Archive for 'Reimbursement'

Clarify Primary VS Secondary to Confidently Code Section I – Active Diagnoses

Posted on 13. Jun, 2014 by .


While coding Section I, identify the active diseases and infections that drive the current care plan and report them on the MDS 3.0.


Confused between which diagnosis is primary and which is secondary? Heed this advice to differentiate between the two and code Section I (active diagnoses) as accurately as possible:

1.      Demystify ‘Direct Relationship’ Concept

To accurately code Section I, it is critical to understand the concept of “direct relationship”.  A disease that drives the resident’s plan of care is taken as one that has a direct relationship to the resident’s status, and therefore is considered to be an active diagnosis. While coding Section I, you must spot the active diseases and infections that drive the current care plan and report them on the MDS 3.0.

2.      Two Steps  with Specific Look-Back Periods

In order to code Section I, you must take two steps with specific look-back periods. Identify diagnoses in the first step by ensuring a physician-documented diagnosis in the last 60 days. Depending on your state licensure laws, you may meet the physician-demonstrated diagnoses by a nurse practitioner, physician’s assistant or clinical nurse specialist.

3.      Figure Out Whether Diagnoses are Active

Next is to determine whether the diagnoses are active. Active diagnoses are those that, during the seven-day look-back period, have a direct relationship to the resident’s present functional, cognitive, or mood behavior status; medical treatments, nursing monitoring or risk of death.


The following are not considered active diagnoses. So don’t

  • Include ‘conditions’ that have been resolved
  • Affect the resident’s current status
  • Drive the resident’s plan of care during the seven-day look-back period.
  • Expect the physician to always specifically indicate in the medical record that a diagnosis is active.

You’ll need to look for other sources of info documenting a specific diagnosis. 

4.      Check for Documentation in These Places

You can look for information to determine whether a diagnosis is active in the last seven days in places such as transfer documents, recent history and physicals, physician’s progress notes, recent discharge summaries, nursing assessments, care plans, medication sheets, physician’s orders, etc.

5.      Refrain from Treating Section I Diagnoses as ‘All-Inclusive’

Even though Section I lists many diagnoses by major disease category and some diagnoses listed have examples of diseases included in those diagnoses, it is important to note that these examples are not all-inclusive.

6.      Identify the Primary Diagnosis

Moreover, correct Section I coding depends on specific and accurate documentation. Facilities in general should work to clarify any nonspecific diagnoses as much as possible. Remember: Non-specific diagnoses along with confusion between primary and secondary diagnoses can lead to coding mistakes in Section I.

7.      Watch out for Look-back Exception for I2300

Even though Section I specifies a look-back period of seven days, there’s an exception for: I2300 — Urinary Tract Infection (UTI), which has a look-back period of 30 days. As such, don’t allow this different look-back period trouble you when you are coding Section I. You must also identify four elements to code this diagnosis:

  • The UTI must be present in the 30-day look-back period, with a diagnosis made by a physician/other authorized licensed staff in accordance with your state law.
  • Identify at least one sign or symptom attributed to UTIs.
  • Significant laboratory findings or urine culture, as the physician deems fit.
  • Staff administered a medication or treatment for a UTI within the last 30 days.


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CLASS Act Aims to Defray LTC Costs for People With Functional Limitations

Posted on 14. Apr, 2010 by .


Find out what the CLASS Act provides and a potential Achilles’ heel.

How many times have you admitted residents who were counting on Medicare to pay for their long-term care needs way beyond a 100-day SNF stay? In reality, of course, the federal government has passed the buck for long-term care to Medicaid. But the healthcare reform legislation seeks to create a new federal program to pick up some long-term care costs.

 The legislation incorporates the Community Living Assistance Services and Supports (CLASS) Act, which is a national insurance program designed to help pay for long-term care, says attorney Wayne J. Miller, founding partner of the Compliance Law Group in Los Angeles.

Here’s how it works …

“The CLASS Act will make long-term care insurance available to all Americans, who will be automatically enrolled with the choice to opt out,” explains Miller.  

Those who pay premiums for a five year vesting period and develop functional limitations are eligible to receive an average $50 cash per day benefit to defray the costs of long-term care services. There’s no limit on how long a beneficiary can access the benefits. “Premium costs will be tied to age.” The program is set to be established by September 2012, says Miller.

