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Case Study:

Ready, Set, Audit: Ensure Your Skilled Nursing Documentation Makes The Grade For Part A Coverage

Published on Sat Jan 01, 2005

Top-notch documentation builds a solid case for the resident being skilled ... here's how to getthe job done.

If you wonder exactly what to chart to prove you're providing skilled nursing care, you're not alone - and there's help.

Check out these recommendations based on a recent audit of SNF nursing documentation, compliments of Ann Lambert Kremer, OTR/L, MHSA, CPC, a consultant in Portland, ME.

Kremer found that residents in the facility were receiving the following skilled nursing services:

  • Management and evaluation of a patient care plan;
  • Observation and assessment of patient's condition;
  • Teaching and training activities.

    Yet the medical record doc-umentation often did not support  the fact that nursing was providing services at a skilled level, Kremer relates. Instead, nursing notes   frequently included documentation of a number of non-skilled services, such as routine continence care  (use of diapers and protective  sheets) or routine administration of oral medications.

    For a complete list of what Medicare considers nonskilled supportive or personal care services, see the online Medicare Benefit Policy Manual, chapter, 8, pp. 31 and 32 at     www.cms.hhs.gov/manuals/102_policy/bp102c08.pdf.

    Target These 2 Shortfalls

    The audit also uncovered two problem areas that a savvy medical reviewer might spot right off the bat:

    1. Lack of continuity between nursing and therapy in the area of activities of daily living (ADLs).  For example, some nursing notes stated "resident attending therapy," but the documentation didn't elaborate on how the therapy was helping (or not) the patient to achieve goals in the ADL arena.

    Example: "Therapy might be working on range of motion or stretching that would allow the resident to use a reacher on the nursing unit," says Marilyn Mines, RN, BC, a consultant with FR&R Healthcare Consulting in Deerfield, IL.

    2. Generic notes or ones that contradict the patient's status. In one case, the nurse notes the resident is "attending OT" when the OT had been discontinued days prior. Generic statements such as "attending therapy" don't really support skilled services and progress toward discharge goals. Yet Medicare does allow for skilled care that transitions a patient to discharge, Kremer says.

    Shore Up Documentation
     
    Kremer offers the following strategies and case examples to help SNFs improve documentation of skilled nursing care:
  • Make sure nursing progress notes accurately capture direct skilled nursing services (such as IVs, IV feedings, nasopharyngeal or tracheal aspiration). See the complete list of specific direct skilled nursing services in the online Medicare Benefit Policy Manual, chapter 8, pp. 26 and 27 at www.cms.hhs.gov/manuals/102_policy/bp102c08.pdf.
  • Provide more comprehensive supporting documentation when the skilled service involves develop-
    ment, management and evaluation of a patient care plan     - or when the sum total of unskilled services requires skilled nursing involvement to meet the patient's medical needs, promote recovery and to ensure medical safety.

    Example: An aged patient recovering from pneumonia is lethargic, disoriented, has residual chest congestion, is confined to the bed as a result of her debilitated condition, and requires restraints at times. To decrease the chest congestion, the physician has prescribed frequent changes in position, coughing and deep breathing.

    The residual chest congestion alone would not represent a high-risk factor, Kremer says, but when you factor in the patient's immobility and confusion, the resident has a high probability of relapse. In this situation, providing skilled oversight of the non-skilled services would be reasonable and necessary to assure the resident's medical safety until the chest congestion resolves.

    Appropriate nursing documentation might be: "Patient remains lethargic and disoriented. Her chest remains congested and patient has a persistent cough. To help reduce congestion and the risk of a recurrence of pneumonia, [nursing staff] changed the patient's position in bed hourly during the day shift. With much verbal and visual coaxing by nurse, patient performed deep breathing exercises as directed."
  • Provide more comprehensive documentation when providing observation and assessment of the patient's condition as the daily skilled nursing service.

    Observation and assessment qualifies as a skilled service when the likelihood of change in a patient's condition requires skilled nursing to identify and evaluate the patient's need for possible modification of treatment - or initiation of additional medical procedures - until the patient's treatment regimen is essentially stabilized.

    Example: A patient with arteriosclerotic heart disease with congestive heart failure requires close observation by skilled nursing personnel for signs of decompensation, abnormal fluid balance, or adverse effects resulting from prescribed medication. The patient requires skilled observation to determine whether his digitalis dosage needs reviewing or if he might require other therapeutic measures until his treatment regimen is essentially stabilized.

    Appropriate nursing documentation might be: "Patient continues to take the new cardiac medications as prescribed. Heart rate remains at 110 while resting. No change in elevated blood pressure. Patient's feet remain swollen and patient continues to complain of not being able to don his shoes or slippers. Dr. Jones was notified at 13:00 of the above."
  • Include more comprehensive nursing documentation of teaching and training activities. Teaching a patient how to manage his treatment regimen would constitute skilled services. For a complete list of the teaching and training activities that qualify for skilled Medicare coverage under Part A, see chapter 8 of the online Medicare Benefit Policy Manual (pp. 25 and 26) at www.cms.hhs.gov/manuals/102_policy/bp102c08.pdf.

    Note: In the last two examples above, the resident's RUG category would fall into one of the lower 18 RUGs, says Mines.

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