nursing documentation: do your medical records support skilled care?

Nursing Documentation: Do Your Medical Records

Support Skilled Care?HARMONY UNIVERSITY

The Provider Unit of Harmony Healthcare International, Inc. (HHI)

Presented by:

Beckie Dow, RN, RAC-MTDirector of MDS / Nursing Education & Training

Director of MDS/Nursing Education & Training for Harmony Healthcare, International, Inc.Over 20 Years Experience in Long-Term CareClinical and Reimbursement Accuracy in AssessmentsQuality Assurance ActivitiesInterrelation between MDS, Care Planning, QA, and Clinical Excellence at the Bedside

AANAC Master Teacher

Speaker Bio (Beckie Dow)

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Nursing Documentation: Do Your Medical Records Support Skilled Care?

Disclosure: The planners and presenters of this education activity have no relationship with commercial entities or conflicts of interest to disclosePlanners:

Elisa Bovee, MS, OTR/LDiane Buckley, BSN, RN, RAC-CTBeckie Dow, RN, RAC-MTKeri Hart, MS CCC, SLP, RAC-CTKristen Mastrangelo, OTR/L, MBA, NHAChristine Twombly, RNC, RAC-MT, LHRM

Presenter: Beckie Dow, RN, RAC-MT Director of MDS / Nursing Education &

TrainingCopyright © 2013 All Rights Reserved

Harmony Healthcare International, Inc.

Nursing Documentation: Do Your Medical Records Support Skilled Care? Disclosure Speaker: Beckie Dow, RN, RAC-MTDirector of MDS / Nursing Education & Training

The speaker has no relevant financial relationships to disclose

The speaker has no relevant nonfinancial relationships to disclose

Copyright © 2013 All Rights Reserved 4


Nursing Documentation: Do Your Medical Records Support Skilled Care?

Criteria for Successful Completion

Complete Sign-in and Sign-Out on Attendance FormAttendance for entire sessionCompletion and submission of speaker evaluation form


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Program Objectives

The learner will be able to describe the technical and clinical requirements for Medicare coverageThe learner will be able to state the goal of supportive skilled nursing documentationThe learner will be able to identify sections for the MDS 3.0 assessment that are vulnerable to error and articulate strategies to support these areas in medical record documentationThe learner will be able to identify the correlation between medical record documentation, the MDS 3.0, and publicly reported information for the Quality Measures and 5 Star Quality rating

Copyright © 2013 All Rights Reserved

Program Goals

This program will enable Healthcare providers to provide quality healthcare through understanding the requirements of skilled Medicare documentation and provide examples of skilled nursing documentation that will support a skilled level of care.


What is Medicare?

Medicare is a federal health insurance program for people 65 or older and certain disabled peopleIt is administered at the federal level by the Centers for Medicare and Medicaid Services (CMS)Two parts--Hospital insurance and medical insuranceMedicare payments are handled by private insurance organizations under contract with the GovernmentOrganizations handling claims from hospitals, SNFs, and HHAs are called intermediariesOrganizations handling claims from doctors, supplies for SNFs and other suppliers of services covered under the medical insurance part of Medicare are called carriers


Medicare Coverage

In each benefit period Medicare Part A pays for all covered services in the first 20 days in the SNF.Daily co-insurance amount is assessed to the beneficiary from 21st to 100th dayMedicare only covers skilled careMedicare does not cover custodial careCopyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 9


Medicare Part A Coverage

Requirements

Technical Requirements

Technical requirements are not eligible for appeal—if the patient does not meet technical requirements their stay will not be coveredIt is the responsibility of the facility to determine if technical eligibility requirements are metBest practice: The facility should have a process for determining technical eligibility prior to admission




Beneficiary is enrolled in Medicare Part A and has available daysBeneficiary had a three-day qualifying hospital staySkilled care must begin within 30 days after discharge from a hospital or the last covered Medicare day of a SNF stay


Three-day qualifying stay does not include nights spent in observation status or in an ER bedCan be in different hospitals, but nights must be consecutiveThe day of admission, but not the day of discharge, is counted in the three days



Skilled care must begin within 30 days (unless the Medical Appropriateness Exception applies)Medical Appropriateness Exception-Physician determines that an immediate skilled stay would not be appropriate for the patientSkilled stay can be deferred longer than 30 days after hospitalization



