Documentation, Billing & Coding

Updates on MDS Diagnoses as of October 1, 2024: Important Information, Including Details on Sepsis

Starting October 1, 2024, the Centers for Medicare & Medicaid Services (CMS) implemented updates to the Minimum Data Set (MDS) that directly affect how diagnoses are captured and coded in Section I, Active Diagnoses. These updates matter because they impact reimbursement, care planning, and regulatory compliance. If you have not revisited your diagnosis coding process recently, now is the time. Who is Qualified to Diagnose, and Where to Find these Diagnoses? Understanding who can diagnose…

Are You Documenting Prescription Drug Management Properly?

In clinical settings, proper documentation of prescription drug management is essential for ensuring patient safety, compliance with regulatory standards, and accurate billing. Additionally, understanding the differences between prescription and over-the-counter (OTC) medications is crucial for effective medication management. Here we outline the documentation requirements for prescription drug management and highlight the key differences between prescription and OTC medications. Documentation Requirements for Prescription Drug Management According to the AMA, appropriate documentation of prescription drug management involves…

Ensuring Your Moderate Level of Service Meets the Coding Criteria

Does your documentation match your moderate level of service billed?  With the changes implemented by the American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS), it is very important to make sure your documentation matches the level of service you are billing.  Many providers are finding themselves billing more moderate level of service visits now than they did previously under the old guidelines.   Criteria for Code Selection To achieve a moderate level of service, at…