Anderson Health Information
Systems, Inc.
714-558-3887Office @ahis.net
940 W. 17th Street, Suite BSanta Ana, CA 92706
Medicare Documentation Requirements
Medicare
• Medicare diagnosis needs to be consistent with covered services & MDS.
Certs / Re-Certs
Advanced Beneficiary Notice
Daily documentation
• Supporting documentation should be consistent and reflective of MDS responses
• Standard of practice requires documentation of care and services delivered and resident’s response to care and services provided
ICD-9-CM Coding
Purpose of ICD- 9-CM Coding
• Gather statistical data• Reporting diagnoses and provides a
method for sequencing diagnosis to support reimbursement
• Ensure compliance with Federal Reporting Standards for diagnoses
• Provide insight into the types of residents and conditions
• Health Research
Types of codes used in LTC
• Aftercare – used when the initial treatment of a disease or injury has been performed and the patients still requires continued care to heal or recover.
• Late Effects – a late effect is a residual condition that remains and requires medical evaluation, rehab treatments and/or nursing care after the initial illness or injury.
Types of Codes -3
• History of – (Hx) – history codes are acceptable on any Medical record regardless of reason for admission/encounter.
• A history code is distinct from a “status” code in that history codes indicate that the patient no longer has the condition and “status” codes indicated a present state.
• There are two types of history V-codes, personal and family.
Types of Codes -3
• History of – (Hx) – history codes are acceptable on any Medical record regardless of reason for admission/encounter.
• A history code is distinct from a “status” code in that history codes indicate that the patient no longer has the condition and “status” codes indicated a present state.
• There are two types of history V-codes, personal and family.
Quality Assurance Process
Data Collection, Trending and
Analysis
Care Plan Documentation
0%
20%
40%
60%
80%
100%
120%
Current Short term careplans Updated
2009
2007
0% 20% 40% 60% 80% 100%
IDT Notes
D/C Planning
SS Assessmens
Dietary Assessments
Activity Assessments
2007
2009
100%
0%
80%
Relates toProblem
Individualized Measurable
Care Plan Goal
0% 20% 40% 60% 80% 100%
How to assess
Non Pharmacological Interventions
Minimize effects on ADLs
Assess for effectiveness of med
Updated with changes
Care Plan Approaches
HIPAA Compliance
Reviews
HITECHACT
Breach Notification
Requirements
“Red Flags”
RACRecovery Audit
Contractors
Regulatory Updates
Inteview Tools
Skills Competency Reviews
Work Flow and
Systems Analysis
•On Site Training
•Workshops
•Webinars