In the ever-evolving landscape of skilled nursing facilities (SNFs), the stakes have never been higher. With constant advancements in data analytics, regulatory bodies are sharpening their focus on compliance and accountability for payment accuracy, leading to an uptick in audits. This shift underscores the critical importance of robust skilled service justification charting—ensuring that every patient’s care is not only clinically appropriate, but also thoroughly documented. This week we’ll explore the intricacies of skilled service justification, and set the stage for next week’s blog which will focus on practical applications for SNFs to achieve the highest standards of skilled care and to consistently maintain documentation that supports the skilled level of care..
The Medical Review Landscape
Data analytics contribute sharply to selection for both pre and post payment audits. The Medicare Part A Skilled Nursing Facility (SNF) Prospective Payment System (PPS) FY2025 Final Rule also confirms the intent for future rulemaking to establish a MDS validation review process to monitor accuracy of SNF MDS data reported to CMS—this process may be similar to the SNF 5 Claim Probe & Educate process that providers have experienced over the last 18 months. Adding to this dynamic, independent researchers have increasingly dissected SNF practices, scrutinizing outcomes and identifying trends that may influence regulatory expectations. For example, a recent SNF analysis revealed an examination of the skilled nursing industry suggesting possible upcoding in PDPM based on a 7 year study. While SNF advocacy groups pushed back on the study that has not yet been peer reviewed, this is just one example of the scrutiny providers face daily.
Skilled Services—Back To Basics
Let’s go back to the basics of skilled requirements as detailed in Chapter 8 of the Medicare Benefit Policy Manual. Review of this 58-page document is a great starting point for complying with the regulations, and can serve as the guide to outlining staff education that equips nurses and therapists with the knowledge necessary to effectively document skilled services that meet Medicare Standards. The bottom line is that nursing and therapy notes should allow the reader to clearly determine what skilled services are being received by the resident and why those services need to be rendered in the SNF setting.
SNF care is covered if 4 factors are met:
The patient requires skilled nursing services or skilled rehabilitation services
- The patient requires skilled nursing services or skilled rehabilitation services
- must be performed by or under the supervision of a qualified professional;
- ordered by a physician; and
- rendered for a condition for which the patient received inpatient hospital services or for a condition that arose while receiving care in a SNF
- The patient requires these skilled services on a daily basis; and
- As a practical matter, considering economy and efficiency, the services can be provided in a SNF.
- The services delivered are reasonable and necessary, 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 services must also be reasonable in terms of duration and quantity.
- The patient requires skilled nursing services or skilled rehabilitation services
Documentation to support skilled care determinations:
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.
Such determinations would be made from the perspective of the patient’s condition when the services were ordered and what was, at that time, reasonably expected to be appropriate treatment for the illness or injury. However, if it becomes apparent at some point that the goal set for the patient is no longer a reasonable one, then the treatment goal itself should be promptly and appropriately modified to reflect this, and the patient should then be reassessed to determine whether the treatment goal as revised continues to require the provision of skilled services. By the same token, the treatment goal itself cannot be modified retrospectively, e.g., when it becomes apparent that the initial treatment goal of restoration is no longer a reasonable one, the provider cannot retroactively alter the initial goal of treatment from restoration to maintenance. Instead, it would make such a change on a prospective basis only.
Although the presence of appropriate documentation is not, in and of itself, an element of the definition of a “skilled” service, such documentation serves as the means by which a provider clearly establishes justification for skilled care, and an A/B MAC (A) is able to confirm that skilled care is, in fact, needed and received in a given case. It is expected that the documentation in the patient’s medical record will reflect the need for the skilled services provided. The patient’s medical record is also expected to provide important communication among all members of the care team regarding the development, course, and outcomes of the skilled observations, assessments, treatment, and training performed. Taken as a whole, then, the documentation in the patient’s medical record should illustrate the degree to which the patient is accomplishing the goals as outlined in the care plan. In this way, the documentation will serve to demonstrate why a skilled service is needed.
The medical record must document as appropriate:
- The history and physical exam pertinent to the patient’s care;
- 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.
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
Vague entries such as the example above do not provide a clear picture of the results of the treatment, or planned “next steps”. 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 documented results of the provided services.
A deeper dive
In Part 2 of this blog next week, we’ll delve deeper into the skilled service justification landscape, exploring specific examples of skilled nursing and therapy services, and sharing key insights and strategies for effective documentation to ensure compliance in meeting Medicare standards for payment.
Join Proactive November 19, 2024 for virtual training to enhance Documentation for Skilled Care Justification
