SUPPORTING DOCUMENTATION FOR MEDICARE RESIDENTS

 Adequate documentation is essential to support skilled services. Medicare payment for services may be denied if the supporting documentation is not thorough.

Make sure Physician’s orders for therapies and treatments stating type, frequency, and duration are in place and signed in a timely manner.

Check that the orders are carried over to the MAR and TAR, and that all initials and signatures are in place.

Develop and maintain acute and long term care plans related to the care.

Included in the billing requirements for Medicare payment, the physician must certify on an ongoing basis that there is a need for skilled nursing services and the reasons for continued need of those services. Upon the admission of a Medicare resident, fill in the name, Medicare number, admission date, and recertification dates on the Certification form. Place the form in the resident’s chart in front of the Physician’s Orders, and flag the page for the physician to sign. Check the form with each MDS 3.0 assessment, and flag again when needed.

The MDS 3.0 Coordinator can help to assure compliance by making sure the nursing staff is well informed. One way to do this is to place a sheet in front of the nurses notes stating why the resident is skilled, what exactly needs to be assessed and charted, and how frequently charting is needed. Good documentation describes the resident’s conditions and responses to the specific skilled treatment. A Medicare sticker can be placed on the chart to flag it for daily skilled charting.  

Skilled Charting Guidelines provide clear instructions for the supporting documentation required for Medicare reimbursement, and can also assist in determining what conditions may be considered skilled care.

More information on maximizing MDS 3.0 reimbursement can be found in the book:

 The MDS Coordinator's Handbook