August 3, 2023

Timely Documentation Failures Can Be Costly

Often, therapy documentation comes under an audit with focus on quality patient care, continuity of care, and supporting the medical necessity of the services provided for coding and billing. Although allegations of malpractice are raised less often, the importance of thorough documentation as a defense against allegations of malpractice cannot be overstated. Regardless of the reason for the documentation review, it is also important to remember appropriate documentation is necessary to prevent licensing board actions.…

Understanding ICD-10-CM Codes: The Important, Comprehensive, and Distinct Facts [Part 1 of 6]

The International Classification of Diseases, Tenth Revision, Clinical Modification, known as ICD-10-CM, is the required standard for reporting diagnoses or condition codes on all healthcare claims, including Medicare. When attending an ICD-10-CM course, one of the first instructions is to obtain and use the current ICD-10-CM Coding Manual, which is updated every October. It is emphasized NOT to search for code(s) from the internet, the phone, or a list of codes. Yes, use the actual…

F-Tags in Review: F-Tag 949 Behavioral Health Training-Implementation November 2019

One regulation pending Phase 3 implementation is F-Tag 949 Behavioral Health Training. This regulation has significant connections to two other regulations for skilled nursing facilities: §483.70 Administration F-Tag 838 Facility Assessment (which should have been completed and submitted by November 2017) and §483.40 F-Tags 740-745 Behavioral Health Services. As part of the facility assessment, skilled nursing facilities should have included in their plan a procedure to educate and provide competencies for behavioral health services through…