LicaMedMan

09/28/2026

FROM FACEBOOK ADMINISTRATOR FORUM PAGE:
𝗠𝗗𝗦 𝗖𝗟𝗔𝗥𝗜𝗙𝗜𝗖𝗔𝗧𝗜𝗢𝗡 𝗙𝗢𝗥 𝗦𝗡𝗙𝘀 -
KEY 𝗧𝗔𝗞𝗘𝗔𝗪𝗔𝗬𝗦 from the Updated RAI MANUAL, effective 10/1/2026:
🔹 MAJOR CLARIFICATION: The 𝗥𝗔𝗜 𝗠𝗮𝗻𝘂𝗮𝗹 𝗽𝗿𝗼𝘃𝗶𝗱𝗲𝘀 𝗖𝗠𝗦’𝘀 𝗶𝗻𝘀𝘁𝗿𝘂𝗰𝘁𝗶𝗼𝗻𝘀 𝗳𝗼𝗿 𝗰𝗼𝗺𝗽𝗹𝗲𝘁𝗶𝗻𝗴 𝗮𝗻𝗱 𝗰𝗼𝗱𝗶𝗻𝗴 𝘁𝗵𝗲 𝗠𝗗𝗦. States and other payers cannot substitute conflicting requirements for federal MDS coding instructions.
🔹 𝗥𝗲𝘀𝗽𝗶𝗿𝗮𝘁𝗼𝗿𝘆 𝗧𝗵𝗲𝗿𝗮𝗽𝘆: Clarification of what qualifies as skilled respiratory therapy and the documentation needed to support it.
🔹 𝗦𝗵𝗼𝗿𝘁𝗻𝗲𝘀𝘀 𝗼𝗳 𝗕𝗿𝗲𝗮𝘁𝗵 (𝗦𝗢𝗕): Updated guidance reinforces accurate assessment and documentation.
🔹 𝗜𝘀𝗼𝗹𝗮𝘁𝗶𝗼𝗻: Clarification of when isolation can appropriately be coded and what must support it.
🔹 𝗣𝗛𝗤/𝗗𝗲𝗽𝗿𝗲𝘀𝘀𝗶𝗼𝗻: CMS clarified guidance regarding signs and symptoms of depression.
🔹 𝗣𝗿𝗲𝘀𝘀𝘂𝗿𝗲 𝗨𝗹𝗰𝗲𝗿𝘀/𝗜𝗻𝗷𝘂𝗿𝗶𝗲𝘀 & 𝗔𝗱𝘃𝗮𝗻𝗰𝗲𝗱 𝗪𝗼𝘂𝗻𝗱 𝗖𝗮𝗿𝗲: Revised guidance reinforces alignment of assessment, documentation and MDS coding.
⚠️ 𝗡𝗢𝗧E: This impacts clinical practice, documentation, reimbursement and quality. The entire IDT (including your physicians) needs to know the changes.
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⚖️ 𝗔𝗗𝗗𝗘𝗡𝗗𝗨𝗠 — 𝗝𝗨𝗦𝗧 𝗠𝗬 𝟮 𝗖𝗘𝗡𝗧𝗦:
Disclaimer: “No CMS manual—or algorithm—told me to say this. 😊 Just my personal opinion, 𝗕𝗔𝗦𝗘𝗗 𝗢𝗡 𝗠𝗬 𝗥𝗘𝗖𝗘𝗡𝗧 𝗠𝗘𝗗𝗜𝗖𝗔𝗟 𝗥𝗘𝗩𝗜𝗘𝗪/𝗔𝗣𝗣𝗘𝗔𝗟 𝗘𝗫𝗣𝗘𝗥𝗜𝗘𝗡𝗖𝗘:
When faced with a denial, ask:
🙋🏻‍♀️. 𝗪𝗵𝗮𝘁 𝘀𝗽𝗲𝗰𝗶𝗳𝗶𝗰 𝗮𝘂𝘁𝗵𝗼𝗿𝗶𝘁𝘆 𝘀𝘂𝗽𝗽𝗼𝗿𝘁𝘀 𝘁𝗵𝗲 𝗱𝗲𝘁𝗲𝗿𝗺𝗶𝗻𝗮𝘁𝗶𝗼𝗻?
👉. Know the applicable source: Medicare statute/regulations, NCD/LCD, MBPM Ch. 8, MPIM Chs. 3 & 6, MCPM Ch. 6, RAI Manual, or ICD-10-CM Official Guidelines.
👉. 𝗔𝘀𝗸 𝗳𝗼𝗿 𝘁𝗵𝗲 𝘀𝗽𝗲𝗰𝗶𝗳𝗶𝗰 𝗰𝗶𝘁𝗮𝘁𝗶𝗼𝗻. Then compare it against the actual clinical record and facts of the case.
👉. A reviewer’s interpretation, standing alone, does not establish a new statutory, regulatory, coverage or coding requirement.
🤔👉. Claims review may involve algorithms, AI or other automated analytics, as well as human medical review. We may not know which—or what combination—was used in a particular determination.
👉. That makes PRECISION even more important. 𝗔𝗻𝗮𝗹𝘆𝘇𝗲 𝘁𝗵𝗲 𝗿𝗲𝗰𝗼𝗿𝗱. 𝗧𝗲𝘀𝘁 𝘁𝗵𝗲 𝗿𝗮𝘁𝗶𝗼𝗻𝗮𝗹𝗲. 𝗖𝗶𝘁𝗲 𝘁𝗵𝗲 𝗮𝘂𝘁𝗵𝗼𝗿𝗶𝘁𝘆.
👉. If 𝘁𝗵𝗲 𝗱𝗲𝗻𝗶𝗮𝗹 𝗶𝘀 𝗻𝗼𝘁 𝘀𝘂𝗽𝗽𝗼𝗿𝘁𝗲𝗱 𝗯𝘆 𝘁𝗵𝗲 𝗮𝗽𝗽𝗹𝗶𝗰𝗮𝗯𝗹𝗲 𝗮𝘂𝘁𝗵𝗼𝗿𝗶𝘁𝘆 𝗮𝗻𝗱 𝘁𝗵𝗲 𝗿𝗲𝗰𝗼𝗿𝗱 — 𝗰𝗵𝗮𝗹𝗹𝗲𝗻𝗴𝗲 𝗶𝘁.
BOTTOMLINE:
𝗞𝗻𝗼𝘄 𝘁𝗵𝗲 𝗮𝘂𝘁𝗵𝗼𝗿𝗶𝘁𝘆. Analyze 𝘁𝗵𝗲 𝗿𝗲𝗰𝗼𝗿𝗱. 𝗞𝗻𝗼𝘄 𝘁𝗵𝗲 𝗱𝗶𝗳𝗳𝗲𝗿𝗲𝗻𝗰𝗲 𝗯𝗲𝘁𝘄𝗲𝗲𝗻 𝗹𝗮𝘄, 𝗿𝗲𝗴𝘂𝗹𝗮𝘁𝗶𝗼𝗻, 𝗰𝗼𝘃𝗲𝗿𝗮𝗴𝗲 𝗽𝗼𝗹𝗶𝗰𝘆, 𝗺𝗮𝗻𝘂𝗮𝗹 𝗴𝘂𝗶𝗱𝗮𝗻𝗰𝗲, 𝗮𝗻𝗱 𝗰𝗼𝗱𝗶𝗻𝗴 𝗴𝘂𝗶𝗱𝗲𝗹𝗶𝗻𝗲𝘀. CHALLENGE 𝘁𝗵𝗲 𝗱𝗲𝘁𝗲𝗿𝗺𝗶𝗻𝗮𝘁𝗶𝗼𝗻 𝘄𝗵𝗲𝗻 these 𝗱𝗼 𝗻𝗼𝘁 𝗮𝗹𝗶𝗴𝗻!