Clinical (Level of Care) Requirements

The patient requires physician-ordered skilled nursing or rehabilitation services that relate to the hospital stay or a condition that arose while receiving post-hospital careThe services are dailyAs a practical matter, the services must be delivered in the SNFThe services are reasonable and necessary for treatment of the illness/injury

Medicare Coverage/Skilled Care

Provided on a “daily” basis:Rehabilitation (PT, OT and/or SLP) must be at least five days per week

An isolated break of “a day or two” is allowable

Skilled nursing (or combination of nursing and rehabilitation) must be seven days per weekRestorative nursing Programs must be at least six days per week



What is Skilled Care?

Nature of service requires the skills of a licensed person (e.g. technical or professional personnel)Skilled services are provided directly by or under general supervision of a licensed nurse or therapist to assure the safety of the patient and to achieve the medically desired resultDiagnosis and prognosis do not determine what is skilled care – it is the care of the patient that is the deciding factor


“Practical Matter” Criterion

“As a practical matter, considering economy and efficiency, the daily skilled services can only be provided in a skilled nursing facility”



1.Outpatient services are not available in the area where the individual lives.

2. Outpatient services are available in the area where the individual lives, but transportation to the closest facility could cause an excessive physical hardship, be less economical, or less effective that placement in the skilled nursing facility.



3.The availability at home of a capable and willing caregiver should be considered, but the care can be furnished only in the skilled nursing facility if home care would be ineffective because there would be insufficient assistance at home for the patient/patient to reside there safely.

4.If the use of alternative services would adversely affect the patient’s medical condition, then as a practical matter the daily skilled service(s) can only be provided on an inpatient basis.

Copyright © 2013 All Rights Reserved 21Harmony Healthcare International, Inc.

SNF Level of Care CriteriaLeave of Absence

“An SNF should not interpret the practical matter criteria so strictly that it results in the automatic denial of coverage for patients who have been meeting all of the SNF level of care requirements but who have occasion to be away from the SNF for a brief period of time.”


Skilled Nursing Documentation Requirements


Basics of Documentation

Medicare has no specific requirements related to documentationDaily skilled care is required and must be proven in the record Documentation should be precise and contain information supporting the skilled care given No specific format is required by Medicare



The person reading your note was likely not present during your observations; you need to paint a picture with your words for themWritten entries must be in terms easily understood by anyone reading the notesDocumenting occurrences during your shift is like writing a story with a beginning, a middle and an end (each needs to be accurately depicted in the record)



The physician relies on documentation in order to make adjustments to the plan of careThe record must reflect the physical and mental status of the patient upon admission and changes during the stay in the facility. This will help serve as a tool to identify the changing care needs of the patient.



Keep the purpose of your entry in your mind

Summary of general observationsIdentification of specific problemsFollow-up of previously identified problems

Don’t leave the next reader in suspense and wondering what happened. When you have identified a problem, follow-up later to include the status at the end of your shift.Be descriptive and concise



Your notes should be: Objective, not critical or subjectiveClear, concise, and comprehensiveAccurate, truthful and honest; documentation should not appear self-serving, especially if an incident or injury occursReflective of observations, not of unfounded conclusions


Copyright © 2013 All Rights Reserved 28Harmony Healthcare International, Inc.

Medicare Nursing Documentation

Goal: Skilled nursing documentation should clearly delineate the medical complexity of the patient and skilled nursing services provided


Medicare Documentation

There are increased reviews nationallyThese are often focused on patients that do not reflect skilled levels of care (e.g., those in the lower 14 RUG-IV groups)There is an increase in the likelihood that someone will review your Medicare documentationHarmony Healthcare International, Inc.


Medicare Nursing Documentation

The key to documenting skilled services is understanding the Medicare coverage requirements

Key Point: Nursing Rules the World!

Skilled Nursing Services anchor ALL Part A benefits


Skilled Nursing Documentation 101

Skilled Nursing Documentation falls under the following categories:

Direct Nursing SkillsSkilled Observation and AssessmentManagement of a Care PlanTeaching and Training Activities



Skilled Nursing Documentation

Some questions to answer in your notes:

Why does the patient require 24 hour care in the SNF?What does the nurse do to ensure medical safety and promote recovery?What patient issues require licensed nurse intervention?

