Top Tips to Improve Skilled Documentation

Quite often, we receive questions related to whether or not a patient can be “skilled.” Perhaps a resident has a new onset cardiac condition, is receiving wound care, or is not making progress in therapy and will be transitioning to a restorative nursing program.

In order to make an appropriate judgement on whether or not services are skilled, consider these questions:

• • Are the requirements for daily skilled care met?
  • Can the daily skilled service only be provided on an inpatient basis in a SNF?
  • Are the services reasonable and necessary, including the quantity and duration?

Keep in mind, however, that not only must the resident meet Medicare Coverage criteria, but the documentation must support that the services and care meet the definition of skilled services, and that the services are so inherently complex they can only be provided by or under the supervision of professional or technical personnel. Section 30 in Chapter 8 of the Medicare Benefit Policy Manual outlines factors for consideration in determining SNF level of care, defines skilled services, and further lists principles for determining whether a service is skilled.

Although the presence of appropriate documentation is not, in and of itself, an element of the definition of a “skilled” service, documentation serves as the means by which providers justify that skilled care is, in fact, needed and received for each Medicare patient. It is expected that the documentation in the medical record will reflect the need for the skilled services provided.

Top tips to improve skilled documentation in 2022:

• • • Understand the 3-day hospital stay and 100-day benefit period waivers for SNF Coverage during the PHE
      • Providers must document both the skilled need for the SNF admission and how the admission was related to the crisis created by the public health emergency and its aftermath. These emergency measures don’t waive or change any other existing requirements for SNF coverage. Therefore, it is essential that all providers involved in the care include documentation regarding the emergency waiver and how it’s in the best interest of the patient to treat in place at the SNF in addition to meeting the daily skilled requirement.
    • Establish an admission policy with a process to determine skilled level of care
      • The process should start preadmission and consider the following: Beyond meeting technical Medicare criteria, what will the team be doing for the patient that could not be delivered in a lesser level of care? Why does the patient require daily skilled services in the SNF setting versus going home with home health? Why is a licensed nurse or therapist required to deliver the care instead of a non-skilled professional or family member? Why are the services required on a daily basis?

• • • Ensure staff understand the primary reason for the stay
      • Nursing, therapy, and the entire interdisciplinary team must know the reason why the patient is being skilled. Medical complexities as well as other care and services should also be clear in order for documentation to best support PDPM reimbursement items. With this in mind, nursing assessments should be targeted and individualized.

• • • Focus on documentation that clearly supports the daily nursing skilled services
      • Nursing services are considered skilled when they are so inherently complex that they can be safely and effectively performed only by, or under the supervision of, a licensed nurse.  Documentation supports coverage when an individualized assessment of the patient’s clinical condition demonstrates that the specialized judgment, knowledge, and skills of a licensed nurse are necessary.  Care should be taken to complete a skilled note at least daily, focusing on the patient’s clinical needs, along with skilled assessment of clinical conditions and notation on the resident’s response to care delivery.

• • • Therapy documentation should clearly support an evolving plan of treatment
      • Therapists must closely analyze the patient’s response to skilled interventions and adjust treatments, strategies, and techniques accordingly as the rehab course progresses. The patient’s positive outcomes alone will not support ongoing medically necessary services for an extended length of stay if services become seemingly rote or routine. Documentation must prove that the complexity and sophistication of a licensed therapist is required to deliver the services and could not be trained to family or non-skilled staff to facilitate the same progress toward the patient’s discharge goals.

• • • Establish a thorough interdisciplinary review, at least weekly
      • The patient’s medical record is 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, the documentation in the patient’s medical record should illustrate the degree to which the resident is accomplishing goals as outlined in the care plan. In this way, the documentation may serve to demonstrate why a skilled service is needed. During the regular Medicare Utilization Review meeting, the team may consider entering an IDT note to support each skilled service provided for the review period and why inpatient care is necessary, versus home health or outpatient care. This will typically involve documenting key rehab goals, resident responses to treatment, observations of performance on the unit, as well as rehab nursing procedures and any barriers to discharge with next steps for overcoming obstacles for safe transition home.

Proactive’s experts offer remote audit solutions for skilled documentation compliance and reimbursement accuracy. Contact us today to learn more about our quality assurance audits or for information on Medical Review support services including ADR preparation and Appeals management.

Stacy Baker, OTR/L, RAC-CT, CHC
Director of Audit Services

Learn more about the rest of the Proactive team.