Category: Q&A

Question: When resuming Medicare Part A within the 30-day transfer rule, which GG observation period should be used on a Significant Change in Status (SCSA) combined with a 5-Day? Answer from Jennifer LaBay, RN, RAC-MT, RAC-MTA, QCP, CRC: The GG observation period is the first three days of the Medicare …

Question: Does “at risk for malnutrition” qualify for coding if it is only documented by a dietitian and not by a physician? Answer from Jeff Taylor: The steps for assessment and coding instructions for I5600 require provider documentation during the 60-day observation period. You need a provider (physician, nurse practitioner …

Question: If a resident dies before an assessment is completed, should the MDS be finished or canceled? Answer from Jennifer LaBay, RN, RAC-MT, RAC-MTA, QCP, CRC: When a resident dies while in the middle of the completion of an assessment but before it is required to be completed, you should …

Question: If a resident develops a blood blister or pressure ulcer but has no other decline in ADLs, cognition, or condition, is a Significant Change in Status Assessment (SCSA) required? Answer from Carol Maher, RN, GERO-BC, RAC-MTA, RAC-MT, CPC: A new pressure ulcer is one area of decline. We are …

Question: A dialysis patient is going out of the facility for dialysis. We use the appropriate N18 code, but would Z99.2 be excluded since dialysis isn’t provided in-house? Answer from Carol Maher, RN, GERO-BC, RAC-MTA, RAC-MT, CPC: The resident remains your SNF’s resident while receiving dialysis. Coding should reflect the …

Question: We have a patient who is on hospice but elected to be sent out over the weekend for an acute illness, so he revoked his hospice status. He came back less than 24 hours later. If he is picked back up on hospice within the next day or two, …

Question: If a resident has a fall that causes a hairline clavicle fracture, is that automatically considered a major injury? Answer from Carol Maher, RN, GERO-BC, RAC-MTA, RAC-MT, CPC:Yes, any traumatic fracture related to a fall is a fall with major injury—even a finger or toe. This AAPACN resource is …

Question: A resident’s last therapy day was on 3/5. He didn’t go home until the afternoon of the next day, 3/6. Can I combine the OBRA Discharge and the PPS Discharge assessments, or since the last covered day and physical discharge are different days, do they need to be done …

Question: A resident’s wheelchair tipped backward in therapy. The physical therapy assistant was able to catch him, but it resulted in a skin tear to the arm. The resident remained in the wheelchair and did not come to rest on the ground. Should this be coded as a fall? Answer …