This page addresses issues related to MDS corrections, modifications and inactivations.
It is the responsibility of MDS coordinators and other MDS personnel to read, understand, and implement the correction policy described in the RAI Manual, Chapter 5. Please contact the state MDS Automation or RAI Coordinator if you have any questions about what you have read. Below is a list of issues that nursing facilities encounter when correcting assessments and how to address them.
Edit: To change MDS item values without completing Section X
Modify: To complete Section X and change MDS item values in other sections
Correct with a modification: Refer to definition of Modify
MDS 3.0 Correction Issues
How far back can facilities go to make corrections?
Currently, facilities can make corrections to MDS 3.0 records up to 36 months (3 years) back. Missing tracking records should be submitted up to 36 months back if they are discovered. The only exception to this is that Entry tracking records for entries that occurred between October and November of 2010, but were not submitted, do not have to be submitted now (according to CMS). However, all Entry tracking records for entry dates on or after December 2010 must be submitted.
When must items be edited instead of corrected?
All items in an MDS record that is not accepted into the CMS system can be edited. In other words, an MDS record that has not been submitted, or that was submitted and rejected, must be edited — it cannot be modified or inactivated.
Which items must be corrected with a special form?
The Facility ID (FAC_ID) and item A0410 must be corrected using a special form that can be requested from the state MDS Automation Coordinator. An MDS record must be accepted into the CMS system before it can be corrected using the special form. Test records that need to be deleted from the CMS system after being accepted require the special form, as well.
Inactivations: When and how do facilities correct MDS records with an inactivation?
Inactivations negatively impact facilities due to the personnel time required for the correction and the possible need to bill at the default rate or no rate at all. First read about how inactivations must be correctly completed, then read how to avoid the need for inactivations.
The MDS 3.0 Resident Assessment Instrument (RAI) Manual, page 5-12, gives the following information:
- An Inactivation (Item X0100 = 3) must be completed when any of the following items are inaccurate: Type of Provider (Item A0200), Type of Assessment (A0310), Entry Date (Item A1600) on an Entry tracking record, Discharge Date (Item A2000) on a Discharge/Death in Facility record, or Assessment Reference Date (A2300) on an OBRA or PPS assessment. Note: There is no need to inactivate an MDS assessment to correct the A1600 Entry Date. The Entry Date may be modified on an MDS assessment but not on an Entry record.
- An inactivation can only be completed after MDS 3.0 records have been accepted into the Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) system.
- When inactivating a record, the provider is required to submit an electronic Inactivation Request record. This record is an MDS record with only the Section X items completed.
- For instances when the provider determines that an event date (ARD, entry date, and discharge date) or type of assessment item (A0310) is incorrect, the provider must inactivate the record in the QIES ASAP system, then complete and submit a new MDS 3.0 record with the correct event date or type of assessment, ensuring that the clinical information is accurate.
CMS Clarification: CMS staff clarified the information in the fourth bullet to ensure that all facility staff understand that when an MDS is inactivated, the facility must complete and submit an entirely new MDS 3.0 record (X0100=1 Add New Record) with a correct event date or type of assessment. This is true whether the record is an assessment or an Entry or Death in Facility record.
If the MDS 3.0 record is an assessment:
- Facility staff must set a new Assessment Reference Date (ARD) on a paper copy of the MDS Item Set or in the facility MDS software,
- Complete a new MDS assessment, coding all MDS items based on the new ARD and the appropriate look-back period, and
- Enter new completion dates in Section V (if active on that item set) and in Section Z.
If the MDS 3.0 record is an Entry or Death in Facility record:
- Facility staff must complete a new record with the correct event date or type of assessment, and
- Enter new completion dates in Section Z.
Inactivation of assessments used for Medicare or Medicaid payment, and completion of new assessments, may result in payment consequences. If the resident has been discharged and is no longer in the facility, records with an MDS assessment type listed in A0310A cannot have an ARD set after the date of discharge. If the resident has been discharged from Medicare Part A, whether the resident remains in the facility or not, records with an MDS assessment type listed in A0310B and A0310C cannot have an ARD set after the date of Medicare discharge. Without an ARD set on or before the day of discharge, these OBRA and PPS assessments may not be completed or submitted.
To avoid the negative impacts of inactivations (additional staff time and possible financial loss), DADS MDS staff recommend a quality double-check on every MDS record of the items that would cause an inactivation. It is recommended that a second person (other than the person who originally entered the data) who is familiar with MDS scheduling perform the quality double-check.
There may be instances when a facility has already inactivated an MDS record and resent an edited version of the record instead of completing a new MDS record. Such edited versions of the record are invalid and should be inactivated, as well.
How would a facility correct an MDS record that has a correct reason for assessment combined with an incorrect reason for assessment?
Any time the Reason for Assessment, or any other MDS item, is incorrect, the MDS must be corrected. The invalid MDS would be inactivated and a new MDS assessment would be completed with the correct reason for assessment. A new Medicare assessment could be completed with a new ARD if the resident has not been discharged from Medicare before the ARD. A new OBRA assessment could be completed with a new ARD if the resident has not been discharged from the facility before the ARD.
For example, what must be done when a facility submits a combined Admission/14-day assessment and then realizes that the resident was discharged from Medicare before the Assessment Reference Date (ARD) of the assessment?
