Long-Term Care

How to get reimbursed for restorative nursing

Contemporary Long-Term Care Weekly, April 13, 2004

Source: Briefings on Long-Term Care Regulations

It's possible that you're not getting reimbursed for all the services you provide to your residents-especially in the area of restorative nursing.

Cheryl Field, MSN, RN, CRRN, director of clinical and reimbursement services at LTCQ Inc. in Bedford, MA, often sees nursing facilities with good restorative nursing programs that aren't taking credit for the services. "This happens because they have not met the coding criteria outlined in the Resident Assessment Instrument User's Manual," she says.

Quality care and reimbursement, too
Under the prospective payment system, restorative nursing provided in conjunction with skilled rehabilitation therapy can place a resident in the low Resource Utilization Group (RUG) category.

"The lower 18 RUGs are all broken down as to whether the resident receives restorative nursing services or not, which affects the skilled nursing facility's [SNF] payment," explains Patricia Boyer, a clinical operations consultant with the Milwaukee office of BDO Seidman.

Restorative care can also help residents maintain the functioning they achieve by participating in skilled rehab therapy. "In such a case, the rehab therapists set up the program as a step down," Boyer says.

Boyer adds that therapists can help set up a restorative care program that's just nursing-and they get reimbursed under Part B for setting up the program if it's due to a decline in condition and is a medically necessary service. "Rehab therapy could pick up the resident for Part B service for a short period of time and train the CNAs [certified nursing assistants] in restorative care as part of the plan of care," she says.

Medicare PPS criteria
SNFs have to meet very specific criteria before Medicare Part A will cover restorative nursing care. "You have to provide two restorative programs equal to or more than 15 minutes in a 24-hour period, six out of seven days-that's 30 minutes or more per day," Boyer explains.

Your program must be supervised by a licensed nurse and provided by people who are trained to do the program, although there are no specifications as to how much training or what types of staff can do it, says Boyer. The facility can have activities staff or even trained volunteers do restorative programs, she adds.

"The restorative program also has to be an integral part of the resident's plan of care with clearly measurable goals and interventions and periodically evaluated by a licensed nurse," Boyer says. "The goal for the resident does not have to be progress-it can be to maintain functioning."

Proper documentation
"The documentation on the MDS that triggers the RUG must be accurate and complete," notes Annette Fleishell, RN, BSN, vice president for clinical services at Joann Wilson's Gerontological Nursing Ventures in Laurel, MD. "If the MDS is not coded accurately, even if the facility provided the services, it won't get paid for them."

The clinical record and other documentation must substantiate the MDS coding of the restorative minutes, services, and days. The clinical record must also show evidence that the restorative program is being evaluated periodically by the licensed nurse. Boyer suggests using a documentation tool such as a flowsheet, which has the times restorative nursing staff have provided treatments. "The 15 minutes per program can be broken up throughout the 24-hour day-it doesn't have to be all at one time," she says.

Activities that count toward restorative nursing

Here are the possible areas your restorative nursing program can encompass. Nursing staff need to code these activities in Minimum Data Set items P3a-k, which ask for the number of days each of the following rehabilitation or restorative techniques or practices were provided to the resident for more than or equal to 15 minutes per day in the last seven days:

  • Range of motion (passive)
  • Range of motion (active)
  • Splint or brace assistance

The following address training and skill practice:

  • Bed mobility
  • Transfer
  • Walking
  • Dressing or grooming
  • Eating or swallowing
  • Amputation/prosthetic care
  • Communication
  • Other

The following are three areas in which different types of programs combine to count as one program:

  • Bladder training and scheduled toileting
  • Walking and bed mobility (such as turning and positioning people or helping them become more independent in moving in bed)
  • Active and passive range of motion

Source: Briefings on Long-Term Care Regulations, January 2002.

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