The Significant Change in Status Assessment (SCSA) has been a federal requirement since the inception of the Resident Assessment Instrument (RAI) process that resulted from the Omnibus Budget Reconciliation Act of 1987. The specifications of how to complete this assessment are described in chapter 2 of the RAI User’s Manual …
Skilled nursing facilities (SNFs) are increasingly subject to skilled medical review audits from both fee-for-service Medicare (e.g., the SNF Five-Claim Probe and Educate initiative) and individual Medicare Advantage plans. Audit success ultimately hinges on documentation quality, but the presence of documentation in the medical record is no guarantee of the …
The Significant Change in Status Assessment (SCSA) was not a major focus of the revisions in the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual v1.18.11. However, some of the v1.18.11 MDS coding changes could have an outsized impact on the SCSA process if nurse assessment coordinators (NACs) fail …
In the updated Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User’s Manual, v1.18.11, the Centers for Medicare & Medicaid Services (CMS) added several clarifications to help ease the pressure that nurse assessment coordinators (NACs) experience attempting to code section M accurately. Although strong clinical documentation of these wounds is …
Properly coding pressure ulcers or injuries can be tricky. AAPACN’s Section M Pressure Ulcer/Injury: Algorithms for Present on Admission helps guide the assessor on whether to code present on admission in variety of situations. This AAPACN resource is copyright protected. AAPACN individual members may download or print one copy …
Now that the MDS version 1.18.11 item sets and the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual v1.18.11 are in play, there are still steps that nurse assessment coordinators can take to ensure that MDS processes are as efficient as possible under the new system. These include the …
The Centers for Medicare & Medicaid Services (CMS) recently released the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User’s Manual version 1.18.11, and also a document outlining the draft-to-final changes and updated item sets (v.1.18.11 v5). But the updates and clarifications don’t end there. Nurse assessment coordinators (NACs) need …
Most of the changes in the MDS version 1.18.11 item sets and the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual v1.18.11 are resident-driven, says Jennifer LaBay, RN, RAC-MT, RAC-MTA, QCP, CRC, a curriculum development specialist with AAPACN. “More than ever, resident interviews are the primary source of MDS …
Effective International Classification of Diseases, Tenth Edition, Clinical Modification (ICD-10-CM) coding relies on meticulous clinical documentation. It’s not just about assigning codes; it’s about ensuring consistent and comprehensive documentation that substantiates every facet and the specificity of a diagnosis. This documentation should originate from a provider, that is, a physician …
ICD-10-CM coding requires consistent and complete documentation from the provider (physician/nonphysician practitioner) to support all aspects and specific details of the diagnosis. This AAPACN Provider ICD-10-CM Documentation Tip Sheet for Long-Term Care tool serves as a companion to the Centers for Medicare & Medicaid Services (CMS) presentation ICD-10 and Clinical …
