Question

In an acute care facility, only the physician’s documentation is considered when applying for Medicare reimbursement. Why isn’t nursing documentation considered?

Answer 1

Medicare documentation guidelines may serve as minimum standards adopted by other payers. Documentation components required by Medicare include

• evaluation;
• plan of care (POC, also called treatment plan)
  1. diagnoses,
  2. long-term treatment goals,
  3. type (e.g., group, individual), amount, duration, and frequency of therapy services;
• treatment notes;
• progress reports;
• discharge note (also called discharge summary).

Medicare also requires documentation to comply with requirements related to functional outcomes reporting for outpatient therapy services (commonly referred to as G-codes) and quality outcomes reporting for SLPs in group or private practice (currently called Physician Quality Reporting System [PQRS]).

The nursing documentations are not meeting any of the above-mentioned medicare documentation guidelines.That's why it is not considered for medicare reimbursement.