Question: Is a signed diagnosis list enough to support coding diagnoses in section I, or does the physician need to document the diagnosis as active in their notes? Answer from Jennifer LaBay RN, RAC-MT, RAC-MTA, CRC: Just having a diagnosis list signed by a physician is not quite enough. There …
Listen to this article Your browser does not support the audio element. In September 2025, the Office of Inspector General (OIG) rang the alarm bell on MDS coding inaccuracies involving falls with major injury, and the Centers for Medicare & Medicaid Services (CMS) took actions that every director of nursing …
Listen to this article Your browser does not support the audio element. Skilled nursing facilities (SNFs) frequently manage residents who temporarily leave the building or experience a break in Medicare Part A coverage. On the UB-04, these situations may look the same, often reflected as gaps in covered days or …
Question: If a resident was discharged return anticipated and comes back on day 30, would this be considered a readmission or a new admission? Answer from Carol Maher, RN, GERO-BC, RAC-MTA, RAC-MT, CPC: If the resident comes back on day 30, she would be a readmission not a new admission. …
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 …
Overview What is the Data Validation Process? The Data Validation Process evaluates the accuracy of quality measure data elements derived from the Minimum Data Set (MDS), which are used in the Skilled Nursing Facility (SNF) Value-Based Purchasing (VBP) and Quality Reporting Programs (QRP) for assessing quality of care and measuring …
The Centers for Medicare & Medicaid Services (CMS) is offering a Web-Based Training that provides the latest information about the respecification of the Falls with Major Injury (FMI) Quality Measure (QM) for the Post-Acute Care (PAC) Settings. The training provides an overview of the legacy and respecified FMI Measure, discusses …
Listen to this article Your browser does not support the audio element. As winter gives way to spring, many are relieved to leave behind icy sidewalks and the inevitable steady number of fall-related injuries that come with them. Yet in long-term care, fractures do not simply disappear with the snow; …
This quick reference tool helps interdisciplinary team members accurately distinguish between traumatic and pathological fractures for ICD-10-CM and MDS coding. It provides side-by-side guidance on coding rules, 7th character use, section I diagnosis coding (including I8000), and MDS item J1900C (falls with major injury). Use this tool to improve coding …
