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