Key Point: Nursing always anchors skilled care!


Skilled Nursing Documentation What To Consider Including:

Patient is at high risk for …Skilled assessment of …Daily skilled monitoring of …Potential for recurrence of …Potential for the following complications…There is a likelihood of change related to…The medical regimen is not essentially stabilized as evidenced by…



Patient continues to require daily skilled rehab for …Observation and assessment for potential complications related to …Potential for medical complications related to the diagnosis of …Plan of care is being monitored to promote recovery and ensure medical safety related to …The patient requires daily skilled management and evaluation of the plan of care related to …



Skilled neurological assessment resulted in…Daily skilled monitoring for signs and symptoms of exacerbation of _____ secondary to _______.Patient is high risk for ______ secondary to _______.Medications adjusted to _____________, ongoing skilled assessment of regimen to promote recovery and ensure medical safety.Patient continues to require daily skilled nursing as his treatment regimen is not essentially stabilized and there is a potential for recurrence of ________.


Non-Supportive Nursing Documentation

Plateau in progressVoiced no complaintsPatient requires custodial carePatient requires intermittent carePatient is unable to follow directionsPatient requires intermittent services

Patient has poor rehabilitation potentialPatients medical treatment is essentially stabilizedRefuses to participate in therapy (instead give the reason the patient is unable)Condition stableSlept well/family into visit


Daily Nurses Note

Describe a skilled observation, assessment and/or actionThis note can be episodicDescribe pertinent skilled happenings of the day or shift


Nursing Documentation:Daily Narrative Documentation

Should evidence the critical thinking, judgment decision making by skilled nurses Daily nursing notes should evidence assessment of the data recorded on flow sheets and treatment sheets etc. vs. re-stating the data



Nursing Documentation: Daily Narrative Documentation

Documentation must justify the clinical reasons and medical necessity for:

Medicare Part A coverageThe skilled services being deliveredThe on-going need for coverage



Nursing Documentation: Daily Narrative Documentation

Diagnosis Driven Diagnosis related to acute hospitalizationsThose which arose at the SNF Chronic conditions that potentially complicate the patient’s clinical status, stability or level of care needed



Nursing Documentation:Admission and Re-Admission Nursing Notes

Admission Nursing Note:Follows the admission nursing assessment and is based on those findingsIs done by the nurse admitting the patientIncorporates information in referral and assessment data This nurse knows more about the patient than any other nurse will for several days




HHI suggests that the following information be included in all Admission Notes:

Exact time and date of admissionRoom numberLocation prior to admissionAge, primary diagnosis, other pertinent medical historyAssist level and number of assist with transfers and bed mobility provided by staff (2 assist to transfer)List any identified skilled needs which have been identified




HHI suggests that the following information be included in all Admission Notes (Cont.)

Prior level of functioning and if possible, discharge destinationList of all nursing assessments which relate to the primary diagnosis and related secondary diagnosisDetailed skin assessment and historic skin staging reportedMost ADL care provided (Bed mobility, Eating, Transfer, Toilet use) during the shift



The Bottom Line

Will the documentation in the patient’s medical record support the care and/or services provided to the patient as well as the coding on the MDS (which resulted in the daily rate for the care of that patient)?


Review of a Few Key MDS 3.0 Sections


MDS 3.0

Section D:MOOD

Section D: Mood

Intent: The items in this section address mood distress, a serious condition that is underdiagnosed and undertreated in the nursing home and is associated with significant morbidityIt is particularly important to identify signs and symptoms of mood distress among nursing home residents because these signs and symptoms can be treatable



A Key Point from the RAI Manual

…the presence of indicators in Section D does not automatically mean that the resident has a diagnosis of depression or other mood disorder. Assessors do not make or assign a diagnosis in Section D, they simply record the presence or absence of specific clinical mood indicators.


