0500 LA MI Vendor No Co0600 LA MI NPI API No C0700 LA IDD Contract No cosoo LA IDD Vendor No cosoo LA IDD NPI API No 174 v 2013 1127 LTC Nursing Facility Hospice User Guide PASRR Level 1 Screening Section D TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR Home Submit Form Form Status Inquiry Current Activity Drafts Vendors Letters Printable Forms Alerts Help PASRR LEVEL 1 SCREENING Current Status Name DLN O Save ss ora J Section A Section B Section C Nursing Facility Choices D0100 Nursing Enter Contract No and Vendor No and click lookup tool to populate NF information Facilities El Hide NF Information A Contract No B Vendor No mmm Q C NPI D Facility Name E Street Address F City G State H Zip Code 9 I Phone v 9 J NF Contact First Name K NF Contact Middle 9 L NF Cont
430. ve to be submitted as a PC E Payment for this gap will be made at the PC E default rate MDS Purpose Code E is used to recover missed assess ment time frames A missed assessment occurs when an MDS is not submitted within the anticipated quarter time frame The anticipated quarter is the 92 day anticipated MDS assessment quarter following the 92 day span of the current MDS assessment A missed assessment can also occur if the Admission assessment is not submitted within 92 days of the assessment date Purpose Code E can only be submitted on the Admission assessment Annual assess ment or Quarterly review assessment The PC E must be submitted within 365 days from the last uncovered day 86 v 2013 1127 LTC Nursing Facility Hospice User Guide Es MISSED DEFAULT RUG 92 Days 92 Days Assessment Assessment on file for this on file for this Assessment received after day 31 92 day period 92 day period but on or before day 92 is considered not on time LATE Assessment received within the first 31 days is ON TIME Payment is based on Payment based on CALCULATED RUG RATE CALCULATED RUG RATE PAYMENT STOPS UNTIL ASSESSMENT IS PROCESSED PAYMENT CONTINUES EVEN IF NOT RECEIVED BASED ON PREVIOUS ASSESSMENT NF Hospice Provider Tips for When to Submit an MDS PC E The following provides information to help NF Hospice providers determine when to submit an MDS PC E PC E can only be submitted on an MDS Admission Annual
431. verage Code 9 1 2010 Program Type Coverage Category e S1f Missed Assessment or Prior Start Date This is the prior eligibility start date e Slg Missed Assessment or Prior End Date The correction of an existing LTCMI Purpose Code to an E or M invalidates the original time frame If the LTCMI is changed to indicate a PC E or PC M and the assessment had been part of the recipients cycle the original time frame is voided e g set to status Corrected and only the PC E or M dates will be covered More information on Purpose Code E and M can be found at www dads state tx us providers communications 2009 letters IL2009 27 pdf The information below is an excerpt from the Information Letter referenced above v 2013 1127 89 LTC Nursing Facility Hospice User Guide What is a Purpose Code M and How Do You Complete a Purpose Code M Purpose Code M an MDS submitted if three months prior to application is granted after the client is certified for Medicaid When there is an application for Medicaid the client s financial eligibility is considered and reviewed based on the month of application If the client is determined to be Medicaid eligible the worker does a consider ation on the three months prior to the application to determine if the client may have been financially eligible at an earlier date The Purpose Code M was designed to allow the provider to submit a MDS Purpose Code M to cover th
432. was normally able to recall A Current season L Location of own room O Caregiver names and faces L Thathe or she is in their own home room None of the above were recalled C1000 Cognitive Skills for Daily Decision Making Made decisions regarding tasks of daily life Enen Independent decisions consistent reasonable _ Modified independence some difficulty in new situations only Moderately impaired decisions poor cues supervision required Severely impaired never rarely made decisions C1300 Signs and Symptoms of Delirium from CAMO Code after completing Brief Interview for Mental Status or Caregiver Assessment and reviewing medical record 4 Enter Codes in Boxes A Inattention Did the individual have difficulty focusing attention easily distracted out of touch or difficulty following what was said Coding Behavior not present B Disorganized thinking Was the individual s thinking disorganized or incoherent rambling or irrelevant conversation unclear or illogical flow of ideas or unpredictable switching from subject to subject Enter Dash if unable to assess Behavior continuously present does not fluctuate A Altered level of consciousness Did the individual have altered level of consciousness Behavior present e g vigilant startled easily to any sound or touch lethargic repeatedly dozed off when fluctuates comes and being ask
