Welcome back to our series! Did you miss the previous blogs in this series? Find them here: Part 1 & Part 2

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 this series, we will highlight the next main risk areas we observed in audits conducted in 2022.

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

Continuing the countdown:

#4 – Goals that are not SMART run risk.

Goals should be…Specific, Measurable, Attainable, Relevant, and Timely written. Goal updates on progress reports and re-certifications that are not objective are cause for concern. Without documenting SMART goals on the evaluation, objectively measuring progress can be a challenge. Without documentation of objective progression  there is a risk that medically necessary, skilled and reasonable services will not be supported. When goals are not SMART, auditors often see the therapist reporting on resident progress with comments (often about potential), unrelated to the original goals. Skilled therapy is not supported to reach “maximum potential.” If the documentation indicates to an auditor that no skilled progress was made because objective updates to the goals were not recorded or limitations to the objective goals were not identified, there is no evidence to support the need for ongoing skilled care. Goals that are not SMART, increase risk.

#3 – Missing therapy orders.

For Medicare Part A, issues arise when therapy orders are not written before or on the day the treatment begins. When treating Medicare Part B recipients, the plan of care must be timely signed to meet the requirement. Without proper orders prior to or on the day of treatment, Medicare Part A services run the risk of not being covered. You must have an order before treatment begins for Medicare Part A beneficiaries to support the requirements of the Medicare Benefit Policy Manual (MBPM) Chapter 8.

 For Medicare Part B residents there are requirements for a timely signed plan of care in order to meet the regulations outlined in the MBPM Chapter 15. Negligence in following regulatory guidelines of obtaining a physician signature causes risk. Chapter 15 of the MBPM states, “The provider or supplier (e.g., facility, physician/NPP, or therapist) should obtain certification as soon as possible after the plan of care is established, unless the requirements of delayed certification are met. “As soon as possible” means that the physician/NPP shall certify the initial plan as soon as it is obtained, or within 30 days of the initial therapy treatment. Since payment may be denied if a physician does not certify the plan, the therapist should forward the plan to the physician as soon as it is established. Evidence of diligence in providing the plan to the physician may be considered by the Medicare contractor during review in the event of a delayed certification. Timely certification of the initial plan is met when physician/NPP certification of the plan is documented, by signature or verbal order, and dated in the 30 days following the first day of treatment (including evaluation). If the order to certify is verbal, it must be followed within 14 days by a signature to be timely. A dated notation of the order to certify the plan should be made in the patient’s medical record.”

#2 – Repetitive Documentation.

Documentation that is repetitive may not support skilled treatment interventions and therefore presents risk. It may be questionable why the skills of a therapist are needed if a resident on a recumbent bike does not require any visual, verbal, tactile cues or physical assistance to perform the task. Simply increasing the duration from ten minutes to twelve minutes in a given session, or from session to session, does not support the skilled need of a therapist to facilitate the task. An auditor may think, “Riding a bike could be done at a gym.” Where’s the need for skilled assistance? 

Documentation should vary from note to note on the skilled tasks that are facilitated. Overuse of “build statements,” as part of the Electronic Medical Record (EMR) library, may improve the speed of documentation for the clinician; however, often build statements neglect to convey the skill of the therapist. Repetitive documentation does not support skilled therapy need and causes the payer to ponder – What is the clinician doing? For a task such as an exercise machine, is the skilled professional checking vital signs? For the safety of the resident, it is expected that the therapist would assess the resident pre, during, and post task particularly if the resident has co-morbidities regarding cardiovascular or pulmonary health. Documenting just the fact that the resident used the bike to increase lower extremity strength or activity tolerance is not enough. Why would a payer reimburse for that unskilled service if the documentation does not indicate the specific skills of a licensed therapist? 

When notes are cloned or very little change is noted from session to session, there is a risk for denial. Giving verbal cues to pace, tactile cues to sit upright or align, monitoring vital signs, cuing the resident based on vital signs, or providing strategies such as hand over hand assist, are some examples of skilled interventions. The documentation must tell the story of the unique need for a licensed professional to support skilled care. 

Tune into the final part of our series, Part 4, where LWCI shares insight into the number one risk area facing clinicians; documentation that does not support skilled reasonable and necessary care.