COVID-19 Vaccine “Up to Date” Guidance Tracker

The Centers for Disease Control and Prevention (CDC) has updated the “Staying Up to Date with COVID-19 Vaccines” guidance twice since requiring COVID-19 vaccinations to be coded on the MDS as of October 2024. Facility teams can track these changes by using AAPACN’s COVID-19 Vaccine “Up to Date” Guidance Tracker. …

Q&A: We have a Medicare Part A resident who was only skilled by nursing at the end of the stay. How do we code GG items that only therapy perform, such as car transfers and stairs, if the resident was no longer receiving therapy services during the 3-day look-back window at the time of discharge? 

Question: We have a Medicare Part A resident who was only skilled by nursing at the end of the stay. How do we code GG items that only therapy perform, such as car transfers and stairs, if the resident was no longer receiving therapy services during the 3-day look-back window …

Q&A: A Medicare Part A resident passed away in the emergency department. I know a Death in Facility record needs to be completed, but do I also need to complete a Medicare Part A PPS discharge assessment?

Question: A Medicare Part A resident passed away in the emergency department. I know a Death in Facility record needs to be completed, but do I also need to complete a Medicare Part A PPS discharge assessment? Answer from Carol Maher, RN, GERO-BC, RAC-MTA, RAC-MT, CPC: We do not complete …

Q&A: To code K0300A for a physician-ordered weight loss, does the physician need to write a progress note that weight loss is intended or will an order for a diuretic automatically make the weight loss planned?

Question: To code K0300A for a physician-ordered weight loss, does the physician need to write a progress note that weight loss is intended or will an order for a diuretic automatically make the weight loss planned? Answer from Carol Maher, RN, GERO-BC, RAC-MTA, RAC-MT, CPC: It is not enough to …

Acentra BFCC-QIO Postacute Newsletter: Recommendations for SNFs to Improve Medical Record Documentation

Several sections may be useful, including Recommendations for Skilled Nursing Facilities to Improve Medical Record Documentation https://acentraqio.com/newsletter/crc/February2025postacute

Section S for MDS Data Specifications V3.10.1 (FINAL) Oct. 1, 2025 Implementation

The Section S portion of the forthcoming MDS Data Specifications V3.10.1 (FINAL) is now available for download under the Downloads section at the bottom of this webpage.  This MDS version will be implemented in production on October 1, 2025.  The ZIP file below contains a PDF of the complete Section S specifications …

iQIES Known Issues: MDS 3.0 Manual Individual Correction/Deletion Request

Open Assessments MDS The electronic change request form titled “MDS 3.0 Manual Individual Correction/Deletion Request” can only be utilized for deletion requests at this time. Please submit A0410 Corrections using the manual process. We are working to resolve this issue. https://iqies.cms.gov/iqies/help/known-issues

Compliance in Diagnosis Selection for Skilled Rehabilitation

For skilled nursing facilities (SNFs), diagnosis selection and accurate ICD-10-CM coding are essential for both quality resident care and compliance with regulations. For therapists providing skilled rehabilitation services, the ability to choose the correct diagnosis code is not only crucial for resident outcomes but also ensures proper reimbursement and avoids …

Care Conference: How Do Resident Rights Connect to Care Planning?

Some nurse assessment coordinators (NACs) may believe that having a care conference (aka care plan meeting) with the resident and/or their responsible party or family member is a regulatory requirement. “However, no regulations actually use the term care conference,” says Scott Heichel, RN, RAC-MT, RAC-CTA, DNS-CT, IPCO, QCP, ICC, director …