Skilled Nursing Documentation

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Skilled NursingDocumentation

• Anne Young, R.N.
• Department of Medical Assistance Services
• October 6, 2009

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Skilled Nursing Services

• Services are to be
• Rendered in accordance to the licensing standards
  and criteria of the Virginia Board of Nursing.
• Performed by a Virginia licensed Registered Nurse
  (RN) or Licensed Practical Nurse (LPN) under the
  supervision of an RN.
• Ordered by MD, NP or PA

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Skilled Nursing Services cont.

• The supervision of the LPN is to be consistent
  with the Board of Nursing regulations.
• DMAS requirement is minimum 30-90 days depending
  on type of service and childs medical condition.
  More medically fragile more frequent
  supervision.
• Skilled nursing must be part of the IEP or the
  IEP must be amended to include the skilled
  nursing service.

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Skilled Nursing Services cont.

• The service provider must be employed by the
  school division or under contract to the school
  division.
• All skilled nursing services must be directly
  provided and medically necessary.
• Services deemed not medically necessary on
  quality management review, will not be covered.

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Skilled Nursing Services cont.

• Services will be consistent with skilled nursing
  services within the scope of their practice.
• These services can include but are not limited
  to
• Dressing changes
• Urinary catheterizations
• Medication Administration

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Assessment

• Completed by RN
• Admission / re-admission to service
• Significant change
• Upon order of MD, NP, PA
• Includes
• Diagnosis
• History
• Current medical findings
• Clinical signs and symptoms
• Needs and deficits

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Plan of Care (MED 10)

• Services will be directly and specifically
  related to an active, written plan of care (POC).
• POC is to be part of the nursing record and is
  the documentation for services.
• The POC is based on MD, PA or NP written order
  for skilled nursing services.
• The RN is to establish, sign, and date the POC.

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Plan of Care cont.

• Medicaid billing can precede POC date up to 21
  days prior to the signature on POC.
• However services may not begin prior to date
  treatment is prescribed by MD, NP or PA.
• The POC is to be periodically renewed or updated
  by an MD, PA or NP.
• Usually this is done at the beginning of each
  school year or at anytime the MD/PA/NPs orders
  are changed.

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Plan of Care cont.

• Must include
• Medical condition(s) to be addressed
• Goals and objectives
• Treatment and procedures required by nurse
• Time tables (date and frequency)
• Actual services to be delivered

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Plan of Care cont.

• Prescriber of services
• Date of POC implementation
• Documentation of RN or LPN
• Signed and dated
• Services shall be specific and provide effective
  treatment for the childs condition in accordance
  with accepted standards of skilled nursing
  practice.

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Plan of Care cont.

• Skilled nursing services that exceed the MD, PA
  or NPs written order for skilled nursing
  services will NOT be reimbursed by DMAS.
• A copy of the Plan of Care shall be given to the
  childs Medicaid Primary Care Physician.
• Reviewed at least annually.

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Progress Notes MED 11

• Documented by the responsible nurse
• Date
• Time of day
• Amount of time
• Actual nursing procedure rendered

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Progress Notes cont.

• Students response to treatment
• N normal
• V variance from normal or standard. Include
  written explanation in Comment section
• Actions related (calling parents, physician,
  etc.)
• Print full name, signature and initials or
  responsible nurse and supervising RN if
  applicable.

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Documentation Tidbits

• Dates and times of nursing service entered by the
  responsible nurse
• Name and Medicaid / FAMIS ID of the child on
  each page of the nursing record
• Services which have been delivered and for which
  reimbursement from Medicaid is to be claimed,
  must be supported with documentation.

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Documentation Tidbits

• The POC will include any prescribed drugs which
  are part of the
• Individualized Educational Program (IEP)
• Including dose, frequency and route
• Follow the Specialized Health Care Procedures
  Manual
• Changes from the MD/NP/PA written order
• All documentation shall be signed and dated by
  the nurse performing the service

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Documentation Tidbits

• Skilled nursing services may include extensive
  documentation
• Documentation shall be written
• Immediately or as soon thereafter as possible
• After the procedure or treatment was implemented
• Make sure to include the date and time

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Documentation Tidbits

• Skilled nursing services documentation will be in
  accordance with the
• Virginia Board of Nursing
• Department of Health Professions
• Department of Education statues, regulations and
  standards relating to school health and
• School Division Medicaid Manual
• Chapter VI (Utilization Review)

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RN Supervision

• If nursing procedures are performed by an LPN,
  they must be supervised by a RN in accordance
  with the Board of Nursing Regulations.
• RN to review the childs progress and make any
  adjustment to goals or treatment modalities

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RN Supervision cont.

• LPNs have to be supervised by RN
• Supervision must be documented by the RN within a
  minimum of 30-90 calendar days
• Supervisory visits are required as often as
  needed to ensure both quality and appropriateness
  of services.

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RN Supervision cont.

• Supervisory visits should be made on-site
  (direct) every 30 calendar days.
• On-site visits may be conducted more frequently
  than every 30 calendar days depending on
  intensity and level of nursing services the child
  is receiving as well as the license requirements
  of the RN and the LPN.

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RN Supervision cont.

• If an on-site visit is not possible every 30
  calendar days, then an indirect visit may be
  conducted via telephone or off-site.
• On-site vs. indirect supervision as well as
  frequency depends on condition of the child as
  well as license requirements of RN.
• An on-site visit must be conducted at least every
  90 calendar days.

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Service Limitations

• Quality management reviews will be performed
  randomly by DMAS to determine if services are
  appropriately provided to Medicaid and FAMIS
  recipients and to ensure the services are
  medically necessary and appropriate.
• Failure to document services in the childs
  school nursing record will be considered not
  performed and payment may be revoked.

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Service Limitations

• Services that can be provided by someone other
  than the skilled nursing professional will not be
  reimbursed by DMAS.
• Unless a concurrent nursing service is being
  provided to the individual.
• Unskilled services may be reimbursable under
  personal care assistant services.

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Skilled Nursing Procedure Codes

• T1001 for an RN assessment
• T1002 for services performed by RN
• T1003 for services provided by LPN

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Skilled Nursing Units

• A unit is 15 minutes of nursing care
• SN services will be limited to 6.5 hrs per day or
  26 units per day
• Need to exceed limits/day?
• Attach medical justification for additional
  authorization

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Skilled Nursing Units cont.

• To calculate these services
• Take the average amount of time for the procedure
• Multiply by the number of times a month the
  service is delivered
• Divide by 15 (a unit) to get the total number of
  units to be billed.
• Ex. 5 mins to give meds x 18 times a month90
  mins div by 15 mins 6 units.

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Skilled Nursing Units cont.

• If the total number of units billed ends up with
  a fraction of a unit, round to the nearest unit
• 50 minutes of care / 15 3.33 3 units
• 100 minutes of care / 15 6.66 7 units
• Regular school year is 180 days
• May vary among school divisions
• Services during the summer school sessions are
  billable as well.

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WebsitesDOE www.doe.virginia.govDMAS
www.dmas.virginia.govFAMIS www.famis.org
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Thank You