Question: How do you code discharge status, A2105, when the resident discharged to a hotel? Answer from Carol Maher, RN, GERO-BC, RAC-MTA, RAC-MT, CPC: A discharge to a homeless shelter, jail, or hotel would be coded as 99, None of the above. This AAPACN resource is copyright protected. AAPACN individual members …
Question: If a resident has a diagnosis of “schizoaffective disorder, bipolar type,” how is this coded on the MDS? Answer from Carol Maher, RN, GERO-BC, RAC-MTA, RAC-MT, CPC: Schizoaffective disorder would be coded at I6000, but ONLY if all of the DSM-5 requirements are met (physician comprehensive assessment present and …
In this LTC NAC Chat podcast episode, Amy Stewart, MSN, RN, DNS-MT, QCP-MT, RAC-MT, RAC-MTA, chief nursing officer for AAPACN, and Janine Lehmen, director of clinical and legal nursing consulting with Proactive LTC Consulting, discuss Lehman’s AAPACN 2026 Conference session on Wednesday, March 18 at 2 pm ET, “The MDS …
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Consistency in documentation is vital to code the MDS accurately. Several MDS items use hospital records to support coding, such as diagnoses, recent surgery, IV fluids/feeding, and tube feeding. Use the PDPM Admission Documentation Request tool as a checklist to ensure a comprehensive review of hospital documentation required to support …
Listen to this article Your browser does not support the audio element. As National Kidney Month arrives in March, so does an important reminder: our kidneys work quietly every day, filtering waste, balancing fluids, and supporting overall health. Now is the perfect time for facility coders in long-term care (LTC) …
Listen to this article Your browser does not support the audio element. All signs point to one universal truth for the nurse assessment coordinator (NAC): MDS accuracy is paramount, says Joel VanEaton, BSN, RN, RAC-MTA, RAC-MT, RAC-CTA, RAC-CT, executive vice president of post-acute care regulatory affairs and education for Broad …
Listen to this article Your browser does not support the audio element. Nurse assessment coordinators (NACs) are often tasked with navigating the complex process of following the Minimum Data Set (MDS) instructions precisely while still ensuring they reflect the resident’s true clinical picture. In many situations, the answer is not …
Question: Can you please clarify “head injury”—the criteria for coding major injury at J1900C? Answer from Jessie McGill RN, BSN, RAC-MTA, RAC-CTA: CMS did not provide a definition of major injury but instead provided a list of comparable injuries: “Includes, but is not limited to, traumatic bone fractures, joint dislocations/ …
Question: When coding height for a resident with bilateral lower leg amputations, do you code the height prior to amputation or after? Answer from Carol Maher, RN, GERO-BC, RAC-MTA, RAC-MT, CPC: You code the height in the 7-day look-back. If the resident now has bilateral amputations, the height would be measured …
Question: If a long-stay resident has a Stage 2 pressure ulcer and it heals, would a Significant Change in Status Assessment (SCSA) be required? Answer from Jennifer LaBay RN, RAC-MT, RAC-MTA, QCP, CRC: On page 2-24 the RAI User’s Manual defines a Significant Change in Status as “a major decline …
