How To Document On Snf Pt Services

Colleen Toebe

Colleen Toebe, manager of consulting services, Pathway Health Services

Medicare Part A postpayment medical review is ramping upwards—and skilled nursing facilities (SNFs) need to be prepare for some changes in what medical reviewers are targeting.

"In August 2020, Medicare Authoritative Contractors (MACs) resumed postpayment medical reviews for claims with dates of service earlier March ane, 2020," says Colleen Toebe, RN-MSN, CWCN, RAC-MTA, RAC-MT, RAC-CTA, RAC-CT, a managing director of consulting services with Lake Elmo, MN-based Pathway Health Services.

"And while the Targeted Probe and Educate program has not all the same restarted, MACs can now carry postpayment medical reviews for subsequently dates of service."

Ane Medicare Office A audit that occurred this past spring offers insight into the sea change that the Patient-Driven Payment Model (PDPM) has brought to medical review for SNFs, says Toebe. "The medical reviewer establish the documentation to exist inadequate, and they took coin dorsum. Under the RUG-IV example-mix organization, therapy documentation typically was the master culprit in these types of take-backs," she points out. "Withal, therapy documentation wasn't the problem. Instead, the inadequate documentation was nursing documentation."

This new focus on nursing documentation is consistent with the fact that many SNFs no longer provide straight therapy to Function A residents, says Toebe. "With PDPM, the quantity of therapy provided has declined, and the commitment of grouping and concurrent therapy minutes has increased."

Monitoring by the Centers for Medicare & Medicaid Services (CMS) confirms this. The implementation of PDPM coincided with a more than thirty percent drop in the average number of therapy minutes per day for SNF residents. In addition, the pct of SNF stays that included concurrent or group therapy increased from well-nigh 1 percent earlier FY 2020 to about 30 pct following the implementation of PDPM (and before the COVID-xix public health emergency), according to the Fiscal Year (FY) 2022 Proposed Dominion for the Skilled Nursing Facility Prospective Payment System (SNF PPS) and Consolidated Billing, and Updates to the Quality Reporting Program and Value-Based Purchasing Plan (CMS-1746-P).

Further, the average instance-mix alphabetize (CMI) went downward for the physical therapy (PT) and occupational therapy (OT) PDPM components in FY 2020 compared to what CMS expected, but increased for the nursing and not-therapy ancillary (NTA) components, equally well equally the speech-language pathology (SLP) component. "We believe these significant increases in the average instance-mix for these components is primarily responsible for the inadvertent increase in spending under PDPM," says CMS.

"The bottom line is that nursing has to step up a scrap to bargain with the new realities of medical review," suggests Toebe. "That includes nurse assessment coordinators (NACs) who serve as the Medicare nurse. There needs to be a skilled nursing progress notation, preferably each shift but at least daily, for any resident who meets a Role A skilled level of care with a skilled nursing need—and NACs should manage that procedure to ensure information technology happens."

Federal skilled documentation guidance

The 874 words in section 30.2.ii.1, Documentation to Back up Skilled Care Determinations, in chapter viii, "Coverage of Extended Intendance (SNF) Services Under Hospital Insurance," of the Medicare Benefit Policy Manual are the full extent of the federal guidance on the documentation needed to support a Part A skilled level of intendance.

While CMS provides limited information on how and what to document, documentation is the lifeblood of medical review. "The goal of medical review is to make up one's mind whether the services are reasonable and necessary, delivered in the appropriate setting, and coded correctly, based on appropriate documentation," co-ordinate to section half-dozen.one, Medical Review of SNF PPS Claims, in chapter half-dozen, "Medicare Contractor Medical Review Guidelines for Specific Services," of the Medicare Program Integrity Manual.

"Clinical documentation that supports medical necessity may exist expected to include: medico orders for care and treatments, medical diagnoses, rehabilitation diagnosis (as appropriate), past medical history, progress notes that describe the beneficiary's response to treatments and his/her concrete/mental status, lab and other test results, and other documentation supporting the beneficiary'southward need for the skilled services being provided in the SNF," continues department half dozen.1.iv, Medical Review Procedure.

Taking the following actions may assist NACs prepare nursing staff to run into the demand for skilled nursing documentation and increase the odds of stress-free audits:

Observe out which nurses need a documentation assist

"The first pace is to assess the documentation skills of the nursing population in your facility," says Toebe. "Some nurses are excellent at documentation, only others aren't. For example, you may think that nurses fresh out of nursing school would have potent documentation skills, but that'due south not always the example."

