December 01, 2009

The care of nursing facility residents over the past decade has become increasingly challenging. Paralleling the complexity that we see in our patients is the increased documentation requirements to satisfy the insurers that pay us for our services. Our documentation must stand up to the test, or we risk being denied reimbursement or facing fraud allegations.

For whom must we document our work? The Centers for Medicare & Medicaid Services reviews our work via random audits, as do state Medicaid programs, trial attorneys, parties responsible for residents, state and federal surveyors, nursing facility staff, and other providers. When we claim to have provided services and charge for them, yet don't have sufficient documentation, that can be considered fraud.

In his 2008 white paper “Call to Action” leading up to the current debate on health reform legislation, Sen. Max Baucus (D-Mont.) signaled that the federal government would take fraud enforcement even more seriously than it has in the past. The senator wrote, “Fraud and abuse connote some level of culpability in that they involve billing practices or behaviors that include misrepresentation of or overcharging for services delivered. Fraud is willing or intentional, and abuse is a deviation from acceptable business and medical standards. Both lead to unnecessary cost to the payer.”

That's Why You're There

Each visit to a resident is for a reason. It may be for a change in condition or a visit mandated by Medicare or other regulations. Your notes should reflect the individuality of the visit. Repeating the same diagnoses for every visit means you're probably not recording the reality of why you saw your patient or what you found—and that's a red flag for a reviewer.

Using vague codes (generalized pain, generalized weakness) likewise tells the reviewer little about your encounter. Broad diagnoses (lung cancer, lymphoma) leave the reviewer wondering if your visit was necessary and maybe whether it overlaps with services covered by hospice.

A good test is to have a colleague review a note and give you feedback both on your documentation and on the time you spent with the resident. If your colleague can't see the value of your visit, then an insurance reviewer won't, either.

Every note you write must be a creation, not a re-creation. It should tell the reviewer exactly what you saw, smelled, discussed, and reviewed. It should relate the complexity of your decision making, the work involved in talking with a family, and the time you took to call a specialist to discuss the case.

It should include the time you spent during the visit calling for a prior authorization, writing prescriptions, answering a consultant pharmacist's inquiry, and completing forms for specialist visits and durable medical equipment. The reviewer must be able to put it all together to get a picture of the intensity of your service and to understand the process you went through to develop a treatment plan.

This is all done primarily to communicate with other health care providers, but it also serves to avoid audits. Audits take up your valuable time and your staff's time to respond. Audits can become costly if you are a repeat offender (you can actually be charged for the reviews). Audits give you heartburn. Avoid them by documenting your work efficiently.

Paper, Still a Good Choice

Does that mean you have to go electronic? No. Pen-and-paper documentation templates are a perfectly good way to document your work. The move to electronic medical records can be costly and cumbersome for small groups. It entails the cost of equipment, the difficulty of carrying it safely to multiple facilities, and the hassle of finding a place to set up your own computer station in a nursing facility.

Paper templates are great for physicians, nurse practitioners, and physician assistants. Bedside documentation becomes easy and leaves you with more accurate and complete assessments of your patients than relying on scattered notes.

Completed templates are invaluable for your coding and billing personnel. These tools also provide immediate documentation for the nursing facility when it's attempting to ensure continuity of care.

Use documentation templates for any official encounter, which is a face-to-face visit with a resident in a nursing home, assisted living facility, or residential care facility. Initiate the template at bedside, and complete it with the patient's full chart available. Always copy the template before leaving the facility.

Getting down to finer points, blue-gel ink pens are a plus, because your marks are easily distinguishable from the black ink of the original document. Keeping a copy of the completed template in your office is mandatory. These documents or any note can be misplaced easily in a facility. Keep a daily encounter sheet so your office manager can check that all templates have been received. Disorganization translates to not getting paid for your time and commitment.

Transcription can be useful when a volume of information is needed. It's cost effective for history and physicals, procedure notes, and letters. But be careful—using transcription for all of your notes can cost you upwards of 10% of what you will be reimbursed.

Using voice recognition software can be helpful in documenting family discussions and items that may someday become part of a legal proceeding.

Know the guidelines put out by CMS for documentation. If you satisfy that agency's requirements, you will probably be satisfying all other payers' requirements, too.

The “1995 Documentation Guidelines for Evaluation and Management Services” and the “1997 Documentation Guidelines for Evaluation and Management Services” can be found on the CMS Web site. These are valuable tools to review and use to make up your own templates. Another helpful tool is AMDA's “Guide to Long Term Care Coding, Reimbursement and Documentation,” which has vignettes and documentation requirements specific to long-term care.

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