Minimum Data Set, Version 2.0 (MDS 2.0)

Section S – NEW YORK STATE SUPPLEMENT (2008)

Item-by-Item Instructions

S0. Operating Certificate Number

  • Definition: The state assigned operating certificate number assigned by Department of Health to the facility for purposes of identification of the facility ownership.

  • Process: Obtain this information from the facility administrative or business office.

  • Coding: The Operating Certificate number is required to be submitted to the MDS database at the state but does not need to be recorded on the MDS form stored in the nursing home. We suggest the Operating Certificate Number be coded into a facility set-up area of the MDS encoding software along with other facility identification information. Alternatively, the encoder will need to enter the Operating Certificate number for each MDS when preparing the assessment record for submission to the state.

S1. Unit Number

  • Definition: The unique two digit number assigned by the facility to each nursing unit for purposes of reimbursement data collection.

  • Process: Look at the clinical/medical record jacket or face sheet for this information.

  • Coding: Enter the correct designation.

S2. Pressure Ulcers

Record the appropriate response. Stage 3 or 4 pressure ulcer sites present upon admission or readmission.

  • Intent: To determine if Stage 3 or 4 pressure ulcers were present upon admission or readmission to the facility.

  • Definition: Any lesion caused by pressure resulting in damage of underlying tissues. Other terms used to indicate this condition include bed sores and decubitus ulcers.

  • Process: Review the resident's record. Consult with the physician regarding the cause of the ulcer(s). Refer to pressure ulcers in item M2a and determine if any are Stage 3 or 4. If so, were these Stage 3 or 4 pressure ulcers present upon admission or readmission to the facility?

  • Coding: Refer to the ulcers reported in item M2a to provide this response. Of the Stage 3 or 4 pressure ulcers reported, if any, were these same pressure ulcer sites present upon admission or readmission.

S3. Substance Abuse

Substance Abuse History. Has the resident with HIV engaged in substance abuse behaviors more than one month ago which continue to influence care currently given to the resident?

  • Intent: To determine if substance abuse which occurred more than one month ago continues to influence the care given to the resident with HIV.

  • Definition: Excessive use of drugs or alcohol on a regular or irregular basis to the point where it interferes with judgement and activities of daily living.

  • Process: Review clinical/medical record for substance abuse history. Validate findings with the resident and direct care staff on all shifts.

  • Coding: Enter the number corresponding to the correct response.

S4. Disease Diagnoses

Diagnoses. Check only those disease diagnoses that have a relationship to current ADL status, cognitive status, mood and behavior status, medical treatments, nursing monitoring or risk of death during the last 30 days. (Do not list inactive diagnoses)

  • Intent: To document the presence of diseases that have a relationship to the resident's current ADL status, cognitive status, mood or behavior status, medical treatments, nursing monitoring or risk of death. In general, these are conditions that drive the current care plan. Do not include conditions that have been resolved or no longer affect the resident's functioning or care plan. In many facilities, clinical staff and physicians neglect to update the list of resident's "active" diagnoses. There may also be a tendency to continue old diagnoses that are either resolved or no longer relevant to the resident's plan of care. One of the important functions of the MDS assessment is to generate an updated, accurate picture of the resident's health status.

  • Definition: Nursing Monitoring – Includes clinical monitoring by a licensed nurse (e.g., serial blood pressure evaluations, medication management, etc.)

  • Diseases Definition:

    1. HIV Dementia – HIV itself invades the central nervous system, starting out as HIV encephalopathy manifested by progressive loss or decline in cognitive, motor or behavioral function.
    2. HIV Wasting Syndrome – Findings of profound involuntary weight loss (more than 10% or baseline body weight) AND EITHER chronic diarrhea (at least two loose stools per day for 30 or more days) OR chronic weakness with documented fever (for 30 or more days, intermittent or constant) in the presence of HIV infection.
    3. Non-psychotic disorder following organic brain damage - The organic factor may be a primary disease of the brain, a systemic illness that secondarily affects the brain, or a substance such as a toxic agent. This factor is either currently disturbing brain function or has left some long lasting effect (e.g., encephalitic syndrome).
    4. Psychotic disorder following organic brain damage – A massive disintegration of integrated ego functioning, causing the person to be unable to deal effectively with self, others and the environment caused by a primary disease of the brain, a systemic illness that secondarily affects the brain or a substance (e.g., epileptic psychosis).
    5. Spinal Cord Injury – Damage to the spinal cord as a result of physical injury (e.g., C4 level with complete lesion of spinal cord).
    6. Hemiplegia – TOTAL paralysis (temporary or permanent impairment of sensation, function, motion) of both limbs on one side of the body, usually caused by cerebral hemorrhage, thrombosis, embolism or tumor. There must be a diagnosis of hemiplegia in the resident's record.
    7. Hemipareses – PARTIAL paralysis (temporary or permanent impairment of sensation, function, motion) of both limbs on one side of the body, usually caused by cerebral hemorrhage, thrombosis, embolism, or tumor. There must be a diagnosis of hemipareses in the resident's record.
    8. Huntington's Disease – An inherited illness of the central nervous system mainfesting severe symptoms such as chorea and other motor adnormalities, dementia and disorders of mood. This condition often gives rise initially to disorders of character and behavior such as irritability, impulsiveness, and violence. Eventually patients suffer from chronic fatigue, apathy, poor memory and progressive dementia.

