(Medicare Benefit Policy Manual)

An aged patient with a history of diabetes mellitus and angina pectoris is recovering from an open reduction of the neck of the femur.  He requires, among other services, careful skin care, appropriate oral medications, a diabetic diet, a therapeutic exercise program to preserve muscle tone and body condition, and observation to notice signs of deterioration in his condition or complications resulting from his restricted (but increasing) mobility.  Although any of the required services could be performed by a properly instructed person, that person would not have the capability to understand the relationship among the services and their effect on each other.  Since the nature of the patients condition, his age and his immobility create a high potential for serious complications, such an understanding is essential to assure the patients recovery and safety.  The management of this plan of care requires skilled nursing personnel until such time as skilled care is no longer required in coordinating the patient s treatment regimen, even though the individual services involved are supportive in nature and do not require skilled nursing personnel.  The documentation in the medical record as a whole is essential for this determination and must illustrate the comple xity of the unskilled services that are a necessary part of the medical treatment and which require the involvement of skilled nursing personnel to promote the stabilization of the patient's medical condition and safety.   EXAMPLE 2:   An aged patient is recovering from pneumonia, is lethargic, is disoriented, has residual chest congestion, is confined to bed as a result of his debilitated condition, and requires restraints at times.  To decrease the chest congestion, the physician has p rescribed frequent changes in position, coughing, and deep breathing.  While the residual chest congestion alone would not represent a high risk factor, the patients immobility and confusion represent complicating factors which, when coupled with the ches t congestion, could create high probability of a relapse.  In this situation, skilled overseeing of the nonskilled services would be reasonable and necessary, pending the elimination of the chest congestion, to assure the patients medical safety.  The doc umentation in the medical record as a whole is essential for this determination and must illustrate the complexity of the unskilled services that are a necessary part of the medical treatment and which require the involvement of skilled nursing personnel t o promote the patient's recovery and medical safety in view of the patient's overall condition.  30.2.3.2 - Observation and Assessment of Patients Condition  (Rev. 179, Issued: 01- 14-14, Effective: 01 -07-14, Implementation: 01- 07-14) A3-3132.1.C.2, SNF -214.1.C.2  Observation and assessment are skilled services when the likelihood of change in a patients condition requires skilled nursing or skilled rehabilitation personnel to identify and evaluate the patients need for possible modification of treatment or initia tion of additional medical procedures, until the patients condition is essentially stabilized.   EXAMPLE 1:   A patient with arteriosclerotic heart disease with congestive heart failure requires close observation by skilled nursing personnel for signs of decompensation, abnormal fluid balance, or adverse effects resulting from prescribed medication.  Skilled obser vation is needed to determine whether the digitalis dosage should be reviewed or whether other therapeutic measures should be considered, until the patients treatment regimen is essentially stabilized.  The medical documentation must describe the skilled services that require the involvement of nursing personnel to promote the stabilization of the patient's medical condition and safety.  EXAMPLE 2:   A patient has undergone peripheral vascular disease treatment including revascularization procedures (bypass) with open or necrotic areas of skin on the involved extremity.  Skilled observation and monitoring of the vascular supply of the legs is required.  The medical documentation must describe the skilled services that require the involvement of nursing personnel to promote the patient's rec overy and medical safety in view of the patient's overall condition.  EXAMPLE 3:   A patient has undergone hip surgery and has been transferred to a SNF.  Skilled observation and monitoring of the patient for possible adverse reaction to the operative procedure, development of phlebitis, or skin breakdown, is both reasonable and necessar y.  The medical documentation must describe the skilled services that require the involvement of nursing personnel to promote the patient's recovery and medical safety in view of the patient's overall condition.  EXAMPLE 4:   A patient has been hospitalized following a heart attack, and following treatment but before mobilization, is transferred to the SNF.  Because it is unknown whether exertion will exacerbate the heart disease, skilled observation is reasonable and necessary as mobilization is initiated, until the patients treatment regimen is essentially stabilized.  The medical documentation must describe the skilled services that require the involvement of nursing personnel to promote the stabilization of the patient's medical condition and safety.   EXAMPLE 5:   A frail 85 -year-old man was hospitalized for pneumonia.  The infection was resolved, but the patient, who had previously maintained adequate nutrition, will not eat or eats poorly.  The patient is transferred to a SNF for monitoring of fluid and nutrient i ntake, assessment of the need for tube feeding and forced feeding if required.  Observation and monitoring by skilled nursing personnel of the patients oral intake is required to prevent dehydration.  The medical documentation must describe the skilled se rvices that require the involvement of nursing personnel to promote the patient's recovery and medical safety in view of the patient's overall condition.   EXAMPLE 6:   A patient with congestive heart failure may require continuous close observation to detect signs of decompensation, abnormal fluid balance, or adverse effects resulting from prescribed medication(s) that serve as indicators for adjusting therapeutic measures.  The medical documentation must describe the skilled services that require the involvement of nursing personnel to promote the patients recovery and medical safety in view of the patients overall condition, to maintain the patients  current condition, or to prevent or slow further deterioration in the patients condition.  If a patient was admitted for skilled observation but did not develop a further acute episode or complication, the skilled observation services still are covered so long as there was a reasonable probability for such a complication or further acute episode .  Reasonable probability means that a potential complication or further acute episode was a likely possibility.   Information from the patient's medical record must document that there is a reasonable potential for a future complication or acute episode sufficient to justify the need for continued skilled observation and assessment.  