Ask Proactive – Why is nursing documentation one of the biggest risks in medical reviews?

Q: Why is nursing documentation one of the biggest risks in medical reviews?   A: Nursing documentation is one of the biggest medical review risk areas because it supports Medicare coverage and directly affects the nursing component, Non-Therapy Ancillaries...

Ask Proactive – One of our long-term residents fell and fractured their femur requiring a hip replacement. They returned to our facility on a skilled stay. The IDT met to discuss a primary diagnosis. Therapy insists we should use Z47.1 Aftercare following joint replacement surgery, but some of the available hospital documentation uses S72.141A Displaced intertrochanteric fracture of right femur, initial encounter for closed fracture. Which is the correct code?

Q: One of our long-term residents fell and fractured their femur requiring a hip replacement. They returned to our facility on a skilled stay. The IDT met to discuss a primary diagnosis. Therapy insists we should use Z47.1 Aftercare following joint replacement...