Medicare Compliance- Therapy and Nursing Documentation
SNFs are in a constant state of review by the Medicare Administrative Contractor in addition to potential reivews by the OIG, RAC and MIC. Facilities will benefit from having an education calendar containing opportunities to review and teach staff supportive skilled documentation. Nursing and therapy documentation is what reimbursement is hinged upon under Medical Review. Many claims that have been brought to Harmony for further review and guidence include treatment plans with utilization of the Rehab Low Program. The Rehab Low program is about preservation of current functional level and small gains with strengthening, range of motion, bed mobility or other individualized focus for the particular patient. Rehab documentation should include any gains made but also emphasize what skills that patient would lose without the skilled intervention from therapy and the Restorative Nursing Program. The therapist's skill is the assessment of the patient and the Restorative Program. Is the program working, is it too high level for the patient, would the patient have more success if approaches were different, at another time, with various verbal cues? All these questions and answers should be documented in the skilled therapy notes.
The therapy goals could stay the same when transitioning from a skilled therapy program to the Rehab Low Program if the goals are set in small enough increments to facilitate attainment by the patient.
PT sample goal:
Transfer from supine to sit, rolling to left and swing legs over side of bed with moderate assist of 1 and 2 verbal cues.
Corresponding Restorative Nursing goal would be:
Transfer from supine to sit, rolling to left and swing legs over the side of bed with restorative aide providing moderate assist to lift trunk and shoulders as instructed by PT.
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