Tag: documentation

CMS updates documentation requirement for nurse practitioners

CMS is updating the requirements when an agency is working with a nurse practitioner for home health orders or the care plan. The new language, added to Chapter 7 §30.2.1 in the benefit policy manual, notes: “In the absence of State law governing collaboration, collaboration is to be evidenced by the NPs documenting their scope […]

Updated CMS vaccine mandate guidance stresses contractor compliance

Make sure contracted staff are compliant with CMS’ vaccine requirement and that these contractors can provide proof of vaccination. CMS updated its guidance to surveyors on Tuesday, April 5, 2022, making it clear that contractor compliance is a high priority during survey reviews of vaccine documentation. The new guidance notes that surveyors should review the […]

ACHC shares vaccine mandate survey priorities

The Accreditation Commission for Health Care (ACHC) recently shared a list of the items its surveyors will be reviewing as they check organizations for compliance with the CMS COVID-19 vaccine mandate. ACHC surveyors are reviewing: Policies and procedures regarding COVID-19 vaccination(s). The tracking process used to log vaccination status of affected personnel. The process to […]

Q&A: Querying for acute respiratory failure

Q: Acute respiratory failure is consistently one of our top denied diagnoses. We’ve tried to address common documentation errors through education but are still seeing issues. How can our CDI staff and coders create more effective queries for this condition? A: The main reason I see for acute respiratory failure denials is a lack of […]

Provider to pay nearly $2.4 million after self-disclosing insufficient documentation

The Visiting Nurse Association and Hospice of Vermont and New Hampshire Inc. (VNH) will pay nearly $2.4 million to address an issue with orders that weren’t signed in line with requirements at the time, according to the Office of Inspector General. After self-disclosing the issue to the OIG, VNH agreed to pay $2,389,706.26 for allegedly […]

Tips for Training Employees Against Cyberattacks

The COVID-19 outbreak has affected almost every area of our pre-pandemic “normal” lives including more telework, a surging demand for toilet paper, and a shrinking workforce, just to name a few. Almost no industry has been spared when it comes to the contagious disease’s impact. In particular, cyberattacks are on the rise in nearly every […]

CMS clarifies medical review requirements for new hospice election statement addendum

A new transmittal to MACs issued Oct. 21, 2021, notes the manual updates for clarification on the election statement addendum requirements. Key among the changes included in the hospice rule that went into effect Oct. 1, 2021: Hospices have five days to furnish the addendum if requested within the first five days of the effective […]

Q&A: Revoking authorization for disclosure

Q: If an individual provides authorization for a disclosure, can the individual later revoke the authorization? Is the covered entity (CE) then required to “take back” or demand the erasure of any documentation by third parties that may have been made following the original authorization? A: Individuals have the right to revoke their authorizations in […]

Carefully log admission source as CMS focuses on hospital errors

CMS recently released an MLN article targeting hospitals and billing for patient care that involves a home health admission. When patients are transferred, a hospital is typically paid at per diem rate. An OIG report last year found improper payments tied to hospital claims that should have been subject to the transfer policy because the […]

Q&A: Coding suspected COVID-19

Q: Can we use U07.1 (COVID-19 virus, identified) for suspected COVID-19 cases? A: The ICD-10-CM guidelines now state you can only code confirmed cases of COVID-19, and only positive COVID-19 test results can be reported as well. For a confirmed COVID-19 diagnosis, code U07.1 should be reported. This is an exception to inpatient coding guidelines, […]