The Importance of Medicare Documentation for SNFs

April 18, 2014

Documentation Counts!

The quality of clinical documentation is critically important to the success of SNFs. Documentation of the medical necessity of skilled services has always been a federal mandate for reimbursement. However, the recent clarifications in Chapter 8, Section 30.2.2.1, of the Medicare Benefit Policy Manual require close attention. Intense federal auditing creates an imperative need for appropriate, complete and accurate clinical documentation. If documentation is lacking, SNFs could face a loss of reimbursement, accreditation, or contract opportunities. SNF providers also are challenged by recoupments, penalties, adverse publicity, exclusion from federal programs and even criminal sanctions.

“Reasonable and necessary,” for coverage purposes, is a legal standard requiring documented clinical judgment applied to each individual and the services ordered for that individual. Documentation must include the following:

  • – Individual’s presentation
  • (signs and symptoms)
  • – Services rendered
  • (treatments and items furnished)
  • – Orders and clinical rationale for orders
  • – Interventions
  • – Level of care

 

Evidenced-based standards of practice are expected. This will justify the intensity, frequency, duration, and scope of services billed.

Auditors want to see the complete story – especially the critical thinking process that leads to the actions and thoughtful decisions. Checklists and fill in the blank charting systems may not be sufficient. Providers must assess the adequacy and functionality of current documentation systems and must train nurses, therapists, and physicians in appropriate standards of documentation.

 

Leadership Strategies to Prevent Medicare Denial of Payment:

  • – Ensure admission notes are comprehensive and individualized and clearly describe why the individual requires skilled personnel and Medicare coverage
  • – Initial care plan should include the clinical and/or rehabilitation approaches/interventions, which clearly define reason(s) for skilled coverage
  • – Review physician’s orders as well as physician certification and recertification documentation is in place and in accordance with Medicare Policy Manual
  • – Conduct clinical record audits – looking for integration of skilled services across disciplines and clear documentation depicting why the resident is receiving Medicare and need for skilled services
  • – Observe Medicare meetings – make sure all team members are participating and can accurately reflect goals, outcomes and approaches to help residents attain desired functional status
  • – Conduct “triple check” pre-bill audits
  • – Review billing and RUGs data – identifying outliers and change in data
  • – Communicate findings and areas for improvement

 

Pathway Health provides the insight, expertise and knowledge to keep your organization on the right path. Visit pathwayhealth.com or 877-777-5463.

 

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