Any tips on Medicare charting or progress notes? I am better at them now but, I could use some advice on charting technique.
More info. I am working as a LPN on a rehab hall. I need to chart on therapy, new orders, condition. I have to chart aspects of their care so that Medicare will be continued. For instance, a lot of people have to go to therapy in order for Medicare to pay for their room. I have post op patients from hip, knee, shoulder and CABG surgeries and more. I also have regular long term residents.
In order for Medicare to pay for services at a SNF, they must be medically necessary. This requires that the services rendered be “skilled”. This means that the nursing services provided require the skills of a nurse. In other words, services that can be provided by non-skilled personnel, without the supervision and/or services of a licensed nurse, cannot be considered “skilled”.
The same applies for therapy. If the therapy services rendered are such that they do not require the skills of a licensed PT/OT/SLP, then they cannot be considered “skilled”.
There are policies unique to each Medicare contractor (MAC). Where do you practice? (city/state). I can guide you to specific documentation policies for your area.
Thanks for the reply. Your advice and help is appreciated! I practice in South Bend, Indiana.
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