Section D – Key Points

PHQ-9OV (staff assessment) should include information from all shifts and disciplinesFollow the interview scriptUse the cue cardsUse the interview techniques from Appendix D of the RAI Users ManualCompetency checks for interviewing staff

Section D – Key Points

Section D has a potential impact on Percent of Residents Who Have Depressive Symptoms (Long Stay)Total Severity Score 10+, andLittle interest or pleasure in doing things OR feeling or appearing down, depressed, or hopeless half or more of the days in the last two weeks (2, 3)


Section D – Key Points For Nurses

Documentation of follow up with patient to talk about areas that are responded to positively and are increased from last assessmentCare planning for mood itemsDaily/weekly documentation about symptom prevalence and the efficacy of medicationsGradual Dose Reduction, when appropriateDocumentation of nursing support in relation to mood symptoms and patient response



MDS 3.0

Section E:BEHAVIOR



Section E: Behavior

Intent: The items in this section identifies behavioral symptoms in the last seven days that causes:

Distress to the resident

Distressing or disruptive to facility residents, staff members or the care environment

This section focuses on the resident’s actions and not the intent of the behavior



E0200: Behavioral SymptomPresence & Frequency Behaviors

Physically Behavioral symptoms directed toward others: Hitting, kicking, pushing, scratching, or sexually abusing others

Verbally Behavioral symptoms directed toward others: Threatening others, screaming at others, or cursing at others



E0200: Behavioral SymptomPresence & Frequency

Other behavior symptoms not directed toward others: Hitting, scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily waste, verbal/vocal symptoms like screaming, disruptive sounds


E: Behavior

Section E also captures the effect the behavior has upon the resident, and upon other residentsCaptures if the behavior puts the resident or others at risk for

Physical injuryAffects privacyDisrupts living environment


Section E – Key Points For Nurses

Section E is often under coded Usual is not normal!Documentation in the medical record must support coding on the MDSBehavioral management programs and Management and Evaluation of the Plan of Care must be captured in skilled nursing documentation Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 57

Section E – Key Points

Surveyor Quality Measures:Prevalence of Psychoactive Medication Use, in the Absence of Psychotic or Related Conditions (Long)—affects exclusionsPrevalence of Antipsychotic/Hypnotic Use (Long)—affects exclusionsPrevalence of Behavior Symptoms Affecting Others (Long)



MDS 3.0

Section G:FUNCTIONAL STATUS


Section G:Principles of Accurate Assessment

7-day look-back period (since admission or readmission only)AssessObserveConsult with all interdisciplinary team across all shifts to capture accurate assist levelsAsk probing questions, beginning with the general and proceeding to the more specific


Section G: Principles of Accurate Assessment

Do NOT include assistance provided by family or other visitors when capturing assist levelDo NOT code ambulance transfer assistance or assistance from hospiceCode assist provided by facility staff onlyNo longer looks back into the hospital


The Four Late Loss Activities of Daily Living (ADLs)

Bed MobilityTransferEatingToilet Use


The Late Loss ADLs Defined

Bed mobility - how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furnitureTransfer - how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position (excludes to/from bath/toilet)


The Late Loss ADLs Defined

Eating - how resident eats and drinks, regardless of skill. Do not include eating/drinking during medication pass. Includes intake of nourishment by other means (e.g., tube feeding, total parenteral nutrition, IV fluids administered for nutrition or hydration)

Toilet use - how resident uses the toilet room, commode, bedpan, or urinal; transfers on/off toilet; cleanses self after elimination; changes pad; manages ostomy or catheter; and adjusts clothes. Do not include emptying of bedpan, urinal, bedside commode, catheter bag or ostomy bag


Section G – Key Points For Nurses

Documentation to support coding is a mustFocus on four late loss ADLsAccuracy begins at the bedside with the C.N.A. all three shifts (don’t forget nights!)Ensure reporting and/or documentation all other disciplines regarding ADLsEducate frontline nursing staff as well as IDTEnsure an audit protocol (MDS and documentation)

Section G – Key Points

Section G coding affects several QMs, as covariates, exclusions, or triggersLong Stay, Short Stay, and Surveyor MeasuresDaily documentation to support ADL assistance provided is critical in ensuring accurate and supported RUG-IV classification



Quality Measures:Percent of Residents with Pressure Ulcers That Are New or Worsened (Short)—covariatePercent of High-Risk Residents With Pressure Ulcers (Long)—stratification to define high-riskPercent of Low Risk Residents Who Lose Control of Their Bowel or Bladder (Long)—exclusion of high risk to identify low



