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Skilled Nursing Facility (SNF/NF) Clinical Documentation Improvement (CDI) Tip Sheets

Author: AHIMA Long Term Care CDI Workgroup

Source: AHIMA Task Force

Publication Date: February 2017

These tips focus on the language and/or wording that will garner greater details and specificity of the coded data for a given diagnosis, condition, and disease. In addition to the focus on coded data, these tips also include information to reflect quality care, frequency of documentation requirements, and documentation sources. These tips are meant to provide guidance in recognizing gaps in the clinical documentation.

Exploring Health Information Exchange Implementation Using Qualitative Assessments of Nursing Home Leaders

Author: Alexander, Gregory L.; Popejoy, Lori; Lyons, Vanessa; Shumate, Sue; Mueller, Jessica; Galambos, Colleen; Vogelsmeier, Amy; Rantz, Marilyn; Flesner, Marcia

Source: Perspectives in Health Information Management

Publication Date: October 2016


Abstract


Objectives: Limited research exists on nursing home information technologies, such as health information exchange (HIE) systems. Capturing the experiences of early HIE adopters provides vital information about how these systems are used. In this study, we conduct a second....

ICD-10-CM Coding Guidance for Long-Term Care Facilities

Author: Liebner, Carole S; Lowery, Amanda L; Maccariella-Hafey, Patricia C; Usher, Joan L; Ward, Maria; Young, Carol

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: March 2015


Diagnostic coding plays several important roles in every healthcare setting, including long-term care (LTC) nursing facilities. Come October 1, 2015, LTC facilities will assign ICD-10-CM codes to capture a resident's clinical conditions.


ICD-10-CM facilitates the collection and....

Survey of State Health Information Exchanges Regarding Inclusion of Continuity of Care Documents for Long-Term Post-Acute Care (LTPAC) Patient Assessment

Author: Hassol, Andrea; Goodman, Laura; Younkin, Jim; Honicker, Mary; Chaundy, Kimberly; Walker, James M

Source: Perspectives in Health Information Management

Publication Date: October 2014


Abstract


Objectives: This study aimed to measure awareness and interest among state health information exchanges (HIEs) in a tool that translates long-term post-acute care (LTPAC) patient assessment information to a Continuity of Care Document (CCD) format for sharing; whether any....

EHR Payment Incentives for Providers Ineligible for Payment Incentives and Other Funding Study

Author: Dougherty, Michelle; Williams, Margaret; Millenson, Michael; Harvell, Jennie

Source: AHIMA report | U.S. Department of Health & Human Services | U.S. DHHS. Assistant Secretary for Planning and Evaluation

Publication Date: June 2013

Report to Congress on the extent to which and manner in which payment incentives should be made available to health care providers receiving minimal or no payment incentives or other funding under HITECH.

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