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Q: I’m not sure how to determine whether I should check MDS item J1j, internal bleeding. Are two positive stool samples sufficient? Also, how does internal bleeding affect PPS reimbursement?

Julia's PPS Chat, December 8, 2004

Welcome again to our PPS chat!

What should you do when you are not sure how to code an item on the MDS? Rather than guessing, you should always consult the updated Resident Assessment Instrument (RAI) User's Manual.

Read on to find out how to code internal bleeding-

Q: I'm not sure how to determine whether I should check MDS item J1j, internal bleeding. Are two positive stool samples sufficient? Also, how does internal bleeding affect PPS reimbursement?

A: Let's begin by looking at the revised RAI User's Manual's definition of internal bleeding. On p. 3-139, the definition states that "bleeding may be frank (such as bright red blood) or occult (such as guaiac positive stools). Clinical indicators include black, tarry stools, vomiting 'coffee grounds,' hematuria (blood in urine), hemoptysis (coughing up blood), and severe epistaxis (nosebleed) that requires packing. However, nose bleeds that are easily controlled should not be coded as internal bleeding."

As indicated in this definition, two positive stool samples definitely qualify as internal bleeding.

When coding this item, remember to not only look for the obvious signs of internal bleeding as listed above, but also the less obvious signs. Abnormal blood work results, the sudden onset of pain, and intense weakness can all be possible indications of internal bleeding and require further assessment.

Internal bleeding can qualify a resident for a clinically complex Resource Utilization Group. Because the presence of internal bleeding can require you to do a large amount of monitoring, assessment, and observation, you could consider treating internal bleeding as a skilled service.

Assess your resident very carefully for internal bleeding. Do not rely only on chart documentation alone, but also talk with staff, the resident, and family members to accurately determine whether this condition exists. Therefore, code item J1j according to the updated RAI User's Manual definition, consult with the physician, and provide the appropriate plan of care.

So, the best way to proceed is to always check the RAI User's Manual. The definitions of the MDS items become even more important when they affect PPS reimbursement. Be sure you are coding correctly so that you get reimbursed what you deserve!

Until we chat again about health conditions-