Such signs and symptoms as abnormal/fluctuating vital signs, weight changes, edema, symptoms of drug toxicity, abnormal/fluctuating lab values, and respiratory changes on auscultation may justify skilled observation and assessment.  Where these signs and symptoms are such that there is a reasonable potential that skilled observation and assessment by a licensed nurse will result in changes to the treatment of the patient, then the services are reasonable and necessary.  However, observation and assessment b y a nurse is not reasonable and necessary to the treatment of the illness or injury where these characteristics are part of a longstanding pattern of the patient's waxing and waning condition which by themselves do not require skilled services and there is  no attempt to change the treatment to resolve them.   Skilled observation and assessment may also be required for patients whose primary condition and needs are psychiatric in nature or for patients who, in addition to their physical problems, have a secondary psychiatric diagnosis.  These patients may exhibi t acute psychological symptoms such as depression, anxiety or agitation, which require skilled observation and assessment such as observing for indications of suicidal or hostile behavior.  However, these conditions often require considerably more speciali zed, sophisticated nursing techniques and physician attention than is available in most participating SNFs.  (SNFs that are primarily engaged in treating psychiatric disorders are precluded by law from participating in Medicare.)  Therefore, these cases mu st be carefully documented.   30.2.3.3 - Teaching and Training Activities  (Rev. 179, Issued: 01- 14-14, Effective: 01 -07-14, Implementation: 01- 07-14) A3-3132.1.C.3, SNF -214.1.C.3  Teaching and training activities, which require skilled nursing or skilled rehabilitation personnel to teach a patient how to manage their treatment regimen, would constitute skilled services.  Some examples are:    Teaching self -administration of injectable medications or a complex range of medications;   Teaching a newly diagnosed diabetic to administer insulin injections, to prepare and follow a diabetic diet, and to observe foot -care precautions;    Teaching self -administration of medical gases to a patient;   Gait training and teaching of prosthesis care for a patient who has had a recent leg amputation;    Teaching patients how to care for a recent colostomy or ileostomy;    Teaching patients how to perform self -catheterization and self -administration of gastrostomy feedings;    Teaching patients how to care for and maintain central venous lines, such as Hickman catheters;    Teaching patients the use and care of braces, splints and orthotics, and any associated skin care; and    Teaching patients the proper care of any specialized dressings or skin treatments.  The documentation must thoroughly describe all efforts that have been made to educate the patient/caregiver, and their responses to the training.  The medical record should also describe the reason for the failure of any educational attempts, if applicable.   EXAMPLE:   A newly diagnosed diabetic patient is seen in order to learn to self -administer insulin injections, to prepare and follow a diabetic diet, and to observe foot -care precautions.  Even though the patient voices understanding of the nutritional principles of his diabetic diet, he expresses dissatisfaction with his food choices and refuses to comply with the education he is receiving.  This refusal continues, notwithstanding efforts to counsel the patient on the potentially adverse consequences of the refusal a nd to suggest alternative dietary choices that could help to avoid or alleviate those consequences.  The patients response to the recommended treatment plan as well as to all educational attempts is documented in the medical record.   30.2.4 - Questionable Situations  (Rev. 1, 10- 01-03)  A3-3132.1.D, SNF -214.1.D   There must be specific evidence that daily skilled nursing or skilled rehabilitation services are required and received if:    The primary service needed is oral medication; or    The patient is capable of independent ambulation, dressing, feeding, and hygiene.   30.3 - Direct Skilled Nursing Services to Patients  (Rev. 179, Issued: 01- 14-14, Effective: 01 -07-14, Implementation: 01- 07-14) A3-3132.2, SNF -214.2   Nursing services are considered skilled when they are so inherently complex that they can be safely and effectively performed only by, or under the supervision of, a registered nurse or, when provided by regulation, a licensed practical (vocational) nurse.  (See 42CFR 409.32)  If all other requirements for coverage under the SNF benefit are met, skilled nursing services are covered when an individualized assessment of the patients clinical condition demonstrates that the specialized judgment, knowledge, a nd skills of a registered nurse or, when provided by regulation, a licensed practical (vocational) nurse are necessary.  Skilled nursing services would be covered where such skilled nursing services are necessary to maintain the patients current condition  or prevent or slow further deterioration so long as the beneficiary requires skilled care for the services to be safely and effectively provided, and all other requirements for coverage under the SNF benefit are met.  Coverage does not turn on the presenc e or absence of an individuals potential for improvement from nursing care, but rather on the beneficiarys need for skilled care.   A condition that would not ordinarily require skilled nursing services may nevertheless require them under certain circumstances.  In such instances, skilled nursing care is necessary only when (a) the particular patients special medical complications require the skills of a registered nurse or, when provided by regulation, a licensed practical nurse to perform a type of service that would otherwise be considered non -skilled; or (b) the needed services are of such complexity that the skills of a registered nurse or, when provided by regulation, a licensed practical nurse are required to furnish the services.  A service is not considered a skilled nursing service merely because it is performed by or under the direct supervision of a nurse.  If a service can be safely and effectively performed (or self -administered) by an unskilled person, the service cannot be r egarded as a skilled nursing service although a nurse actually provides the service.  Similarly, the unavailability of a competent person to provide a nonskilled service, regardless of the importance of the service to the patient, does not make it a skille d service when a nurse provides the service.   Some examples of direct skilled nursing services are:    Intravenous or intramuscular injections and intravenous feeding;    Enteral feeding that comprises at least 26 percent of daily calorie requirements and provides at least 501 milliliters of fluid per day;    Naso -pharyngeal and tracheotomy aspiration;    Insertion, sterile irrigation, and replacement of suprapubic catheters;    Application of dressings involving prescription medications and aseptic techniques (see 30.5 for exception);    Treatment of decubitus ulcers, of a severity rated at Stage 3 or worse, or a widespread skin disorder (see 30.5 for exception);