COMPLIANCE

Pay close attention to new definitions in the new MDS effective October 1, 2025

Avoiding costly compliance errors under the new MDS, Sector experts advise being extra diligent in monitoring and documenting new compliance related to section J, or Falls, and section O, or Therapy Services, according to Alicia Cantinieri, managing director of clinical reimbursement and regulatory compliance at Zimmet Healthcare Services Group.

These sections, in particular, have become known as major sources of compliance errors and revenue loss.

Section J’s redefinition of a “fall” now includes those caused by “overwhelming external force,” which is a reversal of prior guidance. This shift could significantly affect fall-related Quality Measures (QMs) and requires facilities to retrain staff on fall incident reporting.

There are also some very fundamental changes to definitions in the new MDS. Certain fields are never allowed to be left incomplete, so “dashing” these fields violates reporting requirements and could result in rejection.

No longer required data are details that should nevertheless be collected to make documentation more useful. Poorly conducted interviews can lead to inaccurate data, hurting both reimbursement and care planning.

Top Denials

Respiratory therapy remains one of the most common areas for denials and audit findings. In order to code respiratory therapy, there must be a physician or non-physician practitioner (NPP) order that includes frequency, duration, and scope of the therapy, but facilities can overlook this. Moreover, it is required that documentation must be clear, staff credentials must be verifiable, and periodic evaluations of whether the therapy is effective must be conducted, she said.

Cantinieri recounted one audit example that showed a denial that cost the facility over $5,000 due to lack of proper documentation and credentialing, highlighting how missing just one required component invalidated the entire respiratory therapy coding and associated reimbursement.

Weight loss and gain items, pressure ulcers, and long-stay antipsychotic use remain areas of scrutiny.

Falls Coding

Accurate coding of falls on the MDS, remains imperative. The updated fall definitions and the inclusion of additional injury types in the criteria may make it appear as though more residents are falling, even though the increase is due to definitional changes rather than actual incidents.

CMS does not necessarily make Medicare reimbursements without any questions. In fact, the government will audit nursing facilities to make sure reimbursements are properly aligned with services rendered. And when the paperwork doesn’t exactly correspond with the payment, the government will seek to recover what it views as improper reimbursements.

POLICY

Nursing staff mandate withdrawn

• Seniors may face impacts on care quality or access
• Facility operators will have less regulatory pressure and cost burden
• Some staff, due to lower staffing levels, may experience increased work loads
• Policymakers pushed for the repeal to save federal funds and avoid closures of rural facilities

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