A: Medicare Part A in the SNF setting outlines coverage requirements and expectations in Section 8 of the Medicare Benefit Policy Manual. Link to Manual. Medicare made significant updates to the Manual regarding skilled care and documentation in January 2014. Transmittal 179 outlines all the new verbiage added the Manual and is a great resource. All notations in “red” are new as of January 2014. Transmittal 179 link.
As outlined in Chapter 8, we know that Medicare Part A coverage in the SNF, once a resident is deemed eligible, has to meet certain qualifiers. One of those qualifiers is the need for either skilled nursing services DAILY or skilled therapy services at least 5 DAYS per week. Chapter 8 also outlines documentation requirements.
Here is an excerpt from page 53 of Transmittal 179:
Therefore the patient’s medical record must document as appropriate:
The history and physical exam pertinent to the patient’s care, (including the response or changes in behavior to previously administered skilled services); The skilled services provided; The patient’s response to the skilled services provided during the current visit; 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 patient’s overall medical condition and experiences; The complexity of the service to be performed; Any other pertinent characteristics of the beneficiary.
This may be a subtle hint from Medicare… though it is clear that they are looking for documentation of the skilled services, as well as the patient’s response to the service.
Also, therapists should be aware of additional Medicare language that appeared in January 2014, addressing key documentation issues with therapy notes today. This is also from Transmittal 179:
The documentation in the patient’s medical record must be accurate, and 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. 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.
You may find a variety of interpretations from sources out there on Medicare documentation requirements. Keep in mind that if rules are in print in the Manual, Medicare can use them. Medicare, based on the above verbiage, may be able to deny Med A services as “unreasonable and unnecessary” or “unskilled” without supporting documentation.
Medicare’s other documentation regulation is subjective, but BIG..
Claims for skilled care coverage 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 for the treatment of a patient’s illness or injury, i.e., 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.
- The documentation must also show that the services are appropriate in terms of duration and quantity, and that the services promote the documented therapeutic goals.
Total therapy minutes next to a CPT code do not imply skill and will not pass a reviewer with ease. (And CPT codes are not a function of Medicare Part A, they are for Part B billing using the Physician Fee Schedule, so they mean nothing to a reviewer…..it is what you document to justify those minutes that matter!)
Bottom line? Support your skilled services using a daily note!
Dolores Montero, PT, DPT, GCS, RAC-CT, RAC-CTA