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Date ArticleType
9/7/2017 Payment/Reimbursement
Supportive Documentation Requirements – RUG-IV MDS Items 48-Grouper

Right Coding Pays Off
There can never be enough emphasis on accuracy of documentation in a legal clinical record, especially when it directs the plan of care for each resident and how it reflects directly with how a facility will be paid for the services rendered. Accurate assessment and coding will result in quality resident outcomes and correct reimbursement.

The Supportive Documentation Requirements User Guide related to RUG-IV items 48-Frouper was revised on August 15, 2017 by Myers and Stauffer. The revisions are easily identified in blue. Here are a few of the revised highlights:

• When electronic signatures are used, there must be a written policy in place to ensure proper security measures to protect the use of an electronic signature by anyone other than the person to whom the electronic signature belongs.

• Section D: Mood (14 day look back) – The focus of the person-centered care plan should be to identify the underlying cause or causes and contributing factors and include interventions to address symptoms.

• Section E: Behavior (7 day look back) The focus to the person-centered care plan should identify the residents’ s [references and goals including approaches to achieve those goals and incorporate alternative interventions to reduce the frequency of truly problematic behaviors and minimize any resultant harm.

Click here to review the supportive documentation requirements.