Documentation and Reimbursement for Long-Term Care

Softcover: 430+ pages
ISBN 1584261846
978-1584261841
AHIMA
May 2009
(click below for the best currently available price for this important resource)

Documentation and Reimbursement in Long-Term Care is not just about meeting requirements. It provides information on the best methodologies to use. Complete, accurate documentation of all aspects of the resident’s care provides the facility with a wealth of knowledge and information with which to run its business—the business of individualized healthcare for its residents.

Written for long-term care administrators, nursing directors, health information managers, privacy and security managers, and educators, Documentation and Reimbursement in Long-Term Care provides a comprehensive overview of long-term care documentation practices.

Excellent resource for long-term care (LTC) administrators, nursing directors, health information managers, and privacy and security officers
Useful for educators when teaching LTC best practices in documentation and reimbursement
Comprehensive in addressing the Resident Assessment Instrument (RAI) process as well as PPS/Reimbursement and regulatory statute coverage
Experience-based models facilitate individualized healthcare services for residents
Chapters dedicated to reimbursement and patient safety offer critical information and guidance
Effectively addresses care planning, narrative charting, and Medicare documentation for immediate application
New chapters on federal funding and resident safety cover key issues

The theme of Documentation and Reimbursement in Long-Term Care is that, in addition to fulfilling Medicare and Medicaid requirements, accurate and complete health record documentation can actually result in improved outcomes for residents of long-term care facilities. Long-term care documentation is especially important because it supports a variety of care planning and health assessment processes, including:

Regular assessment of resident health status and healthcare requirements
Interdisciplinary care planning
Documentation of resident outcomes
Collection of information for Medicare and Medicaid reporting
Collection of information for completing the Minimum Data Set (MDS) for Long-Term Care
Describes best methodologies and practices that help fulfill Medicare and Medicaid requirements by detailing accurate and complete health record documentation

This expert resource outlines the importance of the Resident Assessment Instrument (RAI), MDS, and Resident Assessment Protocols (RAPs), and discusses care planning, narrative charting, and Medicare documentation. It explains specific Medicare and Medicaid reporting requirements related to the RAI and RAPs. It also discusses:

Admission processes
Consents, advance directives, and face sheets
Documentation for the following therapies: rehabilitative, physical, occupational, speech and language, and respiratory
Physician documentation and orders and the importance of medical oversight
Medication and treatment records, flow sheets, and laboratory and special reports
Discharge documentation
Incident and accident report
Health record confidentiality, privacy, and security

Documentation and Reimbursement in Long-Term Care goes beyond the basic steps to meet minimum federal requirements. It offers experience-based models for gathering the information facilities need to provide individualized healthcare to all their residents.

The American Health Information Management Association (AHIMA) is the community of professionals engaged in health information management, providing support to members and strengthening the industry and profession. A world in which the public values the contribution of health information management professionals and the American Health Information Management Association, in the advancement of health through quality information: 1) Provides career, professional development and practice resources; Sets standards for education and certification; and, Advocates public policy that advances HIM practice. AHIMA fosters the professional development of coding professionals through advocacy, education, certification, and lifelong learning opportunities.

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