The Centers for Medicare & Medicaid Services (CMS) revised Chapter 8 ”Coverage of Extended Care (SNF) Services Under Hospital Insurance” with implementation on January 7, 2014. This manual is the Medicare authoritative publication for making skilled coverage decisions and ensuring documentation supports the care provided. This source document is utilized by Medicare reviewers in detailing why a claim for skilled rehabilitation or nursing services is denied.
The manual revisions clarify that coverage of skilled rehabilitation and skilled therapy services in the Skilled Nursing Facility (SNF) “does not turn on the presence or absence of a beneficiary’s potential for improvement” but rather on “the beneficiary’s need for skilled care.” The manual now details that “skilled care may be necessary to improve a patient’s current condition, to maintain the patient’s current condition, or to prevent or slow further deterioration of the patient’s condition.”
Pursuant to the terms of the Jimmo v. Sebelius Settlement Agreement CMS must complete manual revisions and an “educational campaign” by January 23, 2014. As stated in the December 2013 “Jimmo v. Sebelius Settlement Agreement Program Manual Clarifications Fact Sheet,” CMS has “decided to use this opportunity to introduce additional guidance in this area, both generally and as it relates to particular clinical scenarios.”
The revised manual now includes section 220.127.116.11 titled “Documentation to Support Skilled Care Determinations” which details the role of appropriate documentation in “facilitating accurate coverage determinations” for claims for skilled levels of care. The manual states that “While the presence of appropriate documentation is not, in and of itself, an element of the definition of a “skilled” service, such documentation serves as the means by which a provider would be able to establish, and a Medicare contractor would be able to confirm, that skilled care is, in fact, needed and received in a given case.”
Chapter 8 revision highlights the following related to documentation:
- Physician Documentation: Services to maintain the patient’s current condition, or to prevent or slow further deterioration of the patient’s condition must be documented “by physicians' orders and notes” as well as nursing or therapy notes. The patient’s medical record must document “the history and physical exam pertinent to the patient’s care, (including the response or changes in behavior to previously administered skilled services).”
- Patient Goals: The medical condition of the patient must be described and documented to support the goals for the patient [Nursing and Therapy]. Assessments of all goals [Nursing and Therapy] must be performed in a “frequent and regular manner.” When the goal set [Nursing and Therapy] for the patient is no longer a reasonable one, then the treatment goal itself should be promptly and appropriately modified to reflect this, and the patient should then be reassessed to determine whether the treatment goal as revised continues to require the provision of skilled services. When it becomes apparent that the initial treatment goal of restoration is no longer a reasonable one, “the provider cannot retroactively alter the initial goal of treatment from restoration to maintenance.”
- Duration and Quantity of Services: Documentation that services are appropriate in terms of duration and quantity, and that the services promote the documented therapeutic goals [Nursing and Therapy].
- Interdisciplinary Documentation: The patient’s medical record is also expected to “provide important communication among all members of the care team regarding the development, course, and outcomes of the skilled observations, assessments, treatment, and training performed.”
- Rationale of Skilled Services: The medical record must reflect “the complexity of the service to be performed,” patient’s “response to the skilled services,” “the plan for future care based on the rationale of prior results” and a “detailed rationale that explains the need for the skilled service in light of the patient’s overall medical condition and experiences.” Documentation in the patient’s medical record should illustrate the “degree to which the patient is accomplishing the goals [Nursing and Therapy] as outlined in the care plan.”
- Differentiation of Maintenance Programs: When a maintenance program is rendered to “maintain the patient’s current condition,” such documentation would serve to demonstrate the program’s effectiveness in achieving this goal. When a maintenance program is rendered and intended to “slow further deterioration of the patient’s condition,” the efficacy of the services could be established by documenting that the “natural progression of the patient’s medical or functional decline has been interrupted.”
- Objective Measurement: “Objective measurements of physical outcomes of treatment” should be provided “and/or a clear description of the changed behaviors due to education programs should be recorded.”
- Specific Descriptive Documentation: “Avoid vague or subjective descriptions of the patient’s care.” “The following terminology does not sufficiently describe the reaction of the patient to his/her skilled care: Patient tolerated treatment well, continue with POC nor Patient remains stable.” “Such phraseology does not provide a clear picture of the results of the treatment, nor the “next steps” that are planned.”
The CMS Policy Benefit Manual consistently reinforces the need to include sufficient documentation to enable a reviewer to determine “whether skilled involvement is required in order for the services in question to be furnished safely and effectively and the services themselves are, in fact, reasonable and necessary.” Services that are reasonable and necessary are consistent with the nature and severity of the individual’s illness or injury, the individual’s particular medical needs, and accepted standards of medical practice.”
Harmony (HHI) recommends that facilities review the details of Chapter 8 of the Medicare Benefit Policy Manual to guide coverage determinations and ensure documentation supports rehabilitation and nursing services provided.