Did you know that Medicare paid almost $5.8 billion in wrong payments for skilled nursing facility billing services? Most of the payments were the wrong amount. Always remember one thing that based on what your clinical records contain, Medicare makes payment. Therefore, you must ensure that your documentation is perfect that it clearly tells them about your patient’s condition and provided treatment,,
For you, it is crucial to know the documents requirement for your skilled nursing facility. Here we are going to share tips to help ensure your team’s charting is accurate and compliant. We’ll cover the basics of documentation so you can provide great patient care and be sure you’re getting the right reimbursement for SNF services.
The overall requirements of documentation in SNF billing services:
Documentation in SNFs can be tricky and needs careful review of Medicare guidelines. According to CMS regulations, your facility must keep clinical records for each resident that are:
- Complete
- Accurately documented
- Easily accessible
- Well-organized
You can use either traditional paper charts or an electronic health record (EHR) system. Just keep in mind that state regulations might be stricter than federal ones.
If you use an EHR, make sure you have a system in place to control data and keep patient information secure. Make sure you have qualified staff members who know how to use EHR and submit documentation properly.
To ensure data control and patient-data safety, you must need to have a robust system in place.
Now, it is high-time, you need to know about the SNF documentation requirements –
Your clinical records should accurately reflect each resident’s experiences at your facility. While Medicare doesn’t specify how often you need to update progress notes, your documentation must clearly describe the resident’s condition, their response to treatments, and any changes.
Your documentation should include:
- Enough information to identify the resident
- Records of assessments
- Plan of care and services provided
- Results from any state-required preadmission screenings
- Progress notes
Accurate documentation is crucial for meeting these requirements and getting the right reimbursement. Often, this includes missing documents or not supporting billing codes correctly.
Critical elements related to Medicare documentation:
You need to evaluate residents at admission, discharge, and at other key times like quarterly or when there are major changes in their status. These assessments check the resident’s functional abilities and health needs and are crucial for documentation and Medicare reimbursement rates.
Common assessments you’ll need to document include:
- Pre-admission assessment
- Admission assessment
- Fall assessment
- Skin assessments (risks and actual issues like pressure ulcers)
- Bowel and bladder assessment
- Physical restraint assessment
- Self-administration of medication
- Nutrition assessment
- Activities/recreation/leisure interest assessment
- Social services
- Mental and psychosocial functioning
- Restorative/rehab nursing assessment
- Rehabilitation services
Besides assessments, you also need to document care plans, progress notes (from physicians and nursing staff), Medicare physician certifications, orders, rehab therapy, medication administration records, and discharge documentation. Make sure to use clear, specific language in your notes.
To streamline a perfect documentation process in your SNF billing solutions, it is always critical to know about the documentation challenges coming with skilled nursing facility billing so that you can implement the right strategies to improve the overall documentation process.
Critical Medicare documentation challenges:
Guidelines for skilled nursing facilities can be really complex, and avoiding errors is crucial because they impact patient care, reimbursement, and legal risks. To reduce claim denials, your team should regularly review and update treatment goals, as these help determine coverage.
Most of the denials occur due to physician certification and recertification. This documentation proves the medical necessity for services and must be both complete and timely. These certifications justifies the medical necessity of patient who require skilled nursing care. To avoid denials, make sure your medical records clearly show:
- The patient needs services that only a skilled professional can provide.
- The services are needed to treat the patient’s medical issue and match the severity of the illness or injury, their medical needs, and accepted medical standards.
Required documents include:
- Certification that the patient needs daily skilled care only available in a SNF setting.
- An authenticated plan of care.
- The time (in minutes) for therapy services provided.
Medicare guidelines can also be tough because they require coordination between different clinicians. Conflicting documentation can lead to denials.
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Fortunately, you can avoid all the documentation related challenges by following the tips mentioned below-
- Documentation should be done “timely,” ideally in real-time or as close to it as possible.
- Once you’ve recorded something, don’t change it later.
- Keep records for at least 5 years from the discharge date (or as required by your state).
- Avoid duplicating information in the medical record.
- Make sure your documentation doesn’t contradict other records, especially between different disciplines.
- Write clearly and check for spelling errors—mistakes can raise legal concerns about your competence.
- Use permanent ink for all documentation.
- If you need to correct a mistake, draw a single line through it so it’s still readable, write “mistaken entry” next to it, and date it.
Unfortunately, the truth is that most SNFs lack enough manpower to handle the intricate nature of administrative jobs like documentation, coding, billing and denial management. To avoid all the administrative hurdles, most SNFs outsource their documentation and other billing responsibilities to a professional third-party skilled nursing facility billing company Sunknowledge. Outsourcing documentation process in your skilled nursing facility billing solutions allows you to give your 100% on patient care and avoid any potential documentation-error.