  • Process: Consult transfer documentation and medial record (including current physician treatment orders and nursing care plans). If the resident was admitted from an acute care or rehabilitation hospital, the discharge forms often list diagnoses and corresponding ICD-9-CM codes that were current during the hospital stay. If these diagnoses are still active, record them on the MDS form. Also, accept statements by the resident that seem to have clinical validity. Consult with physician for confirmation and initiate necessary physician documentation.

    Physician involvement in this part of the assessment process is crucial. The physician should be asked to review the items in Sections I and S at the time of visit closest to the scheduled MDS assessment. Use this scheduled visit as an opportunity to ensure that active diagnoses are noted and "inactive" diagnoses are designated as resolved. This is also an important opportunity to share the entire MDS assessment with the physician. In many nursing facilities physicians are not brought into the MDS review and assessment process. It is the responsibility of facility staff to aggressively solicit physician input. Inaccurate or missed diagnoses can be a serious impediment to care planning. Thus, you should share this section of the MDS with the physician and ask for his or her input. Physicians completing a portion of the MDS assessment should sign in item R2 (Signatures of Those Completing the Assessment).

    Full physician review of the most recent MDS assessment or ongoing input into the assessment currently being completed can be very useful. For the physician, the MDS assessment completed by facility staff can provide insights that would have otherwise not been possible. For staff, the informed comments of the physician may suggest new avenues of inquiry or help to confirm existing observations, or suggest the need for additional follow-up.

    Check a disease item only if the disease has a relationship to current ADL status, cognitive status, behavior status, medical treatment, nursing monitoring, or risk of death.

  • Coding: Do NOT record any conditions that have been resolved and no longer affect the resident's functional status or care plan.

    Check all that apply. If none of the conditions apply, check NONE OF THE ABOVE.

S4i. Dementia Registry Reporting – Alzheimer's Disease and Other Dementias Registry

  • Intent: To report cases to the Alzheimer's Disease and Other Dementias Registry as required by Public Health Law, Article 20 in lieu of reporting on the Confidential Case Report form (DOH-1988 (4/97)).

    For reporting cases, to identify the county or residence prior to nursing home placement, to report the license number of the resident's primary care physician when the admission diagnosis was determined or when the resident was diagnosed with dementia while a resident at the facility, and to report the ICD-9 code indicating the specific dementing illness.

  • Definition: Dementia reportable to the Alzheimer's Disease and Other Dementias registry – reportable dementias are previously unreported cases of chronic or progressive irreversible dementia, including but not limited to Alzheimer's disease.

  • Coding: Dementia Registry Reporting – Check if this resident is a new admission with a diagnosis of reportable dementia or if the resident is newly diagnosed with reportable dementia while a resident at this facility. If checked, record the ICD-9 code indicating the specific dementing illness in Section I, Item 3 and complete items 1 and 2 below.

    Do NOT check if the resident does not have reportable dementia or if the resident's reportable dementia was previously submitted to the registry by this facility. If not checked, skip items 1 and 2 below.

    1. County (FIPS) Code of Prior Residence – If item S41 is checked, enter the Federal Information Processing Standards Publication (FIPS) code that represents the resident's county of home address using the following codes for New York State.

