After months of deliberation and confusion surrounding coding for activities of daily living (ADLs), CMS posted clarifying instructions in the RAI User’s Manual, version 1.11,1 which became effective October 1, 2013. While the instructions are clear, the results may be different from what coders might have previously expected. Most notable is the emphasis on coders’ following the “Rule of 3” in sequential steps as opposed to strictly using the ADL algorithm (p. G-7).
In the October update, the “Rule of 3” (p. G-6) states: “Use the first instruction encountered that meets the coding scenario (e.g., if #1 applies, stop and code that level).” For example, when a resident requires multiple episodes of Supervision (e.g., three times), and only one or two episodes of Limited assistance, Extensive assistance or Total assistance, but not three times at any one of these levels, the code would be Supervision. Coders are not allowed to combine episodes of higher levels of assistance when the definition for the first Rule of 3 is met at lower levels of coding.Because of this clarification, coders who exclusively rely on the algorithm to code the MDS might not arrive at the correct score. It is best to think of the algorithm as a tool that “augments” the ADL scoring instructions and is useful in some but not all coding situations (p. G-4). The algorithm is most helpful in cases where the ADL activity occurred at least three times, but not three times at any one level.
The updated RAI User’s Manual outlines the following sequential steps in the Rule of 3 (p. G-6).
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