ICD-10-CM: Navigating the Term “With,” Combination Codes, and Complications of Care

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 …

Why Getting MDS Right Is Non-Negotiable: The Importance of MDS Accuracy

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 …

Direct-Care Staff Are Front-Line Defenders Against Sepsis: What They Need to Know

Since the COVID-19 pandemic began in 2020, the risk of developing sepsis has increased nationwide, according to the September 2024 report An Assessment of Sepsis in the United States and Its Burden on Hospital Care (Sepsis Assessment) from the Agency for Healthcare Research and Quality (AHRQ). Sepsis-related inpatient stays in …

Emergency Preparedness Plan: How the DNS Can Ensure the Nursing Department Is Ready When Disaster Strikes

Emergency preparedness is a vital component of maintaining safety and ensuring continuity of care in post-acute care settings. Facilities face unique challenges in emergency situations. The vulnerable people they care for, including the elderly and those recovering from surgery or a serious illness, are especially susceptible to adverse outcomes. The …

Mastering the Discharge Function Score for Skilled Nursing Facilities

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 …

GG0130 and GG0170: Using Clinical Judgment to Establish Usual Performance

The ability to exercise clinical judgment to define usual performance in MDS items GG0130 (Self-Care) and GG0170 (Mobility) offers nursing homes unprecedented opportunity to impact quality measures (QMs), says Rosanna Benbow, RN, CCM, ICC, IP, DNS-CT, QCP, RAC-CTA, regional director of operations at Proactive LTC Consulting in Evansville, IN. “You …

SNF ABN Update: What Changed and How to Keep the Process Running Smoothly

Effective Oct. 31, 2024, skilled nursing facilities (SNFs) now are required to use an updated Skilled Nursing Facility Advance Beneficiary Notice of Noncoverage (SNF ABN), also known as form CMS-10055, and the corresponding revised instructions to provide financial liability notifications to residents under fee-for-service (FFS) Medicare Part A. Note: The …

Sepsis Primer: What Is It, and How Does It Tie Into Survey and QMs?

Sepsis—a key driver of hospital readmissions—can have negative clinical impacts for residents and negative financial, quality, survey, and even legal impacts for nursing homes. Here is a review of important basics: What is sepsis? The current clinical definition of sepsis is “life-threatening organ dysfunction caused by a dysregulated host response …

Antibiotic Stewardship: Make Sure New IPs Have an Action Plan

Antimicrobial medications are used to treat infections (and sepsis) caused by bacteria, parasites, viruses, and fungi. Antimicrobial resistance (AR)—when germs conquer the drugs that are supposed to kill them and instead keep growing—occurs naturally. However, exposure to antibiotics and other antimicrobial drugs builds resistance mechanisms in germs, speeding up the …