      County  Code  County  Code  County  Code 
      Albany 001 Jefferson 045 St. Lawrence 089
      Allegheny 003 Kings 047 Saratoga 091
      Bronx 005 Lewis 049 Schenectady 093
      Broome 007 Livingston 051 Schoharie 095
      Cattaragus 009 Madison 053 Schuyler 097
      Cayuga 011 Monroe 055 Seneca 099
      Chautauqua 013 Montgomery 057 Steuben 101
      Chemung 015 Nassau 059 Suffolk 103
      Chenango 017 New York 061 Sullivan 105
      Clinton 019 Niagara 063 Tioga 107
      Columbia 021 Oneida 065 Tompkins 109
      Cortland 023 Onondaga 067 Ulster 111
      Delaware 025 Ontario 069 Warren 113
      Dutchess 027 Orange 071 Washington 115
      Erie 029 Orleans 073 Wayne 117
      Essex 031 Oswego 075 Westchester 119
      Franklin 033 Otsego 077 Wyoming 121
      Fulton 035 Putnam 079 Yates 123
      Genesee 037 Queens 081 Out of State 800
      Greene 039 Rennselaer 083 Homeless 897
      Hamilton 041 Richmond 085 Unknown 899
      Herkimer 043 Rockland 087    

    2. Physician License Number – If item S41 is checked enter the physician license number, which is issued by the New York State Education Department. The number is a six digit number, or for physicians with a limited license, the license number is an "L" followed by a 5 digit number. Do NOT include preceding specialty codes or succeeding office site numbers in the physician license number.

S5. Specialty Unit/Facility Reimbursement:

  • Intent: To identify a resident residing in a discrete specialty unit (facility) that is eligible for a discrete specialty Medicaid reimbursement rate in accordance with the applicable regulation or statute.

  • Definition: To be eligible for a discrete specialty unit/facility rate the resident must reside in a unit/facility that is approved by the Commissioner of Health in accordance with the cited regulation(s) and/or statute(s).

    1. Discrete AIDS Unit/Facility - Approved pursuant to 10-NYCRR Part 86-2.10 (p) and Part 710 or any successor regulation and/or statute. (Note: Cannot also be marked as 1 for Question 6 of Section S)
    2. Ventilator Dependent Unit - Approved pursuant to 10-NYCRR Part 86-2.10 (q) and Section 415.38 or any successor regulation and/or statute.
    3. Traumatic Brain-Injured (TBI) Unit- Approved pursuant to 10-NYCRR Part 86-2.10 (n) and Section 415.36 or any successor regulation and/or statute. (Note: Cannot also be marked as 2 for Question 6 of Section S)
    4. Behavioral Intervention Unit- Approved pursuant to 10-NYCRR Part 86-2.10 (w) and Section 415.39 or any successor regulation and/or statute.
    5. Behavioral Intervention Step-Down Unit- Approved pursuant to 10-NYCRR Part 86-2.10 (x) and Section 415.41 or any successor regulation and/or statute.
    6. Pediatric Specialty Unit/Facility- Approved pursuant to 10-NYCRR Part 86-2.10(i) or any successor regulation and/or statute. Department of Health Policy ONLY recognizes pediatric residents up to age 21 for purposes of specialty reimbursement (see Dear Administrator Letter of July 12, 2006).
    7. None of the Above

S6. Resident Eligible for Enhanced Medicaid Reimbursement (Add-On) for the following condition(s):

  • Intent: To identify a resident eligible for enhanced Medicaid reimbursement (Add- On) for an approved specialty program in accordance with the applicable regulation.

  • Definition: To be eligible for an enhanced Medicaid reimbursement rate (Add-On) the resident must be in a specialty program that is approved by the Commissioner of Health in accordance with the cited regulations.

    1. AIDS- (Approved Scatter Beds)- Approved pursuant to 10-NYCRR Part 86-2.10 (p) (3) and Part 710 or any successor regulation and/or statute. (Note: Cannot also be marked as 1 for Question 5 of Section S).
    2. Traumatic Brain-Injury (TBI) Extended Care- Approved pursuant to 10-NYCRR Part 86-2.10 (v) and Section 415.40 or any successor regulation and/or statute. (Note: Cannot also be marked as 3 for Question 5 of Section S)
    3. None of the Above

S7. Primary Payor:

  • Intent: To determine if Medicaid is the payment source on the day of MDS completion.

  • Process: Check with the billing office to review current payment source. Do not rely exclusively on information recorded in the resident's clinical record.

  • Definition: Enter the one source of coverage that pays for most of the resident's current nursing home stay. Record "Other" only if the primary payor is not Medicaid or Medicare. For a patient with Medicaid coverage supplemented by Medicare Part B, record as "Medicaid". Record "Medicaid Pending" if there is no other primary coverage being used for the resident's present stay and the facility has sought or intends to seek establishment of Medicaid eligibility for the present stay.