Harmony Healthcare Blog

Need to Know: Skilled Nursing Documentation for Admissions

Posted by Kathy Monahan on Tue, May 29, 2018

C.A.R.E.

Compliance • Audits/Analysis • Reimbursement/Regulatory • Education/Efficiency


Admission and Re-admission Nursing Notes: Harmony Healthcare International (HHI) suggests that the following information be included in all admission notes: 

  • Time and date of admission.
  • Mode of Transportation, assist level and number of assist with transfers and bed mobility.
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Topics: Documentation

Need to Know: Skilled Nursing Documentation for Admissions

Posted by Kathy Monahan on Tue, May 16, 2017

C.A.R.E.

Compliance • Audits/Analysis • Reimbursement/Regulatory • Education/Efficiency


Admission and Re-admission Nursing Notes: Harmony Healthcare International (HHI) suggests that the following information be included in all admission notes: 

  • Time and date of admission.
  • Mode of Transportation, assist level and number of assist with transfers and bed mobility.
Read More

Topics: Documentation

Medicare Leave of Absence: Home for the Holidays

Posted by Kris Mastrangelo on Thu, Dec 08, 2016

C.A.R.E.

Compliance • Audits/Analysis • Reimbursement/Regulatory • Education/Efficiency


With the upcoming holidays comes increased confusion related to the Medicare beneficiary’s ability to enjoy a temporary visit home to participate in holiday celebrations with his or her loved ones.  While many Medicare beneficiaries are too acutely ill to leave the facility even for a brief home visit, there are no regulations preventing Medicare beneficiaries who are physically able, from enjoying a temporary home visit to participate in the holiday festivities. 

According to the Medicare Benefit Policy Manual, “An outside pass or short leave of absence for the purpose of attending a special religious service, holiday meal, family occasion, going on a car ride, or a trial home visit, is not, by itself evidence that the individual no longer needs to be in a SNF for the receipt of required skilled care.”

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Topics: Documentation, PPS, ARD, Leave of Absence

Skilled Nursing Documentation (Part 1): The Four Pillars

Posted by Kris Mastrangelo on Mon, May 23, 2016

The importance of facility wide comprehension of Medicare Coverage Criteria is a high priority focus for facility managment.  The below four pillars are the foundation for which skilled nursing services anchor the Medicare Part A patient’s coverage and SNF stay. Understanding these elements leads to proper documentation. 

Regardless of the patient’s RUG Category (Nursing or Rehabilitation), the nursing narratives needs to define the medical and nursing rationale for skilled services.  Back in 1998 with the advent of PPS, the industry encountered a huge lapse in the foundation for Medicare Coverage.  (The BIPA – Beneficiary Improvement Protection Act) reinstated the original criterion). 

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Topics: Documentation

Putting 2 & 2 Together: Aligning Therapy & Documentation in the SNF

Posted by Matt McGarvey on Tue, Dec 01, 2015

For years, I’ve been hearing dedicated SNF Owners and Operators around the country say things like “The business is getting harder and harder,” or “I’ve never seen things quite like this.” Well, that sure is right. None of us have seen things quite like this.

Many around the country are energized and excited about new initiatives to improve quality and efficiency, return more patients safely to the community, and implement new and exciting treatments to medically complex patients in the SNF setting. Yet, according to the FY 2016 OIG Work plan, the OIG is ready to hammer down on the delivery of SNF therapy in the upcoming year. I understand that the information derived from the PEPPER report shows a startling increase in high intensity therapy in the past 3 years, up almost 9 percent. Don’t we need to consider the fact that SNFs are taking a more medically complex patient population than ever before? Aren’t shorter acute care stays also a factor in the need for more therapy for improved outcomes?

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Topics: Therapy Documentation, Documentation, External Audit

How to Solve the Biggest Problem with Your SNF Medical Record

Posted by The Harmony Team on Mon, Jun 15, 2015

One of the easiest problems to solve, but one of the biggest problems existing in long term care is getting industry leaders to recognize the importance of qualified medical records staff. Performing my own, informal root cause analysis this week, I determined that the reason my SNF client was unable to produce a complete medical record for a recent Additional Documentation Request (ADR) was because the medical records staff did not understand what was being asked or expected of them. 

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Topics: Documentation, ADR, Medical Record Review, F-Tags

Want To Avoid an Audit? Remember to PREPARE

Posted by Washington Health Care Association on Thu, Oct 16, 2014


This is a featured guest blog article written by: 

WHCA - Washington Health Care Association

 

On Thursday, October 9th, Kris Mastrangelo, Owner and CEO of Harmony Healthcare, presented a webinar entitled “The OIG Report: Best Practices in Audit Prevention.” The report makes strong statements regarding alleged MDS inaccuracies, over coding, and billing by skilled nursing facilities. Mastrangelo outlined keys to success to help communities avoid audits and find success with their compliance programs with the acronym “PREPARE”:

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Topics: Documentation, OIG, Compliance, Audits,

Avoid Lost Revenue by Understanding Your Managed Care Contracts

Posted by Kris Mastrangelo on Wed, Apr 30, 2014

Managed Care Organizations are quickly becoming substantial components of the skilled nursing reimbursement system.  We are noticing a trend in facilities where key players have limited or no access to the specifics of different Managed Care contracts that were negotiated for the facility. 

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Topics: Documentation, Reimbursement, Managed Care

Skilled Therapy Documentation The Importance of Weekly Progress Notes

Posted by Kris Mastrangelo on Fri, Mar 28, 2014

Increased efforts to audit Medicare records by Medicare Administrative Contractors (MACs), as well as other subcontractors of CMS, should make all providers very conscientious regarding skilled documentation that without question supports the need for daily skilled care.  

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Topics: Therapy Documentation, Documentation, Skilled Therapy

Speech-Language Pathology CPT Codes Changes Effective January 1, 2014

Posted by Kris Mastrangelo on Mon, Dec 30, 2013

Effective January 1, 2014, the commonly used CPT code 92506 for evaluation of speech, language, voice, communication, and/or auditory processing will be deleted and replaced with four new, more specific evaluation codes. This code is frequently utilized by Speech-Language Pathologists in the Skilled Nursing Facility setting.

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Topics: Documentation

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