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