Q0620: Reason Referral to Local Contact Agency (LCA) Not Made, Step-by-Step

Step-by-Step Coding Guide for Q0620: Reason Referral to Local Contact Agency (LCA) Not Made

1. Review of Medical Records

• Objective: Thoroughly examine the resident's medical records to determine if there was a need for a referral to a Local Contact Agency (LCA) and identify documented reasons why such a referral was not made.
• Key Documents to Review: Look for comprehensive assessments, care plans, social service notes, and discussions with the resident and their family regarding post-discharge planning and LCA referral considerations.

2. Understanding Definitions

• Local Contact Agency (LCA): An entity designated to assist residents in exploring options for care and services outside the facility, including but not limited to home-based services, community resources, or alternative placement options.
• Reason Referral Not Made: The rationale documented by the facility for not referring a resident to the LCA, despite potential or expressed need for such services or resources.

3. Coding Instructions

For Q0620, code the primary reason a referral to the LCA was not made from the options provided in the MDS item set, which typically include reasons such as resident or family declined, services not available, or resident's needs met within the facility.

4. Coding Tips

• Ensure a clear understanding of all potential reasons for not making a referral and apply the most accurate reason based on comprehensive assessment and documentation.
• Regularly review facility policies and any state-specific guidelines regarding LCA referrals to ensure compliance and accurate coding.

5. Documentation

• Document detailed explanations for not referring a resident to the LCA, including any resident or family discussions that informed this decision.
• Record any assessments or evaluations that support the decision, highlighting how the resident's needs are being met within the current setting or why external services were declined or deemed unnecessary.

6. Common Errors to Avoid

• Overlooking Resident/Family Input: Failing to consider or document the resident's or their family's preferences regarding LCA referral.
• Insufficient Documentation: Not providing a detailed rationale for not making the referral, including how decisions were made and who was involved in the discussion.
• Misinterpretation of Options: Incorrectly coding the reason for not referring without thoroughly assessing the resident's situation or exploring all possible services and resources.

7. Practical Application

• Example Scenario: A resident nearing discharge expressed a desire to return home but was uncertain about available support. After discussions with the resident and their family, and a thorough assessment of available community resources, it was determined the resident's family could provide the necessary care, and they declined the LCA referral.
  • Documentation: Detail discussions with the resident and family, the assessment of the resident's care needs and available support, and the rationale for the decision against the LCA referral.
  • Coding: Based on the specific reasons provided in the MDS item set, select the code that best describes why the referral was not made, such as "resident or representative declined the referral."

The Step-by-Step Coding Guide for item Q0620 in MDS 3.0 Section Q is based on the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.18.11, dated October 2023. Please note that healthcare guidelines, policies, and regulations can undergo frequent updates. Therefore, healthcare professionals must ensure they are referencing the most current version of the MDS 3.0 manual. This guide aims to assist with understanding and applying the coding procedures as outlined in the referenced manual version. However, in cases where there are updates or changes to the manual after the mentioned date, users should refer to the latest version of the manual for the most accurate and up-to-date information. The guide should not substitute for professional judgment and the consultation of the latest regulatory guidelines in the healthcare field.