Tag: documentation

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, […]

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 […]

Q&A: Preparing revenue cycle education for clinical staff

Q: What are some key revenue cycle topics that should be included in education geared toward clinical staff? A: Education for clinical staff should be specifically tailored to their functions and their direct interaction with and impact on the revenue cycle. Clinical staff should not be inundated with information that is not relevant to them. […]

Review documentation to ensure it’s written in understandable language

Ensure caregivers speak to clients in a way that clients can comprehend and that any documentation your agency provides is understandable as well. A huge percentage of U.S. adults have some form of literacy issue, notes Misty Kevech, project coordinator for the Home Health Quality Improvement (HHQI) National Campaign. And clients who are 65 years […]

New Podcast: Skilled Nursing and Documentation Challenges During COVID-19

Today, long-term care expert Maureen McCarthy, RN, BS, RAC-MT, CQP, president of Celtic Consulting, LLC., discusses how nurses can recognize when the care they are providing is skilled and how COVID-19 impacts skilled care and documentation. We also dive into lessons learned from northeast facilities as COVID cases rise in the other parts of the […]

MACs to hold two webinars about referrals and documentation

By Home Health Line. Part A/B and home health Medicare Administrative Contractors (MACs) are collaborating to hold two webinars Dec. 12 about home health referrals and clinical documentation requirements. The webinars will be held 11 a.m. to 12:30 p.m. EST and 3 p.m. to 4:30 p.m. EST. Among the topics slated for discussion: an overview […]

Review documentation to ensure it’s written in understandable language

Ensure caregivers speak to clients in a way that clients can comprehend and that any documentation your agency provides is understandable as well. A huge percentage of U.S. adults have some form of literacy issue, notes Misty Kevech, project coordinator for the Home Health Quality Improvement (HHQI) National Campaign. And clients who are 65 years […]

Does the home health episode have any effect on readmission?

By The Bottom Line Q: We have a patient that was in the hospital for one week. The patient went to another skilled nursing facility (SNF) for 25 days, then went home, but used home health services. The patient now wants to come back into our SNF. It is within 30 days of the previous […]

Pre-pay audits target J5 providers in IA, KS, MO, NE and national

J5 Jurisdiction providers are being targeted for prepayment, service specific, complex medical reviews of Inpatient SNF services conducted by Wisconsin Physician Services Government Health Administrators (WPS GHA), a Medicare Administrative Contractor (MAC) for the Centers for Medicare & Medicaid Services (CMS). J5 Jurisdiction includes skilled nursing facilities (SNF) that submit claims from Iowa, Kansas, Missouri, […]

Ask the expert: Documentation of life expectancy

Q: In order to code Section J1400 of the MDS “yes”, does the facility need documentation from the physician or hospice stating the resident has a life expectancy of less than six months or is just being on hospice sufficient? A: The facility needs documentation from the physician, not the hospice that a resident has a […]