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? And are the services reasonable and necessary, including the quantity and duration?

Although the presence of appropriate documentation is not the only element of the definition of a “skilled” service, documentation illustrates how providers justify that skilled is care needed and how it’s delivered to each Medicare patient. Therefore, it is expected that the documentation in the medical record will reflect the need for the skilled services provided.

Here are the Top 5 ways to improve your skilled documentation:

5.  Admission Policy To Determine the Skilled Level of Care -
The process should start at pre-admission and not only consider Medicare criteria, but even try to project the level of reimbursement you will be receiving under PDPM.  Many companies (like JMD Healthcare) offer projection worksheets or applications to help determine PDPM reimbursement levels to assist with cost management and staffing concerns.  Also, consider if the patient requires daily skilled services in the SNF setting or if going home with home health is an option. 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?  All these questions should be answered prior to the patient admitting.

4.  Understand the Primary Reason For the Stay -
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 and the need for skilled services. Knowing this, all therapy evaluation and nursing assessments should be targeted and individualized.  It is also important to note that conflicting medical records may increase likelihood of reviews and even denials.  Keeping your team on the same page with your patients’ needs will minimize this risk.


3.  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.


2.  Therapy Documentation Should Clearly Support a Specific Plan of Care -

We all can get in a routine and start to talk, walk and even document in a very “routine” fashion.  It is very important that therapy services maintain their skill by clearly showing an individualized and specific plan of care for each skilled patient. Therapists must closely analyze the patient’s response to skilled interventions and adjust treatments, strategies, and techniques accordingly as the rehab course progresses.  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.

1.  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.  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.  This is also the perfect way to ensure that all IPAs (Interim Payment Assessments) are being completed thoroughly and timely.  A few changes in a patient's functional ability could establish a new payment HIPPS score generating up to $50 per day for the remainder of the patient's stay.
Questions or concerns?  Feel free to send JMD Healthcare questions concerning therapy documentation or treatments to receive a FREE risk analysis with referenced Medicare Guidelines to help maintain compliance in your facility. 
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JMD Healthcare Solutions LLC is a skilled nursing facility management service.  The purpose of this email is to provide educational discussions of the skilled nursing facility industry and promote the value of our services. This is advertising material.

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