Welcome back to our series! Did you miss the previous blogs in this series? Find them here: Part 1, Part 2, & Part 3.

Finalizing the Countdown: 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 regulations.

What can be done to improve therapy documentation in your facility? One of the 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.

All of the top risk areas identified in the three prior blogs in this series lead to one major risk:

#1 – The Documentation does not Support Medically Reasonable and Necessary Guidelines.

The Medicare Benefit Policy Manual Chapter 8 Section 30.4 indicates if all other requirements for coverage under the SNF benefit are met, such skilled therapy services are covered when an individualized assessment of the resident’s clinical condition demonstrates the specialized judgment, knowledge, and skills of a qualified therapist are necessary for the performance of the rehabilitation services. 

Section 30.4.1.1 further clarifies services must be directly related to an active written treatment plan, based upon an initial evaluation performed by a qualified therapist after admission to the SNF.

Care in a SNF is covered if all of the following four factors are met:

  • “The patient requires skilled nursing services or skilled rehabilitation services, i.e., services that must be performed by or under the supervision of professional or technical personnel (see §§30.2 – 30.4); are ordered by a physician and the services are rendered for a condition for which the patient received inpatient hospital services or for a condition that arose while receiving care in a SNF for a condition for which they received inpatient hospital services;
  • The patient requires these skilled services on a daily basis (see §30.6);
  • As a practical matter, considering economy and efficiency, the daily skilled services can be provided only on an inpatient basis in a SNF (See §30.7.); and
  • The services delivered are reasonable and necessary for the treatment of a patient’s illness or injury, i.e., are consistent with the nature and severity of the individual’s illness or injury, the individual’s particular medical needs, and accepted standards of medical practice. The services must also be reasonable in terms of duration and quantity. In order to support that the service is medically necessary, the service must be safe and effective for the treatment of a resident’s diagnoses; one of the many reasons why specific ICD-10 coding is important. It should be clear the patient has no contraindications to the service.”

Documentation must demonstrate the service is appropriate. Duration and frequency must be appropriate and individualized to each resident based on the therapist’s documentation which includes co-morbidities, goals, and diagnoses (medical and treatment). When a therapist lists the same frequency and duration for every resident it does not support an individualized plan.

In determining whether skilled services are medically reasonable and necessary, the complexity of the service to be provided and the complexity of the resident must be considered. The knowledge, skills, and judgment of the therapist must be required and demonstrated and aligned with the complexity of the service and/or the complexity of the resident. The use of standardized tests, electrotherapy modalities, specialized manual therapy techniques, progression of exercises, monitoring of the resident and modification of the treatment plan, need for cues and education related to safety, assessment of adaptative equipment or instruction in compensatory strategies are all special skills of the therapist. The need for these skills may be obvious to the therapist; however, the clinician must provide documentation supporting these skills are required in the treatment of the individual resident.

Some diagnoses may indicate more complexity, like acute exacerbation of Chronic Obstructive Pulmonary Disease or Acute on Chronic Congestive Heart Failure, a recent stroke, a recent amputation, cognitive issues, etc.; but the mere presence of a diagnosis does not support the need for skilled treatment. Documenting the reasons why a skilled professional is needed to provide skilled care is imperative. A resident with a recent fall with no related injury, might require skilled therapy because of co-morbidities impacting their function.

The documentation must be very clear that the complexity of the resident and/or the complexity of the service requires the skills of the therapist. The documentation must demonstrate the qualified professional is the only one that can safely and effectively deliver the care. If a treatment can be performed by unskilled personnel, that treatment is no longer considered medically necessary. The treatment must be supported by evidence-based practice and demonstrate the resident’s need through the reason for referral, the prior level of functioning, and the results of the evaluation.

Documentation must clearly point out the reason of the plan:

  • Aid in the recovery or improvement of function
  • Restore function to previous level
  • Maintain a functional level
  • Slow deterioration

The initial evaluation and plan of care should clearly paint a picture showing the purpose of skilled therapy intervention to meet one of these four targets. By executing this strategy, an auditor would be able to understand the purpose of the plan to support the requirement for reasonable and necessary care.

What are Technical Requirements?

Technical requirements are those items that must be present to bill for services; categorized under the conditions for payment and are required for reimbursement.

Medicare Part A and Medicare B requirements differ; therefore, it is important to understand the differences.

As mentioned in the last blog, for Medicare Part A, there must be an order for therapy before the evaluation and treatment begins. For Medicare Part B, the certification of the individual plan of care is the technical requirement.

What does NOT demonstrate Medical Necessity?

One can decrease risk by understanding what is NOT medically reasonable and necessary.

  • Evaluations not individualized, not resident specific, do not provide a clear clinical picture of the resident or demonstrate the reason why skilled therapy is needed.
  • Repetitive documentation indicating the therapist is doing the same exercises day after day with no documented skill.
  • A lack of clinical analysis. If the documentation does not show ongoing clinical analysis of the resident’s response to therapy with modifications made to treatment as appropriate, then skilled care is not being demonstrated.
  • Unclear progress notes and re-certifications regarding the remaining deficits and the specific skilled interventions planned to address residual deficits. The documentation may not justify the need for continuing skilled therapy. Simply because the physician signs the re-certification, does not automatically support the content to demonstrate the need to continue with skilled care.
  • Documentation only records what the resident is doing and does not support the unique skills of the licensed professional. The notes must tell the story. If the therapist is training on compensatory strategies for issues such as spasticity, cognition, or cardiac symptoms, it needs to be clearly documented. The documentation must clearly demonstrate whether the skills of the therapist are needed to continue.
  • Missing the impact of co-morbidities on the resident’s rehabilitation prognosis and performance in therapy. Documentation should highlight the co-morbidities and why the knowledge, skill, and judgment of the therapist are required. What might be a simple task for one person may be complicated for another, all due to co-morbidities. A service usually considered nonskilled could be considered a skilled service because of the medical complexity of a specific resident and the need for the therapist to provide treatment, education, safety precautions and/or clinical supervision. The deciding factor is not the resident’s potential for recovery, but whether the services needed require the skills of a therapist or whether they can be provided by nonskilled personnel.
  • Documentation without any adjustments to the plan of care. Documentation that does not demonstrate progression in goals, specific need of the skilled professional modifying the plan, or no record of resident limitations may not support medical necessity.
  • Documentation that does not focus on the need for a skilled professional to provide the care. A therapist may state a resident has the “potential” for improvement, as a reason for continuing skilled therapy or the reason for continuing skilled therapy is the resident has not reached “maximum potential improvement.” A habit of focusing on the word “potential” is a risky one. Skilled care may be necessary to improve a resident’s current condition, to maintain the resident’s current condition, or to prevent or slow further deterioration of the resident’s condition. Appeals for claims denied have been written due to lack of medical necessity where a Medicare Contractor states he/she did not question the resident would benefit from continued exercise, gait training, and/or therapeutic activity, but questioned whether a skilled professional was needed to provide the care. In other words, based upon the documentation, the reviewer indicated the care could be provided in a restorative nursing program or maintenance program.

Documentation that does not meet medically necessary requirements poses risk. You should be asking yourself “How can we lower our risk?”

Thank you for your time in reviewing the final part of our series on therapy risk.