Experts disagree, however, over how the CLASS Act may play out. In an editorial entitled “CLASS Caveats,” published by McKnights’ Long Term Care News,  LTC insurance guru Steve Moses points out a number of what he sees as inherent problems with the program. And adverse selection is on the list. “People most likely to use the benefits will be far more likely to participate than people who are privately insurable otherwise,” Moses wrote in the editorial.

 In an NPR News  article, Judy Feder, with Georgetown University, counters concerns about adverse selection, noting that “with a federally blessed, federally advertised program, there is a likelihood of higher participation rates from the get-go, which is what you need to make sure that healthy people are signing up.”

Don’t stay in the pre-healthcare reform age:  From RACs to RUGs to new rules affecting survey CMPs, find out what the healthcare reform bill means for your nursing facility.  Subscribe now to MDS Alert and Long-Term Care Survey Alert. 

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AAHSA-Compiled Stats Help You Read Between the Lines for Medicare Initiatives

Posted on 09. Apr, 2010 by .


These resources help you tackle common problems in SNFs.

Statistics can provide a portrait of where long-term care has been and how it’s unfolding. In fact, the American Association of Homes & Services recently created just that with a statistical overview of the LTC landscape and nursing home residents’ profiles and care needs (

“More than 1.5 million people reside in U.S. nursing homes, at a cost of more than $120 billion per year,” notes the AAHSA compilation, citing Advancing Nursing Home Quality Through Quality Improvement Itself, Rachel M. Werner & R. Tamara Konetzka, Health Affairs, January 2010, vol. 29, pg 81.

The stats also help explain the federal government’s growing focus on finding ways to rein in rehospitalization for post-acute patients. Rehospitalization rates for SNF patients jumped by 29 percent from 2000-2006, the AAHSA report notes. “By 2006, more than one-fifth (23.5 percent) of all hospital discharges to a skilled nursing facility returned directly to the hospital, at a total cost of $4.34 billion per year to the Medicare program. (The Revolving Door of Rehospitalization From Skilled Nursing Facilities, Vincent Mor, Orna Intrator, Zhanlian Feng & David Grabowski, Health Affairs, January 2010, vol. 29, pg 62).”

CDC Provides Snapshot of Nursing Home Residents


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Stave Off RAC Denials: Be Careful With These 3 Part B Rehab Areas

Posted on 06. Apr, 2010 by .


Take the time to focus on untimed codes.

If your RAC readiness program for Part B doesn’t prevent or fix these key issues before billing, it may need some quick rehabbing of its own.

1. Non-compliance with the Medicare contractor’s local coverage decisions. “Some FIs/MACs have local coverage decisions where they won’t pay a particular CPT code without a certain therapy treatment diagnosis code being on the claim,” says Victor Kintz, MBA, CHC, LNHA, RAC-CT, CCA, managing director of operations for The Polaris Group based in Tampa, Fla. “Those omissions will be easy ones for RACs to find,” Kintz warns. “If you have a patient who makes two steps forward with therapy and takes two steps backward when therapy stops — that person may not be appropriate for therapy,” Beckley adds. However, “there are exceptions where an intervening event such as a fall or acute illness may have caused the decline,” she adds. If the patient isn’t a candidate for therapy, he may still be a candidate for restorative nursing.

2. Documentation shortfalls. Part B therapy is vulnerable to complex reviews by RACs in the area of medical necessity, says Nancy Beckley, MB, MBA, CHC, a consultant with Bloomingdale Consulting Group Inc. in Brandon, Fla. “The supporting Part B documentation should identify the decline in patient function,” advises Kintz. “Hopefully the nurses’ notes speak to the decline in function prior to the initiation of therapy services, as well.” The medical record and therapy evaluation should also clearly state the patient’s prior level of function, he adds. “It’s not enough to state that the person is in the nursing home.”

Also: “Identify the reason for the therapy referral and if the patient has previously received therapy for the same condition,” advises Beckley. Suppose a patient has a chronic condition, such as Parkinson’s or Alzheimer’s disease and has been treated for it previously. In that case, the therapist has a “duty to differentiate why skilled therapy is needed again and what it is going to accomplish,” says Beckley.

… don’t let this pass you by


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Rehab: Nail Down New Ways to Handle IRF Coverage Criteria

Posted on 26. Mar, 2010 by .


Get crafty with CMS timeframe requirements by flagging your charts.