433. was not paid Conditional This field is required if S1e Purpose Code E or M This would be the last missed assessment date Check MESAV for gaps Enter the date in mm dd yyyy format of the missed assessment or 3 month prior Retro Eligibility Coverage code must be P end date Date cannot be greater than date of submission i e today s date End date cannot be prior to the Start Date Field is correctable These dates are used to locate a gap of time If a gap is not found within the range provided the assessment will not be processed Providers can submit a MDS Purpose Code E with a missed assessment date range greater than 92 days This allows providers to submit one MDS Purpose Code E to cover large gaps in dates S2 PASRR Information S2a To your knowledge does the resident have an intellectual disability Required Choose from the drop down box 0 No 1 Yes S2b To your knowledge does the resident have a developmental disability Required Choose from the drop down box 0 No 1 Yes S2c To your knowledge does the resident have a condition of mental illness according to the PASRR guidelines Required Choose from the drop down box 0 No 1 Yes v 2013 1127 71 LTC Nursing Facility Hospice User Guide LTCMI Fields S2d Is the resident a danger to himself herself Required Choose from the drop down box 0 No 1 Yes gt If unknown then reply with 0 No S2e Is the r
434. y and within the last 7 days Only check column 1 if 1 2 resident entered admission or reentry IN THE LAST 7 DAYS If resident last entered 7 or more days While NOT a While a ago leave column 1 blank Resident Resident 2 While a Resident Performed while a resident of this facility and within the last 7 days J Check all that apply L A Parenteral IV feeding B Feeding tube nasogastric or abdominal PEG C Mechanically altered diet require change in texture of food or liquids e g pureed food thickened liquids D Therapeutic diet e 9 low salt diabetic low cholesterol Z None of the above K0710 Percent Intake by Artificial Route Complete K0710 only if Column 1 and or Column 2 are checked for K0510A and or K0510B 1 While NOT a Resident Performed while NOT a resident of this facility and within the last 7 days Only enter a code in column 1 if resident entered admission or reentry IN THE LAST 7 DAYS If resident last entered 7 or more days ago leave column 1 blank 1 2 3 2 While a Resident While NOT a While a During Entire Performed while a resident of this facility and within the last 7 days Resident Resident 7 Days 3 During Entire 7 Days Performed during the entire last 7 days i Enter Codes J A Proportion of total calories the resident received through parenteral or tube feeding 1 25 or less 2 26 5096 3 5196 or more B Average fluid intake per day by IV or tube feeding 1 500 cc
435. ys If the dates entered on the form equal less than 20 days the provider must add comments to the form explaining the reason for this Once the comments are added the form may be submitted If additional sets of dates are needed to document the qualifying stay the provider must enter a comment that additional forms are being submitted in order for the form to be accepted into the LTC Online Portal with less than 20 days A second Form 3619 must be completed using the same date of above transaction in order to supply the additional set s of dates This form will also require a comment because it will not document a full 20 days of Qualifying Stay either If the recipient has a Medicare Replacement also known as Medicare Advantage plan or Medicare Health Mainte nance Organization HMO the full coverage requirement may vary Please include the following information in the comments section of the Form 3619 e Medicare Replacement e Name of the insurance carrier e Number of Co pay days allowed e Daily Co pay amount Repercussions of Submitting Form 3619 Late Payment will be delayed e he facility may be subject to sanctions such as vendor hold as the result of contractual noncompliance How to Submit Form 3619 Instructions for completing Form 3619 can be found in Module 4 Form 3619 in the Long Term Care LTC Nursing Facility Hospice CBT found at the following link http learn tmhp com 1 Log in to the LTC Online Port
436. zation The recipient has a Service Authorization for Full Medicaid Code 1 as of the Medicare Part A Coinsurance discharge date Review the facility s records to determine the recipient s admission and discharge dates If the recipient is Full Medicaid in your facility pull a MESAV and compare the Service Authorizations to the facility s records If the recipient should be classified as Medicare on this discharge date Determine if the 3618 discharge to the hospital prior to the Medicare Stay has been submitted If not submit that 3618 discharge If it was rejected resolve the issue and resubmit the 3618 discharge Determine if the 3619 admission to begin Medicare Part A Coinsurance has been submitted If not submit that 3619 admission If it was rejected resolve the issue and resubmit that 3619 admission Once the 3618 discharge and 3619 admission are processed and reflected on the MESAV resubmit the rejected discharge If the recipient should not be classified as Medicare on this discharge date Determine if the discharge should be a 3618 discharge instead If so inactivate the rejected form and submit a 3618 discharge to close the recipient s file If the recipient is Full Medicaid in a different facility determine if the 3619 admission to begin Coinsurance has been submitted If not submit the 3619 admission If it was rejected resolve the issue and resubmit the 3619 admission Then resubmit the re

30 LTC NF Online Portal User Manual 03242014

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