In this 3-part blog series, we will focus on issues that were identified in the recent OIG audit of PDPM records and MDS. The first area discussed the lack of documentation to support technical requirements. The second area discussed the requirements for coding diagnoses that meet the active diagnosis requirements. The third and final blog of this series will focus on the requirements to demonstrate medical necessity.
Billing and coding for medical services provided under the Centers for Medicare & Medicaid Services (CMS) should always be accurate and supported by requirements outlined in the regulations. For Skilled Nursing Facilities (SNF), billing for Medicare Part A is outlined in the Medicare Benefit Policy Manual Chapter 8. Billing for Medicare Part A changed from the old Resource Utilization Group (RUGs) based system on October 1, 2019. Under the old system, therapy intensity was a driver in reimbursement. The new system for reimbursement, the Patient-Driven Payment Model (PDPM), correlates the documented patient characteristics to payment.
The Office of Inspector General (OIG) recently completed an audit of 100 sampled claims at a large SNF in New York. The OIG report found that the SNF did not comply with Medicare requirements for 99 of 100 claims. There were three overarching issues identified in the report to explain the errors.
These were defined as:
- The medical record did not support that the individual was assigned the correct reimbursement rate code (HIPPS).
- Individuals did not require skilled nursing services.
- Did not meet documentation requirements. [Coding of active diagnoses is one example of documentation requirements that was identified.]
According to the Medicare Benefits Policy Manual Chapter 8:
- Upon admission to a SNF, an individual must require the skills of technical or professional health care personnel (i.e., registered nurses, licensed practical (vocational) nurses, physical therapists, occupational therapists, speech-language pathologists, or audiologists) for the safe and effective treatment of the patient’s condition(s). In addition, the individual must require skilled nursing or skilled rehabilitation services, or both, daily, and the services must be ones that can only be provided on an inpatient basis in a SNF.
- There must be specific evidence that daily skilled nursing or skilled rehabilitation services are required.
- Nursing services are skilled when they are so inherently complex that they can be safely and effectively performed only by or under the supervision of a registered nurse. Skilled nursing services are covered when an individualized assessment of the patient’s clinical condition demonstrates that the specialized judgement, knowledge, and skills of a registered nurse are necessary. Some examples of direct skilled nursing include:
- Intravenous (IV) or intramuscular (IM) injections and IV feeding
- Application of dressings involving prescription medications and aseptic technique
- Treatment of decubitus ulcers of a severity rated stage III or worse or a widespread skin disorder
Some examples of indirect skilled nursing include:
Management and Evaluation of a Resident Care Plan– the development, management, and evaluation of a care plan is skilled when based on a Provider’s order and supporting documentation. In terms of the patient’s physical or mental condition, these services require a nurse to meet the patient’s needs, promote recovery, and ensure safety.
Observation and Assessment of a Patient’s Condition-when the patient’s conditionis unstable and requires nursing staff to identify and evaluate the need for a modification of their current treatment or initiation of additional medical treatments until the patient has stabilized.
Teaching and Training– activities that require skilled nursing or skilled rehabilitation staff to teach the patient how to manage their treatment regimen.
The documentation for these services is essential and must illustrate the complexity of the services requiring skilled personnel as a necessary part of the patient’s recovery and safety.
We often see, during audits, the residents being monitored for mental health issues, but it’s just a checked box on the Medication Administration Record (MAR). This does not support the need for skilled nursing staff and would not be considered medically necessary. If there were changes to medication or the plan of care, or different coping techniques utilized, this would demonstrate that the skills of the nurse were required. The documentation must show a skilled intervention.
When conducting audits, we often find that the documentation does not support the coding due to the conditions not being met. For example, the documentation will state receiving skilled nursing services. There is no detailed documentation as to what the skilled services are or the clinical condition being treated.
We often see check boxes in the Electronic Medical Record (EMR) for conditions such as shortness of breath (SOB). If the box was checked to show SOB occurred, there should be nursing documentation to support the skilled response to the condition. Was supplemental oxygen provided, instruction in pursed lip breathing, or changes in the resident’s head position? The documentation must show skilled intervention.
Another example is a check box stating “teach resident glucose monitoring and insulin administration,” requiring the nurse to initial the box; however, there needs to be more detailed documentation. Was the resident able to obtain their glucose level? Were they able to administer the correct amounts of insulin if needed? Do they know the signs and symptoms of hyper/hypoglycemia? The documentation needs to demonstrate a skilled need.
Providers must document why a service is essential to the patient’s health. Documentation must include the rationale for the service and how it meets the medical necessity criteria.
Are you confident that your documentation supports the coding? If not, LW Consulting, Inc can help.
LW Consulting, Inc. (LWCI) offers a comprehensive range of services to assist your organization in maintaining compliance, identifying trends, providing education and training, or conducting documentation and coding audits. For more information, contact LWCI to connect with one of our experts!
