Increased efforts to audit Medicare records by Medicare Administrative Contractors (MACs), as well as other subcontractors of CMS, should make all providers very conscientious regarding skilled documentation that without question supports the need for daily skilled care.
In order to effectively support the services provided, weekly progress notes are recommended to highlight the benefits of skilled therapy intervention, while simultaneously recognizing the progress made by the patient as a result of the skilled intervention.
The RAI User’s Manual dictates how the MDS should be completed in order to comply with CMS guidelines for Medicare Part A reimbursement. Harmony (HHI) notes that the RAI User’s Manual defines therapy that may be captured in MDS assessments as follows:
Code only medically necessary therapies that occurred after admission/readmission to the nursing home that were (1) ordered by a physician (physician’s assistant, nurse practitioner, and/or clinical nurse specialist) based on a qualified therapist’s assessment (i.e., one who meets Medicare requirements or, in some instances, under such a person’s direct supervision) and treatment plan, (2) documented in the resident’s medical record, and (3) care planned and periodically evaluated to ensure that the resident receives needed therapies and that current treatment plans are effective.
This statement is frustrating in its lack of specificity. This is especially true in light of the ongoing debate in the industry as to how frequently therapists must document progress for Medicare Part A patients.
Section 184.108.40.206, Chapter 8, of the Medicare Benefit Policy Manual also lacks specificity in relation to Medicare Part A documentation, but does state the following:
It is expected that the documentation in the patient’s medical record will reflect the need for the skilled services provided. 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. Taken as a whole, then, the documentation in the patient’s medical record should illustrate the degree to which the patient is accomplishing the goals as outlined in the Care Plan. In this way, the documentation will serve to demonstrate why a skilled service is needed.
Thorough and timely documentation with respect to treatment goals can help clearly demonstrate a beneficiary’s need for skilled care.
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 so that all concerned can follow the results of the provided services.
Right now we are seeing that the average clinically appropriate stay for Medicare Part A patients in the industry is hovering around 30 days. Use of a 30 day standard for documenting patient progress towards the goals established would mean that essentially no progress notes would be written for the average Medicare Part A patient. Given the complex medical conditions of the majority of Medicare Part A patients in skilled nursing facilities, a standard of more frequent skilled assessments of progress, goals and the plan of care seems prudent and more in line with the stated Medicare guidelines.
Chapter 15 of the Medicare Benefit Policy Manual provides very specific guidelines for Medicare Part B skilled therapy documentation. It is because these guidelines are so specific and the Medicare A guidelines are not, that most providers, as well as contract therapy companies, look to the Medicare Part B standards when setting policies for therapy documentation for Medicare Part A patients.
Section 220.3 outlines documentation requirements for therapy services. These state the following:
Documentation should establish through objective measurements that the patient is making progress toward goals. Note that regression and plateaus can happen during treatment. It is recommended that the reasons for lack of progress be noted and the justification for continued treatment be documented if treatment continues after regression or plateaus.
The minimum progress report period shall be at least once every 10 treatment days. … In many settings, weekly progress reports are voluntarily prepared to review progress, describe the skilled treatment, update goals, and inform physician/NPPs or other staff. The clinical judgment demonstrated in frequent reports may help justify that the skills of a therapist are being applied, and that services are medically necessary. … Clinicians are encouraged, but not required to write progress reports more frequently than the minimum required in order to allow anyone who reviews the records to easily determine that the services provided are appropriate, covered and payable.
Harmony (HHI) has always maintained that weekly progress notes provide the optimal means of demonstrating the need for and provision of daily skilled care. We encourage skilled nursing facilities and rehabilitation teams to consider the benefits of this frequency of documentation. Not only does this give the therapist an opportunity to display the progress towards goals that have been achieved, but it also allows for frequent updates to the plan of care, highlighting the need for the skills of a therapist. With the current climate of RAC audits, ADR requests and ZPIC audits, why wouldn’t a facility want to support the great clinical care being provided?