Medicare Charting guidelines - page 2

Hi, Everyone! I am new to this site and I have some few questions regarding the medicare charting guidelines. Does anyone know where I can get a copy of this? I just started a new position at LTC... Read More

  1. by   proudmommielpn
    I worked in LTC for 5 years and we had to chart the Medicare's q 2hours until the medicare ran out and they went back to Medicaid. All our Medicaid pay sources we charted on q week on the day their skin assessment was due unless they had O2 or tube feeding then we charted q shift. I think it just goes with the facility you work at.
  2. by   catlady
    Quote from proudmommielpn
    I worked in LTC for 5 years and we had to chart the Medicare's q 2hours until the medicare ran out and they went back to Medicaid. All our Medicaid pay sources we charted on q week on the day their skin assessment was due unless they had O2 or tube feeding then we charted q shift. I think it just goes with the facility you work at.
    Q2hours???? Heck, even hospital patients are q4 or q shift! What on earth would you be charting every two hours? All that Medicare requires is documentation to support a daily skilled need. That's daily, not every two hours. Just because they're on a Med A stay doesn't mean they're unstable.
  3. by   proudmommielpn
    We would chart something like , Resp e/u NAD if they were 02 dependent, if they were diabetic we would chart 0 s/s of hypo/hyperglycemia, if they were seizure prone we would chart 0 s/s of seizure activity, just a quick entry q2 hours. That is what we were required to do. They had a green dot on their chart during Medicare billing.:Snow:
  4. by   sis14rn
    I am the nurse manager for a SNF. Your Medicare charting can be dependent on your FI and their guidelines. Essentially your Medicare A & B charting must reflect what dx you are skilling the Resident under. If they are in for a fx hip, you need to document ADLs, transfers, Wt bearing status, pain, ambulation. Think system specific. If your documentation does not support the skilled service, your payment can be denied.
  5. by   renerian
    Thanks everyone for your input.

    renerian
  6. by   Antikigirl
    Yeah, anyone that comes back from the hospital is automatically put on "alert Charting" at my facility. THat means q shift vs with temp (if I don't put temp on there my caregivers won't take them..habit now), and a general notation in charting on their pain levels or activities for three day minimum. If I see things of concern, I will add more implementations or parameters on when to call the LN. The LN's are the only ones that can D/C alert charting for post hospital or post procedure...so we check to see if everything is well, and guage the situation before taking them off alert charting.

    Seems to be a safe way to go, and does prove that the patient is being monitored and taken care of if things with medicare don't go smoothly.
  7. by   NurseKatie08
    Quote from CapeCodMermaid
    We in Massachusetts MUST complete a monthly nursing summary on ALL residents regardless of their payment source.
    And...we just had a corporate audit of 30 of our Medicare charts - say what you want, but you MUST have proper documentation to prove a skill, including a daily medicare note by a licensed nurse. Signing your initials to a med sheet after a Gtube feeding certainly wouldn't suffice for skilled documentation.
    I'm also in MA, and this sounds the same for my facility. On our TCU, all patients need to have daily Medicare notes. They are divided between day & evening shift, as the night nurse has to do chart checks. I think the simplest way to explain them, is the way it was explained to me during orientation---you need to prove why that patient needs to be in the facility. I'm just 5 months in as a TCU/rehab nurse, and was asked to have another new grad shadow me, because admin likes my documentation so much. It does get repetitive, but it is a necessary evil.
    We don't have monthly nursing summaries on the TCU (since they come and go so quickly) but the LTC floors definitely do.
  8. by   barefootlady
    HELP!!!
    Due to the bad weather, call ins, and lack of staff anyway, there have been 3 shifts I worked recently I did not chart one word!!!!! I could not, I had 31 patients to give meds and treatments. Who had time to chart???? Any suggestions would help.
  9. by   CapeCodMermaid
    Could you go back and do late entries? Or really, if it's only 3 days and the rest of the documentation is good, you're probably okay. If your facility doesn't have a history of audits then you're okay.

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