Still treading water from the changes that hit your inpatient rehab facility in January? Get smart solutions on tackling two key challenges.
Challenge #1: How can I keep all the new preadmission screening requirements straight AND stay on time?

→ Audit yourself. “We have started chart audits to ensure that we stay within [CMS’] specified timelines,” shares Jill Bonell, MSA, OTR, CCM, reimbursement coordinator at the Rehab Institute of Michigan in Detroit. “We have also flagged charts with reminders on when the time frames are due. We are then placing the consult and the preadmission assessment onto our chart.” (more…)

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Take a Look at How Medicare Residents in RUG-III Would Fit Into RUG-IV

Posted on 02. Mar, 2010 by .


The change in distribution provides a wake-up call about shifting trends.

CMS provides a comparison chart below to show how the same MDS 2.0 data results in residents going into RUGs under the current system versus the RUG-IV system, which is set to go into effect on Oct. 1, 2010.

Caution: “CMS’ comparison of the RUG-III to RUG-IV distributions for 2008 had to have included some assumptions in the calculation,” says Ron Orth, RN, NHA, CPC, RAC-MT, president of Clinical Reimbursement Solutions LLC in Milwaukee. These include “the amount of concurrent therapy residents received and whether certain services were provided in the hospital lookback,” he says. Thus Orth isn’t sure how “totally accurate” the comparison is. “CMS is using the data to support that RUG-IV is budget neutral,” although “whether it’s budget neutral remains to be seen.”

An alternative: To roughly estimate the impact of RUG-IV on their own SNF, “SNFs could use their own data and recalculate the RUGs based on the RUG-IV indicators,” Orth suggests.

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Get Answers to Your Biggest IRF Coverage Criteria Questions

Posted on 21. Feb, 2010 by .


CMS elaborates nitty-gritty details of Transmittal 119, and here’s where IRFs get some wiggle room.

The new coverage criteria that hit inpatient rehab facilities this year were a lot to swallow. And even with Medicare’s new guidelines in Transmittal 119, is your list of questions still growing? The Centers for Medicare & Medicaid Services has offered information sheets with some answers. Read on for some important highlights.

Know Your Wiggle Room With Preadmission Screenings

CMS has emphasized that a licensed or certified clinician must conduct the preadmission screening, and the agency reiterates this point in its clarification papers. And among other new duties, the rehabilitation physician is responsible for ensuring the clinician is qualified.

Challenge: So many IRFs now are struggling with how to balance all the new tasks, particularly educating physicians on new responsibilities, points out Denese Estep, OTR, senior consultant for DE Consulting LLC in Sherwood, Ark. “It’s not so much confusion over what the rules are, as it is, ‘how do we do this?’,” she says.

The good news … (more…)

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Part B Rehab: New PQRI Bonus Opportunities in 2010, 2011

Posted on 18. Jan, 2010 by .


Good news: SLPs and audiologists get measures to report this year.

The 2010 Medicare Physician Fee Schedule brought more than just new code values for this coming year — it updated the Physician Quality Reporting Initiative (PQRI) as well. See what’s new for rehab so you can cash in on a bonus if your SNF offers Part B rehab services.

Hear the Inside Scoop

Physical and occupational therapists will not see new measures to report this year, experts confirm. But you should be aware of what’s going on behind the scenes. (more…)

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Rehab: Wake Up to a New Wound Care CPT Code in 2010

Posted on 14. Dec, 2009 by .


Here’s what outpatient rehab providers need to know about CPT code 29581.

New CPT codes for SNFs providing outpatient rehab were slim this year, as usual, but make sure you know what applies to you, where to find it, and how to use it.

Careful: A few new codes appeared in the 92xxx section.

If you’re a speech-language pathologist, however, these would not apply to you. “There are no new CPT codes for 2010 that SLPs can bill,” confirms Mark Kander, director of health care regulatory analysis for the American Speech-Language Hearing Association. (more…)

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Medicare Will Pay For HIV Screening

Posted on 14. Dec, 2009 by .


Plus — a tip for how SNFs should code HIV on the MDS

Many people think of HIV as a younger person’s disease, but the statistics say otherwise.

“Almost one-fourth of all people with HIV/AIDS in this country are age 50 and older,” states an article on HIV posted on the National Institute on Aging Web site. The article points out that even more cases may exist. “One reason may be that doctors do not always test older people for HIV/AIDS, and so may miss some cases during routine check-ups.” (more…)

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