If you are a therapist in a SNF, whether it be the short-term rehab side or the long term care side, chances are…you write…a…lot! So how’s that going for you? Well, Medicare seems to think therapists working in the Part A SNF setting need some help in the area of documentation, so let’s see what’s up.

New Provider Compliance Tips Document

The US Department of Health and Human Services, Medicare Learning Network (MLN) recently published a document, Provider Compliance Tips for Skilled Nursing Facility (SNF) Inpatient Services. This document reiterates what Medicare considers skilled [and we know they ONLY pay for skilled services] vs. routine or custodial.

Why Did Medicare Publish This Document?

Data from past reports, including the Supplementary Appendices for the Medicare Fee-For-Service 2015 Improper Payments Report, show that projected improper payment amounts for SNF services during the 2015 report period was $4.0 billion. That means $4 billion was paid to providers for Medicare Part A services that should not have been.

So why was the $4 billion deemed improper payments? A majority {$3 billion} was due to insufficient documentation. Not just therapy, but since Rehab RUG’s make up over 90% of all RUG scores billed in a SNF, it is safe to say that therapy documentation came into question. The rate of insufficient documentation has been climbing steadily since 2009. Hmmm….coincides with increasing demands of PPS and all that came with it including the climb of Rehab Ultra and crazy productivity requirements. Maybe therapists are spread too thin to document effectivly and efficiently? Just a thought…

SNF therapists can always look on the bright side….Home Health and Outpatient Medicare Part A and Part B have much higher rates of insufficient documentation as identified in the Report as $9.6 and $5.5 billion in over-payments respectively [ever see that Oasis…]

SNF therapists curious about their state can check out the report – but here were the top 5 states with the highest rates of improper  Medicare A payments for  insufficient documentation:

  • Improper payments by State
    • TX:  17.3%
    • IL:  14.7%
    • CA:  13.6%
    • FL:  12.7%
    • NY:  10.5%

What Documentation Is Required for Part A?

A quick read of Chapter 8 in the Medicare Benefit Policy Manual will tell you all you need to know about the rules for SNF Part A. It is only 56 pages long and worth the read if you are practicing in the Part A SNF setting. A summary is provided here:

Documentation must prove medical necessity of the SNF services provided and include:

  • Required documents include, but are not limited to:
    • A certification that the beneficiary needed daily skilled care that could only be provided in a SNF setting
    • An authenticated plan of care [evaluation signed by the physician]
    • The time (in minutes) for the therapy service provided
  • Need to include sufficient documentation to enable a reviewer to determine:
    • the beneficiary requires skilled services in order for the services to be furnished safely and effectively
    • the services are reasonable and necessary for the treatment of the resident’s illness or injury
    • the nature and severity of the individual’s illness or injury
    • and the individual’s particular medical needs and accepted standards of medical practice.

Documentation must also show that the services are appropriate in terms of duration and quantity, and that the services promote the documented therapeutic goals. Resident goals must be routinely assessed and documented to provide a sufficient basis for determining Medicare coverage.

Here is the part that most SNF’s miss:

According to the “Medicare Benefit Policy Manual,” Chapter 8, the resident’s medical record must be documented as appropriate with the following:

  • The history and physical exam pertinent to the resident’s care (including the response or changes in behavior to previously administered skilled services)
  • The skilled services provided
  • The plan for future care based on the rationale of prior results
  • A detailed rationale that explains the need for the skilled service in light of the resident’s overall medical condition and experiences
  • The complexity of the service to be performed
  • Pertinent characteristics of the resident
  • and…..wait for it….
  • Document the resident’s response to the skilled services provided during the current visit [YES – therapists need to write a daily treatment note for Part A just as they would for Part B. The only way you can document the resident’s response during the current visit would be to write a note about the current visit, on the current visit! So many SNF’s are skipping this requirement because it “negatively impacts productivity” and it may come back to bite them when an audit deems “insufficient documentation.”

The other kicker is the language Medicare Part A added to the Manual in 2014. See if this pertains to you….

Documentation must avoid vague or subjective descriptions of the patient’s care that would not be sufficient to indicate the need for skilled care. For example, the following terminology does not sufficiently describe the reaction of the patient to his/her skilled care:
Patient tolerated treatment well
• Continue with POC
• Patient remains stable
Such phraseology does not provide a clear picture of the results of the treatment, nor the “next steps” that are planned. Justifying services with these vague phrases may result in denial of coverage.

So What Can a SNF Therapist Do?

For starters, set some time aside to read the 56 pages of Chapter 8 in the Medicare Benefit Policy Manual. You will be glad you did. Get your information from the source….and though you may value you supervisor, sometimes your supervisor is not the best source. Your license…your responsibility to know the rules. Ask questions. If what you are doing in your SNF does not match up with the rules, ask why.

SNF therapy is a fast-paced environment for many facilities these days and the focus is typically on “getting the days work done.” Resident treatment, minutes, RUG targets, avoiding COT’s can dominate one’s day. Therapy may not be looking to the future to prevent denials for “insufficient documentation” because there is so much on a therapists plate each day.

Start with the above tips…right for Medicare’s mouth:

  • Write a daily treatment note to show your treatment was skilled and how the resident responded.
  • Avoid the terms “tolerated well,” “continue plan of care,” and “remains stable.” Replace those terms with what your plan for the next visit is and how you will progress treatment. That’s skill!

If you need any help along the way, our team is here. Submit your clinical questions to our Just Ask Q&A Forum and one of our experts will respond directly to you. We also have 2 Documentation courses available to assist you. See below for details.

In Your Corner-

Dolores and the Montero Therapy Team


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