In this case, the Admission/14-day assessment must be inactivated and the Admission assessment would have to be redone with a new ARD per the inactivation policy. If the resident is no longer in the facility due to death or discharge, a new Admission assessment could not be submitted for that resident and the facility would have to accept a missed assessment status for the Admission assessment.
Other common examples of invalid combinations include:
- A COT completed when the Rehab RUG did not change
- An EOT completed when ALL therapy did not end OR the resident was not in a Rehab or Rehab+Extensive RUG in the first place
- An SOT when it is not a short stay PPS MDS OR it is not 5-7 days after therapy started
Be mindful of the difference between MDS with incorrect reasons for assessment that are invalid and MDS that are done early or late but are valid. For example, a valid COT with an ARD set one day early is not optimal but it should not be inactivated. Conversely, a COT with an ARD set after a resident was discharged from therapy is invalid and must be inactivated.
What must be done when an MDS record has a correct reason for assessment combined with an undesired optional Change of Therapy?
The facility must decide whether or not to inactivate and correct the MDS.
For example, if a combined 30-day/COT was submitted and the COT caused a lower RUG, the facility could not inactivate the assessment without adverse consequences. Inactivating the assessment would mean the 30-day would have to be redone with an ARD no earlier than the date of correction, the COT would be due on the original ARD but would also have to be redone with an ARD no earlier than the date of correction (and probably combined with the new 30-day). That means the 30-day and COT would both be late assessments and payment would be even more negatively affected than the original combined assessment. Thus, facility MDS personnel need to carefully consider the consequences before inactivating an assessment.
If MDS personnel determine NOT to inactivate the MDS, the combined MDS must be utilized for billing as outlined in the MDS 3.0 RAI Manual and billing regulations. Facility staff may NOT change the Assessment Indicator (AI) for a Resource Utilization Group (RUG) when billing. Even though the COT is optional, the facility must still bill Medicare based on the RUG resulting from the optional COT.
Tip: Double-check your MDS before submitting.
What dates do I change when correcting an MDS?
- Except for item Z0400, dates do not change unless a data entry error caused them to not match the information in the clinical record. Do not update (or change) the ARD from the original date set when the RN Assessment Coordinator signed the MDS as complete, unless the original date entered into the MDS record was incorrect due to a data entry error.
- The signatures and dates in item Z0400 should be updated to reflect the most recent corrections.
- The date the RN Assessment Coordinator signed the MDS at Z0500B should not be modified, unless the date listed is not the original date that the RN signed the MDS as complete.
Does the current MDS staff really have to correct old assessments that were done by someone else?
- "Facilities should correct any errors necessary to insure that the information in the QIES ASAP system accurately reflects the resident's identification, location, overall clinical status, or payment status. A correction can be submitted for any accepted record, regardless of the age of the original record. A record may be corrected even if subsequent records have been accepted for the resident. Errors identified in QIES ASAP system records must be corrected within 14 days after identifying the errors." (RAI Manual page 5-10)
- It is important to correct old assessments that have incorrect data because MDS records are not only used for payment but also for quality measures, nursing facility rating, and research that uses nursing facility data. Texas facilities who correct Medicaid MDS over 1 year after completion date are recommended to contact TMHP about possible payment repercussions.
Did you get a validation report error -3745 "No match found"?
- The first possible reason for this error is that the original MDS record was rejected, or not yet submitted, and a correction for that MDS was submitted. The solution is to delete the correction, edit the original MDS, ensure that the original MDS has the correct data, and submit it as if for the first time. Contact your software vendor if you need help with any of these steps.
- The second possible reason for this error is that the original MDS record was accepted and then the MDS record was fixed BEFORE a correction was completed. The solution is to delete the correction, change the MDS data back to the old incorrect data, complete a new correction, and THEN fix the data in the MDS. Always remember to complete the correction first (Section X) before fixing the data in the MDS assessment. Contact your software vendor if you need help with any of these steps.
Did you get a validation report error -3783 "Inconsistent X0800"?
- Each correction to an individual MDS record is assigned an incremental number, starting with 1. Your first correction for a particular MDS record will have X0800=1 and the second correction of the same MDS record will have X0800=2. Solution: Assuming the issue discussed in the second bullet is not the problem, edit the existing rejected correction, change X0800 to the appropriate number, and resend the correction as if for the first time. Do NOT start another correction until all previous corrections have been accepted.
- A mistake that some facilities make is submitting a second correction after the first correction was rejected or not properly submitted. If the first correction is not yet accepted by CMS (check the validation reports) then do not send another correction with X0800=2. Solution: Delete the second correction, edit the first correction (X0800=1) with correct information, and resubmit it.
Contact your software vendor if you need help with any of these steps.
Did you get a validation report error -1007 "Duplicate Assessment"?
- Double-check your final validation reports. Someone definitely submitted the record such that it was accepted.
- If you get this error after correcting an MDS that was submitted and accepted then it is likely that you edited the MDS instead of modifying it.
- To fix this issue: edit the MDS, change the data back to the original incorrect data, and then modify the MDS. Always remember to complete the correction first (Section X) before fixing the data in the MDS assessment. Contact your software vendor if you need help with any of these steps.