Ask the payment expert

Share this content:
Ask the payment expert
Ask the payment expert
You've recently written about an increase in medical review activity. How should we teach our nurses to support the skilled services we are providing?

One of the biggest factors from medical review denials is contradictory documentation in the medical record. In most facilities, more than 70% of residents are rehabilitation residents, and yet nursing is doing little to support that service. Nurses have a tendency to chart how well the resident is doing instead of charting to the functional limitation of the resident and the need for continued care in the facility.

Many times therapy is treating the resident, the therapy documentation is being kept in the therapy department until the end of each month and nursing has no idea what the therapist is treating the resident for. Nurses' notes then become very “canned” and we write how well the resident is doing.

An example of a basis for denial is a nurse charting that the resident is ambulatory with one assist, when, in fact, the resident is unsteady, balance is poor and the nurse is providing weight-bearing assistance to the resident with transferring out of bed.

The solution is education and better communication. First, you need to teach your nurses how to do skilled charting.

You need to give them guidelines. Don't assume they know how to chart. This is not taught in nursing school.
Secondly, develop a system where therapy is informing nursing what modalities of service they are providing to the resident and what nursing should be doing with the resident.

Finally, if the resident is truly ambulating with one assist without difficulty, maybe the resident should be placed on restorative care instead of continuing skilled therapy.

The reality is Medicare is trying to find ways to recoup dollars. Another reality is we don't do a very good job in supporting the care we are providing.