Welcome back to our series! Catch up on Part 1.

Top Risk Areas Identified in Skilled Nursing Therapy Audits. Auditors at LW Consulting, Inc. (LWCI) review thousands of skilled nursing facility (SNF) records every year and yet negative trends continue to be identified in documentation. Looking ahead to 2023, after several years of experience working with the Patient Driven Payment Model (PDPM), therapy issues contribute to these negative trends in documentation. It is astonishing to see the inconsistencies in therapy documentation related to content, skill, demonstration of medical necessity, accurate coding and billing practices. There are steps that can be taken to improve accuracy in therapy documentation and comply with regulation. 

What can be done to improve therapy documentation in your facility? One of the first integral steps to take is to have external audits completed as part of a comprehensive compliance plan. LWCI partners with many providers to complete audits, discuss findings, educate staff, and strategize and implement operational improvement plans.

In the second blog in this series, we will highlight the next three most cited risk areas LWCI observed in audits conducted in 2022.

What are some of the top risk areas noted this past year in therapy documentation?

Continuing the countdown:

# 7 –  Absence of or non-supported medical and treatment diagnosis codes.

Therapists must code the diagnosis documented by the provider in the medical record. The medical diagnosis is the medical condition that the resident is being referred to therapy. It should be supported in the documentation and be relevant to the primary diagnosis of the SNF admission. Treatment diagnosis describes the focus of the therapy treatment and should be current and most pertinent. Goals should be devised reflecting the chosen treatment code. Treatment codes should be specific to each resident and relate to their most pressing need(s) being addressed by therapy. Auditors should see varying diagnoses based on the resident’s needs. Also, it is important to record relevant co-morbidity codes. As appropriate, co-morbidity ICD-10 codes should be listed on the evaluation and re-certifications. The diagnosis codes on the claim provide the reviewer with the primary reason(s) of therapy. 
Codes should support billing, be specific and must be documented by the physician.

# 6 – Limited use of standardized tests.  

Over the years, the use of standardized assessments has improved; however, auditors continue to identify issues with either a standardized objective tool not being used, or overuse of the same tool for every resident. Issues still persist with recording baseline measurements, but not re-assessing the resident using the same tool as reflected in progress notes, re-certifications and discharges. Using standardized assessments provides objective data to help justify skilled progression and makes the documentation objectively measurable. Consider these best practices:

  • Use the tools based on evidence.
  • Use the tools based on the resident’s needs, not the fact a specific tool is routinely used per therapist preference.
  • Use the tools in devising goals to ensure skilled progress is demonstrated throughout the episode of care.

How easy it would be to write a great discharge summary if the medical record consisted of rich data to demonstrate the resident’s skilled progress and what the therapist did to facilitate the progression. What if the medical record does not have this content?

  • If the resident has regression in progress, document the reasoning. List the barriers, list the resident’s limitations, adjust the plan of care to reflect those issues.
  • If the resident is not making progress in a particular goal, document the cause, discharge the goal, create a new one, modify the goal or incorporate a different tool.
  • If adaptations and modifications to the plan of care are not done, a reviewer has no idea why the lack of progress occurred. A reviewer would not know all the skilled tactics the therapist tried to progress the resident because the therapist may not have told the story well enough. If a plan of care reflects  minimal to no significant change when the resident is not making progress, supporting medical necessity may be at risk.

# 5  – Documenting the same frequency and duration for every resident is a risk.

Routine does not support reasonableness. If the resident requires contact guard assist to supervision for most tasks, a routine duration of eight weeks is not really supported in the documentation based on baseline status and goals. The same could be said for a resident who requires maximal assistance to dependent; a routine duration of 30 days may not be reasonable for someone who most likely requires more time. Just keep in mind when choosing a duration and frequency there really should be variances from resident to resident based on their specific clinical needs. If the same frequency and duration are documented for every resident, it may indicate the documentation may not be individualized to each resident’s clinical needs. The same documented frequencies and durations should be avoided unless clinical reasoning is reported. 

The same principle is applied for documenting medically unnecessary ranges of therapy. An intensity range of receiving therapy three to five times a week without documentation to support why a resident may clinically need this range (for example a resident who is medically unstable, on dialysis, or demonstrates inconsistent behaviors due to cognition), poses the risk of not supporting medical necessity. A range may be clinically indicated, but the therapist needs to convey the reasoning through documentation. Furthermore, when documenting a specific frequency, it should be evident that all attempts are made to meet that frequency. Not meeting frequency may raise a question of quality of care or staffing; over meeting frequency could raise a question of the need of all that “extra” therapy. Whatever the case may be, it is important to support the varying therapy intensity in documentation. The documentation of a missed visit contributes to the attempt to meet an identified frequency. For example, documentation of why care was not provided if the resident is sick, is key. As an auditor, seeing routine duration and frequency is a noted problem. The therapist does not provide justification for the duration and frequency of services provided. The amount, frequency, and duration of the services must be reasonable under accepted standards of practice. Documentation must be individualized, specific and relevant to each resident’s needs or it poses risk. 

Tune into Part 3 of this blog series where LWCI shares insight into the next top three risk areas focusing on inadequate goal writing, issues with orders, and repetitive documentation identified in 2022 audits.