Medicare Charting guidelines

Talino · Jun 7, 2003

Welcome!

There is no specific guideline. The purpose of documentation is to prove to your Fiscal Intermediary that a skilled need is present and the care provided. During a Medicare audit, they will be scrutinizing the medical record for these services you have claimed for.

1. If you have a resident who comes back from the hospital for Pneumonia, you will need a daily note to prove that you are actually observing a resident from adverse effects. The reason for a daily note is that you cannot document elsewhere that you provided this skilled care. One daily note would suffice.

2. A resident who is covered for a new gastrostomy feeding does not necessarily require a daily nurses note unless you need to document any untoward reactions from use of the device or formula. Why? You already have an MD order for the GT feeding. You are recording the daily intake; and you are signing the MAR when a feeding has been provided.

3. A resident who is on Physical therapy will have an MD order, a therapist evaluation, and an attendance record.

Some will disagree strongly about daily charting. All I can say is that it is simply repetitive and unnecessary. It is an old habit. This is one reason why MDS/PPS was implemented.

Back in 1996, my facility joined the New York City pilot study for PPS. The primary concern raised by the participants was the voluminous and redundant documentation that Medicare required. MDS/PPS will eliminate the dilemma.

We have a Fiscal Intermediary auditor who comes annually at our facility since 1998. Not once were we ever questioned about the inadequacy of our method of documentation.

Common sense... if you claimed for a skilled need, simply show evidence that the care is provided.

FutureRNMichael · Jun 7, 2003

Good post talino. I agree 100%!

CapeCodMermaid, RN · Jun 8, 2003

Where I work, the Medicare residents must be charted on q shift for their first 72 hours and then daily after that, regardless of where else the information may be found

CapeCodMermaid, RN · Dec 9, 2004

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.

Talino · Dec 9, 2004

CapeCodMermaid said:
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.

The Medicare "daily nursing notes" you mentioned may be imposed upon you by your Fiscal Intermediary, not by CMS. But I would be surprised if the requirement specifically says that a "nurse" has to make such documentation.

The skilled need for tube feeding is not determined by a daily nurse's note but by the reason for need and the amount of fluid and caloric intake.

I do not dispute each facility's practice. Do what worked best for you.

Antikigirl, ASN, RN · Dec 9, 2004

We will chart every 90 days if a resident is stable with no changes in condition. If a condition is a fall, cold s/sx, UTI..things of this nature that will pass but need to be monitored, a nurse will put the patient on 'alert charting' and designate the type of charting needed. That has really helped us cut down the unneeded shift charting on some issues like skin tears or bruises (why chart q shift on a condition of these? We also monitor these issues on the MAR, so it is documented daily anyway).

We also do random chart audits every month..actually that is what I did! We would have a random list of 12 patients per month and I would go over their last month and make sure I felt charting was sufficient. Making it random helps, but last month...the random only showed 2 people that had a change in condition, so the others were rather borring..LOL! But I did find some slack in charting on weights or I/O or even bowel monitoring..and since a patient is charged for this...I caught it and got things back on track!

If a person is on hospice it is q-shift for communication reasons to hospice nurses. If they came back from the hospital, depending on condition it is policy to chart q shift for 3 days..but we nurses can extend it if we wish. Falls are 3 days too, same guidelines about lengthening it (ie pain issues or increased confusion post fall...).

The nicest thing we started doing is if things are very important to chart, caregivers must sign the MAR stating that they charted, or simply that they checked on that particular issue (ie skin issues). They have to fill out a shift summary and a 24 hour communication report as well...so if I don't sometimes see it in the chart..it will be in there, and I have them do a late entry if needed in the chart. That has been sooooo helpful and cut down unneeded charting quite a bit (or charting the same things in three or five different areas!).

IT has been helpful that the nurses have say over charting, and we have some guidelines for when we go "shoot...ummmmm I don't know" LOL! It really caters to need of individuals specific to their changes or conditions as they progress, and has improved over the year we have tried this! We have also gotten kudos for documentation of skin issues via the MAR (we also have weekly checks by LN on larger than 2cm tears or over 3 cm bruises till resolved on a separate sheet of paper in the MAR, and charting...so it is very followed through, especially since medicare kept on declining to pay for dressing supplies!).

blessed02 · Dec 9, 2004

Thank you all for the info-this is really scary for me.I work in an assisted living and most nurses do not get time to chart because of work overload-we have one nurse on duty in a 7 floor facility and you have to chart on people who have something going on-but at the end of the shift you have taken no break and you're not supposed to stay more than half an hour over-i stay anyways and chart and i'm waiting for the day i'll be fired for staying over-problem is other nurses just go home and do not chart.

proudmommielpn · Dec 10, 2004

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.

catlady, BSN, RN · Dec 22, 2004

proudmommielpn said:
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.

proudmommielpn · Dec 22, 2004

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:

sis14rn · Dec 28, 2004

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.

Medicare Charting guidelines

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