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06/13/2026

June, 2026 Reflections

FROM MCKNIGHTS: MA denials being overturned at ‘extremely high’ rate, proving SNF care is inappropriately denied: OIG
Medicare Advantage organizations denied 12% of requests for skilled nursing admission, according to a new federal study. But a 95% overturn rate on appeal is raising fresh questions about access to needed care and the thousands of denials that are not filed. An Office of Inspector General report published Tuesday morning serves as a snapshot of plan practices, capturing denial and appeals data from 19 major plans in June 2024. It called on the Centers for Medicare & Medicaid Services to collect more patient-level data to identify and respond to concerning patterns of prior authorization denials.
FROM CMS: CMS Updates Guidance for Vaccine Coding on SNF Claims
(CMS) has provided updated guidance for institutional providers for coding claims for vaccine administration when the vaccination is the only service billed on the claim.
The effective date is for claims with a date of service beginning April 13, 2026.
Below is the modified CMS guidance. The new coding requirements are in the bold and italicized text:
The following diagnosis code must be reported. If the sole purpose for the visit is to receive a vaccine or if a vaccine is the only service billed on a claim, the applicable following diagnosis code may be used.
ICD-10-CM Diagnosis Code = Z23 -- Description - Encounter for Immunization
NOTE: ICD-10-CM diagnosis code Z23 is to be used for all encounters for preventive vaccine immunizations, including COVID-19 immunizations.
The following condition code must be reported on institutional claims when diagnosis code Z23 is required for a vaccination.
Condition Code = A6 -- Description - Vaccine / Medicare 100% Payment
All claims must have the appropriate diagnosis code, procedure, and admin code to process correctly.
See the instruction to your Medicare Administrative Contractor (PDF).

