Wiki Nursing Home notes

[PennyG]

Is there any documentation about how nursing home notes should be retained? Our physician sees patients in the nursing home. Do we need to scan the notes in to individual patient records or can these notes be scanned in to a nursing home visit chart based on date or service. Patients are not seen in our clinic, only the nursing home.

Any guidance or references you can give me will be greatly appreciated.

 

[JenniferB7]

Is the office billing for the services or is the nursing home billing for the physician services?

If the office is billing for the physician services, then you are required to have documentation in your patient's chart to support your billing. The following addresses home health services documentation, which is the same situation with the same requirements to maintain physician documentation. According to Novitas (a Medicare Contractor) (https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00081587&_adf.ctrl-state=kod3l02qz_4&_afrLoop=1313627221196321#!):

It is not sufficient that the HHA maintain documentation in their records for the physician. The physician must maintain his/her own records, including periodic summary reports provided by the home health agency.

Documentation of all face-to-face E&M visits and any phone communications with the patient or immediate caretakers must be present in the patient’s chart. This documentation must indicate an ongoing knowledge of any changes in the patient’s condition, drugs, or other needs, and how they are being met.

All medical record documentation must be maintained by the physician certifying/recertifying the home health services and must be made available to the Medicare contractor upon request.​

Hope that helps!