Determining medically necessary Medicare coverage
It is time to establish a clear understanding of Skilled Medicare Coverage. The settlement in Jimmo vs. Sibelius marked the first step in examining how we, as providers, determine Medicare eligibility. Although there was no expansion of Medicare coverage, there was clarification of the current Medicare program. Medicare benefits apply not only to residents who will improve, but also to those with a goal of maintaining their current condition, without declining.
Accurate and thorough nursing documentation is the crucial factor in determining medical necessity. As nursing leaders in long-term care, we are obligated to ensure that Medicare documentation standards meet the premise of reasonable and necessary care and services.
Key principles in determining services are reasonable and necessary:
- The complexity of the services prescribed for the resident can only be performed safely under the general supervision of skilled-nursing or skilled-rehabilitation personnel.
- Skilled care coverage may be necessary to improve the resident's current condition, to maintain the resident's current condition or slow further decline of the resident's condition.
Nursing documentation must maintain a standard to meet the skilled level of determination. The medical record should provide a clear picture, to anyone reviewing the claim, of how the resident is accomplishing the goals.
Fundamental elements to document to support skilled care:
- Skilled involvement is required for the services in question to be furnished safely and effectively.
- The services themselves are reasonable, necessary and consistent with the scope and severity of the resident's illness or injury.
- The resident's medical needs are being met by an accepted standard of practice.
- The services are appropriate in terms of duration and quantity, and promote the therapeutic goals.
How does documenting these fundamental elements change the actual practices in our organization? The documentation in the medical record must be accurate and avoid vague, non-descriptive notes on resident care. Non-descriptive documentation can result in a claim denial or reduction in payment. Common documentation pitfalls may include phraseology such as:
- Resident ate 100% of meals and rested throughout the day.
- Tolerates therapy; received pain medication prior to treatment.
- Slept through the night.
- Faxed lab results to physician.
- No change in overall status from yesterday.
- Combative with staff daily; administered Ativan.
- Participates daily in therapy.
So what are our next steps? The end goal is to verify nursing documentation that consistently reflects reasonable and necessary services. Although this task may seem daunting, these simple steps will lead an organization's staff to success:
- Develop a Medicare educational program for all licensed nurses, not only at the time of hire but also yearly.
- Review Medicare documentation weekly.
- Provide ongoing mentoring of your nursing staff.
- Review the updated Medicare Benefit Policy Manual for Extended Care SNF Services.
- Commit, as a leader, to guarantee your systems truly reflect the Medicare documentation standards.
Colleen Toebe is a consultant with Pathway Health and a master trainer with AANAC.