In long-term care, the Minimum Data Set (MDS) ensures appropriate care planning, accurate reimbursement, and quality measurement while maintaining compliance with federal and state regulations. However, MDS coding may pose some ethical challenges. Completing the MDS accurately and according to the Long-term Care Facility Resident Assessment Instrument 3.0 User’s Manual …
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 …
Medications are an essential part of the care and interventions provided to residents in a skilled nursing facility. These medications may be used to manage chronic conditions, slow disease progress, ease symptoms, or even prevent a condition. With each medication, the associated risks and benefits must be considered. High-risk medications …
On Oct. 1, 2024, the Centers for Medicare & Medicaid Services (CMS) released the draft MDS version 1.20.1 item sets and item matrix for implementation on Oct. 1, 2025. The change history included with the item sets indicates planned changes to sections A (Identification Information), B (Hearing, Speech, and Vision), …
Accurate diagnosis coding is critical in nursing facilities (NFs) for care planning, reimbursement, and quality measurement. NF coders must understand ICD-10-CM conventions, general coding guidelines, and chapter-specific coding guidelines that affect how diagnoses are assigned. Coding guidance can be found in the ICD-10-CM Official Guidelines for Coding and Reporting for FY …
Question: When a resident received IV fluids (K0520A) for hydration, but did not have any calories from the fluids, do we code K0710A (Proportion of total calories the resident received through parenteral or tube feeding) as 1. 25% or less? Answer from Carol Maher, RN, GERO-BC, RAC-MTA, RAC-MT, CPC: Correct, …
Question: A resident was admitted to our facility on Medicare Part A and passed in facility after only a couple of hours. I had scheduled a 5-Day/Admission for the 7th day before she passed. How do I set up MDS assessments? I know I can’t combine the death in facility …
By Greg Seiple Navigating the complexities of healthcare, especially in post-acute care, can often feel daunting. For professionals involved in skilled nursing facilities, understanding the metrics that influence patient care is crucial. One of these key metrics is the Discharge Function Score (DFS), a valuable tool that helps gauge a …
Written by Kristine Martinez BSN, RN, RAC-CTA, QCP Completing a Minimum Data Set (MDS) correctly is no small task. With approximately 510 answers or choices on a comprehensive MDS (not including CAA investigation), and approximately530 answers or choices on a 5-day MDS, the potential for missed or miscoded information on any …
By Greg Seiple Discharge planning is an essential component of patient care in skilled nursing facilities. But how do healthcare professionals determine when a resident is ready to leave and manage daily activities independently? Enter the Discharge Function Score—a critical tool in evaluating a resident’s ability to function outside of …
