MDS items GG0130 (Self-Care) and GG0170 (Mobility) are a common source of headaches for both the nurse assessment coordinator (NAC) and the interdisciplinary team (IDT). While there is no one-size-fits-all approach for obtaining accurate documentation to support functional status coding, there are steps that the NAC can take in conjunction …
Section GG has greatly evolved since 2016. It was first introduced as just a few functional items completed only for Medicare Part A residents, but now it requires 26 functional tasks for all long-term care residents. The accuracy of section GG not only impacts reimbursement but also plays a fundamental …
Effective communication with residents in skilled nursing facilities (SNFs) is essential to understand their needs and preferences. In accordance with Appendix D of the Long-Term Care Facility Resident Assessment 3.0 User’s Manual (RAI User’s Manual) and the principles outlined in the Center for Medicare & Medicaid Services (CMS) Video on …
Identifying and dealing with a suspected change in condition before a clinical crisis occurs is a critical aspect of caring for fragile, elderly nursing home residents. To achieve that goal, nursing staff must think critically about the residents in their care. The director of nursing services (DNS) can take steps …
Over the last decade, a strong orientation and onboarding process has been linked to higher levels of knowledge, critical thinking skills, and job satisfaction among nursing staff—leading to lower staff turnover and improved retention. Conversely, an inadequate onboarding process can quickly turn new hires into former employees, forcing providers to …
Fall is here, and respiratory virus season is around the corner. Nursing leaders must take proactive steps to protect residents from these viruses, which carry the potential for serious illness and can lead to hospitalization. This article will spotlight areas to focus on for respiratory virus prevention and control, as …
The Medicare Part A PPS Discharge assessment (i.e., the NPE item set) is now a crucial assessment with far-reaching impacts for skilled nursing facilities (SNFs) in the Skilled Nursing Facility Quality Reporting Program (SNF QRP), the Skilled Nursing Facility Value-Based Purchasing (SNF VBP) program, the Five-Star Quality Rating System, and …
Effective Oct. 1, 2024, the Centers for Medicare & Medicaid Services (CMS) removed column 2, discharge goals, from items GG0130 and GG0170 on the Minimum Data Set (MDS). Many nurse assessment coordinators will welcome the reduced coding of these expansive GG items. But just because these goals are no longer …
The ICD-10-CM code captured in MDS item I0020B (ICD-10 Code/Primary Medical Condition Category) is the foundation of case-mix classification for the Physical Therapy (PT), Occupational Therapy (OT), and Speech-Language Pathology (SLP) payment components in the Patient-Driven Payment Model (PDPM) under the fee-for-service Medicare Part A skilled nursing facility prospective payment …
The International Classification of Diseases, Clinical Modification, 10th revision (ICD-10-CM), coding system is an essential tool needed to document and bill accurately for healthcare services in the long-term care (LTC) setting. Annual updates to both the coding guidelines and the actual codes reflect updated clinical practices, advancements in medical understanding, …