FROM MCKNIGHTS Observation Stays Would Count Towards Stay Requirement For Medicare SNF Coverage Under Bipartisan Bill
McKnight’s Senior Living (5/26, Author) reports time spent in the hospital under "observation status" would count toward "a patient’s required three-day hospital stay for Medicare coverage of skilled nursing care" under bipartisan legislation re-introduced last week by Sens. Susan Collins (R-ME) and Peter Welch (D-VT). The Access to Medicare Coverage Act is "supported by more than 30 organizations representing older adults and their health care needs, including the American Health Care Association, / National Center for Assisted Living."

FROM MCKNIGHTS: Physical Exercise Is Associated With Improvements Across Multiple Cognitive Domains Among Patients With Alzheimer Disease And MCI, Research Indicates
Neurology Advisor (5/26, Saha) reports, "Physical exercise is associated with improvements across multiple cognitive domains among patients with Alzheimer disease (AD) and mild cognitive impairment (MCI), according to a systematic review and meta-analysis." This "analysis included 28 studies involving 2088 participants, with 8 studies in AD, 16 in MCI, and 4 in" Parkinson’s Disease. The findings were published in European Review of Aging and Physical Activity.

FROM AHCA: NEW TOOLKIT AVAILABLE TO HELP NURSING HOMES & ASSISTED LIVING COMMUNITIES STRENGTHEN FALLS PREVENTION PROGRAMS
The American Health Care Association (AHCA) recently developed a new falls toolkit, Safe Steps Forward, to support providers in strengthening their fall prevention programs through practical, evidence-informed strategies.
Falls are among the most common adverse events affecting residents in skilled nursing and assisted living settings. These events may result in injury, decreased functional ability, and diminished quality of life. Taking reasonable steps to prevent falls is a critical component of delivering high-quality, person-centered care and ensuring the safety and well-being of every resident.
While not all-inclusive, this toolkit provides information for various resources designed to help interdisciplinary teams identify risk factors, implement targeted interventions, and continuously evaluate outcomes as part of an effective quality assurance and performance improvement (QAPI) approach.
Download your copy today! Send questions to [email protected].

FROM MCKNIGHTS: FLYING ‘BLIND’ NO LONGER: CMS TO RELAUNCH PEPPER COMPLIANCE REPORTS AFTER 3-YEAR HIATUS
The Centers for Medicare & Medicaid Services said Thursday it will relaunch PEPPER reports for all provider types in “coming months,” restoring an important tool many nursing homes use for internal compliance and auditing purposes.

FROM AHCA: THE LONG-TERM CARE DATA COOPERATIVE: THE COOPERATIVE CONNECTION
The LTC Data Cooperative gives long-term care providers insights from their own electronic health records (EHR) data and offers the opportunity to participate in research that matters. Through secure data sharing, participating nursing homes and assisted living communities contribute to a national data resource used to generate insights, identify care trends, and support research. Learn more about how your organization can get involved here

04/27/2026

The deadline for nursing homes to report health care personnel (HCP) influenza vaccination coverage in the Centers for Disease Control and Prevention's (CDC's) National Health Safety Network (NHSN) is fast approaching. This reporting is required by the Centers for Medicare and Medicaid Services (CMS) for SNF Quality Reporting Program (QRP), and the submission deadline is May 18, 2026.

The reporting period for the 2025-2026 influenza season is from October 1, 2025, through March 31, 2026. Facilities are only required to submit one report that covers the entire reporting period by May 18, 2026.

Failure to report complete data in NHSN by 11:59pm on May 18th for the SNF QRP will result in a 2% reduction in the nursing home's annual Medicare reimbursement rates.

Tips for Reporting the Annual Influenza HCP Vaccination Data:

Facilities are strongly advised not to wait until the deadline to report. If your facility has not yet submitted its data, it is advised to submit now.
Data is submitted via the Healthcare Personnel Influenza Vaccination Summary Form, NOT the Seasonal Survey on Influenza Vaccination Programs for Healthcare Personnel (the latter is optional).
Confirm data entry after submission:
Print the data entry screen (or take a screenshot).
Run the CMS Report Line Listing – HCP Flu Vaccination Data for CMS SNF PPS in the NHSN application.
Training materials are available on the NHSN website.
If your facility is having difficulty accessing the NHSN Healthcare Personnel Safety (HPS) Component to submit this data, email [email protected] with "HCP Flu Summary" in the subject line and specify that you are a LTC facility.
Questions on CMS SNF QRP requirements can be sent to [email protected].