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Under the Patient-Driven Payment Model (PDPM), skilled nursing facilities (SNFs) need to have documentation in the medical record that will allow a medical reviewer, in the case of an additional documentation request (ADR), to determine that Medicare Part A skilled services were provided and that those services were reasonable and necessary, says Suzy Harvey, RN-BC, RAC-CT, managing consultant at BKD in Springfield, MO.
“While DNSs have a higher-level oversight role with regard to most aspects of Medicare Part A, you should have a more active role in ensuring that nursing documentation supports the skilled need. You or whoever you delegate this duty to needs to work with the MDS coordinator or Medicare consultant to ensure that nursing staff are documenting appropriately to support the skilled need.”
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