Documentation to Support Skilled Care Determinations

30.2.2.1 – Documentation to Support Skilled Care Determinations (Rev. 179, Issued: 01-14-14, Effective: 01-07-14, Implementation: 01-07-14) Claims for skilled care coverage need to include sufficient documentation to enable a reviewer to determine whether— • Skilled involvement is required in order for the services in question to be furnished safely and effectively; and • The services themselves are, in fact, 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 documentation must also show that the services are appropriate in terms of duration and quantity, and that the services promote the documented therapeutic goals. Such determinations would be made from the perspective of the patient’s condition when the services were ordered and what was, at that time, reasonably expected to be appropriate treatment for the illness or injury. Thus, when a service appears reasonable and necessary from that perspective, it would not then be appropriate to deny the service retrospectively merely because the goals of treatment have not yet been achieved. However, if it becomes apparent at some point that the goal set for the patient is no longer a reasonable one, then the treatment goal itself should be promptly and appropriately modified to reflect this, and the patient should then be reassessed to determine whether the treatment goal as revised continues to require the provision of skilled services. By the same token, the treatment goal itself cannot be modified retrospectively, e.g., when it becomes apparent that the initial treatment goal of restoration is no longer a reasonable one, the provider cannot retroactively alter the initial goal of treatment from restoration to maintenance. Instead, it would make such a change on a prospective basis only. Although the presence of appropriate documentation is not, in and of itself, an element of the definition of a “skilled” service, such documentation serves as the means by which a provider would be able to establish and an A/B MAC (A) would be able to confirm that skilled care is, in fact, needed and received in a given case. It is expected that the documentation in the patient’s medical record will reflect the need for the skilled services provided. The patient’s medical record is also expected to provide important communication among all members of the care team regarding the development, course, and outcomes of the skilled observations, assessments, treatment, and training performed. Taken as a whole, then, the documentation in the patient’s medical record should illustrate the degree to which the patient is accomplishing the goals as outlined in the care plan. In this way, the documentation will serve to demonstrate why a skilled service is needed. Thorough and timely documentation with respect to treatment goals can help clearly demonstrate a beneficiary’s need for skilled care in situations where such need might not otherwise be readily apparent, as when the treatment’s purpose changes (for example, from restoration to maintenance), as well as in establishing the efficacy of care that serves to prevent or slow decline—where, by definition, there would be no “improvement” to evaluate. For example, when skilled services are necessary to maintain the patient’s current condition, the documentation would need to substantiate that the services of skilled personnel are, in fact, required to achieve this goal. Similarly, establishing that a maintenance program’s services are reasonable and necessary would involve regularly documenting the degree to which the program’s treatment goals are being accomplished. In situations where the maintenance program is performed to maintain the patient’s current condition, such documentation would serve to demonstrate the program’s effectiveness in achieving this goal. When the maintenance program is intended to slow further deterioration of the patient’s condition, the efficacy of the services could be established by documenting that the natural progression of the patient’s medical or functional decline has been interrupted. Assessments of all goals must be performed in a frequent and regular manner so that the resulting documentation provides a sufficient basis for determining the appropriateness of coverage. Therefore the patient’s medical record must document as appropriate: • The history and physical exam pertinent to the patient’s care, (including the response or changes in behavior to previously administered skilled services); • The skilled services provided; • The patient’s response to the skilled services provided during the current visit; • The plan for future care based on the rationale of prior results. • A detailed rationale that explains the need for the skilled service in light of the patient’s overall medical condition and experiences; • The complexity of the service to be performed; • Any other pertinent characteristics of the beneficiary. The documentation in the patient’s medical record must be accurate, and avoid vague or subjective descriptions of the patient’s care that would not be sufficient to indicate the need for skilled care. For example, the following terminology does not sufficiently describe the reaction of the patient to his/her skilled care: • Patient tolerated treatment well • Continue with POC • Patient remains stable Such phraseology does not provide a clear picture of the results of the treatment, nor the “next steps” that are planned. Objective measurements of physical outcomes of treatment should be provided and/or a clear description of the changed behaviors due to education programs should be recorded so that all concerned can follow the results of the provided services.