McKnight’s published an excellent article last Thursday titled “Poor documentation crippling providers with Medicare denials.” The article, written by Elizabeth Newman, states that when Marilyn Mines was asked to assist with a therapy denial, the therapy documentation was sub-standard. However, I wanted to clarify how the documentaiton indicated how “…No progress had been made; there was no change in a plan of treatment.” While the article makes several valid points, “progress” is not and never has been the determinant of skilled care, and this was confirmed by Jimmo vs Sebelius (2013).
According to Chapter 8 of the SNF Manual, “Coverage of nursing care and/or therapy to perform a maintenance program does not turn on the presence or absence of an individual’s potential for improvement from the nursing care and/or therapy, but rather on the beneficiary’s need for skilled care.” One of the fallacies that we suffer under as therapists in SNFs is the mythology of the “Plateau.”
How many times have you heard a case manager, insurer, reviewer, or even a therapist say “This patient doesn’t require skilled therapy anymore. Her progress has plateaued.”
While we all agree that poor documentation is frequently the reason that a skilled service is denied (if it’s not documented, it didn’t happen, right?), the documentation should not just show progress, it must show the skilled service that was delivered.
It’s not enough to state that the patient walked 50 feet with a walker last week with minimal assist and this week is walking 75 feet. Gaining endurance is rarely a skilled service. The “skilled” part that’s missing from that note is what the therapist did to gain that improvement. The correct documentation would read “Patient walked 75 feet with a walker and minimal assist of one person. During the walk the patient required verbal cues for proper hand placement, weight bearing was manually facilitated through the patient’s right upper extremity by the therapist in order to promote proprioception and decrease neglect on the affected side.” In other words, it’s less important what the patient did; it’s more important to document what the therapist did that was skilled.
I’ve often told therapists that we can deliver skilled therapy to a comatose patient who has no expectation of recovery. How? Where’s the progress? We can offer skilled services because we do caregiver education, spasticity inhibition and flaccidity facilitation, positioning, etc. Because we’re therapists, we have a very individualized toolbox. That is our specialty.
As therapists, we possess a skill-set that cannot be replicated by any other person in the facility. If the documentation shows repetition of exercises (e.g. patient performed alternating straight-leg raises with 2-pound weights to promote strength), the claim will likely be denied because anyone can monitor those exercises. If our documentation does not show the specifics that only therapists can deliver, we are in danger of losing the claim. We all know documentation is everything. We just need to do it right.
Jean Wendland Porter, PT, CCI, WCC, CKTP, is the regional director of therapy operations at Diversified Health Partners.