How do you document "skill" appropriately when performing modalities?
Many Medicare administrative contractors state that modalities are an adjunct to treatment and they do not expect to see more than two to three treatments before something active should be added to the treatment program. There's language in the RAI manual regarding modalities. In my organization, we've had to refer to this often when talking about documenting for modalities. This statement from the RAI manual states that only the time that is skilled may be recorded on the MDS. For example, a resident receiving TENS for pain management, the portion of treatment that is skilled, would be proper electrode placement, establishing proper pulse frequency and duration, and determining the appropriate stimulation mode, shall be recorded on the MDS. The use and rationale for all therapy modalities, whether skilled or unskilled, should always be documented as part of the resident's plan of care. My organization's Medicare administrative contractor is Noridian (these do vary depending on where you are located in the US). The portion of time that can be can be recorded and what they list as billable time with modalities are: proper electrode placement, establishing proper settings, removal of electrodes, and examining the skin before and after treatment. There is not a lot of "skilled" time for physical agent modalities. Documentation is key to supporting all skilled interventions no matter the procedure, including modalities. We need to note that the presence of a modality on a plan of care or in a daily note does not necessarily make it skilled, just because it's there. All regulatory language concerning skilled therapy delivery and documentation also applies to physical agent modalities.
Key components of documenting skill are:
- modality must be clarified as part of the treatment plan including the location, frequency, and anticipated duration
- the reason for the modality must be clearly described
- the modality must be supported by the documentation in the rest of the chart
- documentation should highlight the complexity and the necessity of using the modality,
- relate the modality to an objective scale such as pain scale or edema,
- document any adjustments and modifications.