Quality Measures (cont.)Percent of Residents Whose Need for Help with Activities of Daily Living Has Increased (Long)—trigger and exclusion



MDS 3.0

Section I: ACTIVE

DIAGNOSES


Section I: Coding Instructions

Code diseases that have a documented diagnosis in the last 60 days and have a relationship to any of the following in the last 7 days:

Functional status Cognitive statusMood or behavior statusMedical treatmentsNursing monitoringRisk of death



A Two-Step Process:• Diagnosis identification (Step 1) is

a 60-day look-back period• Determining diagnosis status:

Active or Inactive (Step 2) is a 7-day look-back period (except for Item I2300 UTI, which does not use the active 7-day look-back period)



Do not include conditions that

Have been resolved orNo longer affect the resident’s functioning or plan of care


Section I – Key Points For Nurses

Ensuring provider documentation to support codingIs physician documentation needed to add to support to the diagnosis is active in the last seven days?Documentation (including care planning) to reflect actively impacting care of the resident

Section I – Key Points

Quality Measures for Antipsychotic, Antianxiety, and Hypnotic use have several diagnosis-based exclusions and covariatesDiagnosis-driven daily documentation to support the inherent complexity of the patients condition and the need for ongoing skilled nursing observation and assessment



MDS 3.0

Section M:SKIN CONDITIONS


Section M: Skin Conditions

Asks the clinician to determine if at risk for pressure ulcersIncludes updated pressure ulcer definitions Must determine present on admissionIncludes diabetic foot woundsNo longer back stage pressure ulcersOnly stage pressure ulcers


Section M – Key Points

Clear, concise, and accurate documentation of all skin areas as soon as possible after admissionMeasuring practices and staging competencyDetermination and documentation of wound etiology (scope of practice and QOC issues)

Section M: Key Points For Nurses

Accuracy in wound documentationClear and descriptive wound documentationPatient’s response to treatment (pain, infection, healing process)Daily documentation that supports the overall clinical picture of the wound


Section M – Key Points

Percent of Residents with Pressure Ulcers that are New or Worsened (Short)Percent of High-Risk Residents With Pressure Ulcers (Long)


MDS 3.0 Affect on Quality Measures and the 5 Star Rating (Long Stay)

Percent of residents whose need for help with daily activities has increasedPercent of high-risk residents with pressure ulcersPercent of residents who have/had a catheter inserted and left in their bladderPercent of residents who were physically restrainedCopyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 80

MDS 3.0 Affect on Quality Measures and the 5 Star Rating

Quality Measures information is 100% derived from MDS 3.0 dataThere are 35 total Quality Measures (12 Short Stay, 23 Long Stay)Nine of these Quality Measures will influence your final 5 Star Rating (two Short Stay, Seven Long Stay)Four additional surveyor measures


MDS 3.0 Affect on Quality Measures and the 5 Star Rating (Long Stay)

Percent of residents with a UTIPercent of residents who self-report moderate to severe painPercent of residents experiencing one or more falls with major injury


MDS 3.0 Affect on Quality Measures and the 5 Star Rating (Short Stay)

Percent of residents with pressure ulcers that are new or worsenedPercent of residents who self-report moderate to severe pain

MDS accuracy leads to Quality Measure and 5 Star Rating

accuracy!Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 83

KEY POINT:

Final Thoughts…

Daily skilled nursing documentation must support the skilled services that are being providedMost claim denials are due to lack of supportive clinical documentation


References

Medicare Program Integrity Manual, Chapter 6 http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/pim83c06.pdfMedicare Benefit Policy Manual , Chapter 8 http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c08.pdf


http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/pim83c06.pdf



http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c08.pdf



References

5 Star Technical Users Guide http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/downloads/usersguide.pdfQuality Measures Users Manual http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Downloads/MDS-30-QM-Users-Manual-V60.pdf


http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/downloads/usersguide.pdf




http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Downloads/MDS-30-QM-Users-Manual-V60.pdf




References

RAI Users Manual http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual.html


http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual.html




Questions/Answers

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Harmony Healthcare International, Inc. 8888Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc.

Questions/Answers

Harmony Healthcare International1 (800) 530 – [email protected]

Harmony Healthcare International, Inc. 8989Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc.

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