Agencies in Review Choice Demonstration states are facing a flood of non-affirmations in pre-claim review around medical necessity. In a new message to providers, Medicare Administrative Contractor Palmetto GBA notes the type of documentation reviewers expect to see to justify skilled care.
“The medical record from the certifying physician, allowed practitioner or acute/post-acute care facility should present a clinically consistent picture of the patient,” Palmetto states. “It must include objective clinical documentation that supports both the need for skilled services and the patient’s homebound status.”
For recertifications, agencies must include clinical documentation that clearly demonstrates the patient’s ongoing need for skilled services in the home.
This could include outside documentation, like recent visit notes with the certifying practitioner or recent lab results.
Nursing or therapy visit notes from the previous episode of care and the recertification OASIS could also support the need for continued skilled care.
“If the patient’s condition has changed, worsened or if a new condition has emerged, the documentation should reflect this and provide clinical evidence supporting the need for continued skilled care,” Palmetto states.