Medicare charting. Charting in general

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This topic contains 11 replies, has 5 voices, and was last updated by Profile photo of Melissa Alexander Dupre MelissaAlexanderDupre 4 years, 7 months ago.

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  • #6871
    Profile photo of Bo Stone
    Bo Stone
    Member

    Any tips on Medicare charting or progress notes? I am better at them now but, I could use some advice on charting technique.

    #6875
    Profile photo of Bo Stone
    Bo Stone
    Member

    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.

    #6881

    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.

    #6882
    Profile photo of Bo Stone
    Bo Stone
    Member

    Thanks for the reply. Your advice and help is appreciated! I practice in South Bend, Indiana.

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