So, NACs have to ensure that the nursing staff understands both what the annotation is and how to make the note, says Toebe. "Yous have to become back and re-brainwash, but you also need to build their skill set. Specially with make-new nurses, sometimes veteran nurses look too much. You should help them build their skill set to brand sure that they understand how to exercise a note and feel proficient almost their note."

Get back to the basics of the nursing process

To build nurses' documentation skills, NACs should return to the nursing procedure: Cess, Diagnosis, Planning, Implementation, and Evaluation (ADPIE), suggests Toebe. Unlike a straight narrative note, several types of nursing notes provide a structure for charting that aligns with the nursing process. For example, these include the post-obit:

The problem-oriented Subjective, Objective, Cess, Plan (SOAP) note and its successors, including the SOAPIER note, which adds in Intervention, Evaluation and Revision.
The focus-oriented Focus – Information, Action, Response (F-DAR or FDAR) notation, which is also known as the DAR notation.

Note: YouTube offers an array of videos that may exist helpful educational tools (although quality levels vary). For example, these include What You Demand to Know Almost Writing a Progress Notation (Nursing School Lesson) and F-DAR Charting for Nurses.

These tools provide a documentation framework for nursing notes, much the aforementioned fashion that the Situation, Background, Cess, Recommendation (SBAR) tool and its successor (the ISBAR tool adds Introduction) provide a documentation framework for nurses to communicate with physicians and doctor extenders, points out Toebe.

"I apply the DAR format for notes. While DAR allows the use of both objective and subjective data in the Data section, the overall format helps keep the note objective and not based on your opinion," she says. "In one case you've identified the focus of the note, what is the Data from assessment and interview? What is the Activeness or nursing intervention? What is the resident'due south Response to the action? Information technology's a simple, effective fashion to evaluate what you need to include in the note because you tin apply the nursing process to assist you decide how to answer those questions."

Post-obit the nursing procedure is the primal to writing any nursing note—no matter the manner—including a annotation to back up a skilled level of intendance for Part A or Medicare Reward residents, stresses Toebe. "A skilled nursing note should exist an objective, comprehensive note that provides the assessment Data related to the resident's skilled needs (i.eastward., why they are there for that stay), the Actions of the nurse (i.eastward., the skilled nursing services provided to address those skilled needs), and the resident's Response to the skilled nursing services, including whatsoever further actions that the nurse may need to take."

Note: The guidance in section 30.2.2.1, Documentation to Back up Skilled Care Determinations, in chapter viii of the Medicare Benefit Policy Manual, includes examples of generic phrasing that fails to adequately describe a resident'due south response to skilled services.

Accept advantage of the EMR

Most electronic medical records (EMRs) allow providers to create user-divers cess tools (i.due east., build-your-own documentation), says Toebe. "Some facilities with this capability take developed tools that provide fifty-fifty more structure to guide the nurse to make a actually solid, objective annotation. For example, the tool may force the nurse to certificate the number of times something happened, what the chore they did included, and what level of intendance was needed."

Consider case studies

Case studies are a tried-and-truthful method of building documentation skills, says Toebe. "Doing this with a group of nurses tin be particularly effective. You provide a case study and have them document the notation. Working on it as a group takes away some of the pressure and helps them feel adept virtually edifice their documentation skills."

Read the skilled notes daily

"No 1 wants to hear this because it'south labor-intensive for the NAC, but when charting is inconsistent, the simply way to ensure that nurses complete comprehensive skilled nursing notes is to read those notes every day," says Toebe. "Saturday and Sunday'southward notes should exist included in this review, which can brand Mondays difficult. Even so, skilled nursing services must exist needed and provided seven days a week to authorize for a skilled level of care, so the skilled nursing notes have to be 7 days a week as well."

There besides needs to be a process in the nursing section for addressing any problems plant in those daily reviews, says Toebe. "For instance, the NAC could read the notes and take the incomplete documentation to the advisable nurse director. Then that nurse manager could do a counseling or preparation to establish the process to ensure that that nurse is writing a solid comprehensive solid notation using DAR charting. Yous have to establish some manner to mentor the nurses who demand help."

Rethink how bureau staff work in the facility

Agency nurses are somewhat notorious for inadequate documentation. "Nonetheless, function of the trouble may be the way they are frequently deployed in nursing homes," suggests Toebe.

"For example, i provider got amend documentation from agency nurses by taking two steps," she explains. "First, the facility booked agency staff for three months at a time because that is how long it took to fill empty staff positions. Second, the facility had bureau staff work on specific units with consistency, which allowed nurse managers to build upward their documentation skill set to the necessary level."