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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.

ICD-9-CM Coding Guidance for LTC Facilities. Appendix B: Reporting and Sequencing Diagnoses on the Health Record and UB-04 Claim Form

Author: AHIMA

Source: AHIMA practice brief attachment

Publication Date: October 2010


The "ICD-9-CM Official Guidelines for Coding and Reporting" is updated annually, thought it may be changed more frequently. Coders should be familiar with the guidelines and use the most current version.

The guidelines provide the following guidance for principal/first-listed and con....

ICD-9-CM Coding Guidance for LTC Facilities. Appendix C: Regulatory Guidance for Reporting Diagnoses Related to Reimbursement

Author: AHIMA

Source: AHIMA practice brief attachment

Publication Date: October 2010


In August 2000, the HIPAA Transaction and Code Sets required the use of the ICD-9-CM code set. Subpart J, section §162.1002 Medical data code sets, states the adoption of the following code sets as standard medical data code sets:
ICD-9-CM, volumes 1 and 2 (including the "ICD-9-CM Official....

ICD-9-CM Coding Guidance for LTC Facilities - Retired

Author: AHIMA

Source: AHIMA practice brief

Publication Date: October 2010


Diagnostic coding plays several important roles in every healthcare setting, including long-term care (LTC) nursing facilities. LTC facilities assign ICD-9-CM codes to capture a resident's clinical conditions.


ICD-9-CM facilitates the collection and organization of healthcare stat....

RAC Primer for LTC Facilities

Author: Leonard, Mary Ann

Source: Journal of AHIMA

Publication Date: January 2010



Last year the Centers for Medicare and Medicaid Services (CMS) began rolling out the Recovery Audit Contractor (RAC) program to all 50 states and all providers, including long-term care facilities. HIM professionals working in LTC facilities need to understand the basics of the program in....

Role-based Model for ICD-10 Implementation: Long Term Care

Author: AHIMA

Source: AHIMA

Publication Date: November 18, 2009

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On the Leading Edge in Long-term Care

Author: Heubusch, Kevin

Source: Journal of AHIMA

Publication Date: April 2008


Margie White started out as a nursing assistant in acute care. A brochure for AHIMA’s independent study program introduced her to HIM. She completed the program and applied for a job as medical record clerk in a long-term care facility.

And she kept going. White earned her RHI....

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