(Medicare Benefit Policy Manual)

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);    Heat treatments which have been specifically ordered by a physician as part of active treatment and which require observation by skilled nursing personnel to evaluate the patients progress adequately (see 30.5 for exception);    Rehabilitation nursing procedures, including the related teaching and adaptive aspects of nursing, that are part of active treatment and require the presence of skilled nursing personnel; e.g., the institution and supervision of bowel and bladder training programs;    Initial phases of a regimen involving administration of medical gases such as bronchodilator therapy; and   Care of a colostomy during the early post -operative period in the presence of associated complications.  The need for skilled nursing care during this period must be justified and documented in the patients medical record.   30.4 - Direct Skilled Therapy Services to Patients  (Rev. 179, Issued: 01- 14-14, Effective: 01 -07-14, Implementation: 01- 07-14) A3-3132.1.C, SNF -214.1.C   The following sections contain examples and guidelines concerning direct skilled therapy services to patients, including skilled physical therapy, occupational therapy, and speech/language pathology therapy.   Coverage for such skilled therapy services does not turn on the presence or absence of a beneficiarys potential for improvement from therapy services, but rather on the beneficiarys need for skilled care.  Therapy services are considered skilled when the y are so inherently complex that they can be safely and effectively performed only by, or under the supervision of, a qualified therapist.  (See 42CFR 409.32)  These skilled services may be necessary to improve the patients current condition, to maintain the patients current condition, or to prevent or slow further deterioration of the patients condition.  If all other requirements for coverage under the SNF benefit are met, such skilled therapy services are covered when an individualized assessment of the patients clinical condition demonstrates that the specialized judgment, knowledge, and skills of a qua lified therapist are necessary for the performance of the rehabilitation services.   30.4.1  Skilled Physical Therapy  (Rev. 1, 10- 01-03) A3-3132.3A, SNF -214.3.A   30.4.1.1 - General  (Rev. 179, Issued: 01- 14-14, Effective: 01 -07-14, Implementation: 01- 07-14)  Skilled physical therapy services must meet all of the following conditions:    The services must be directly and specifically related to an active written treatment plan that is based upon an initial evaluation performed by a qualified physical therapist after admission to the SNF and prior to the start of physical therapy services i n the SNF that is approved by the physician after any needed consultation with the qualified physical therapist.  In those cases where a beneficiary is discharged during the SNF stay and later readmitted, an initial evaluation must be performed upon readmi ssion to the SNF, prior to the start of physical therapy services in the SNF;    The services must be of a level of complexity and sophistication, or the condition of the patient must be of a nature that requires the judgment, knowledge, and skills of a qualified physical therapist;    The services must be provided with the expectation, based on the assessment made by the physician of the patients restoration potential, that the condition of the patient will improve materially in a reasonable and generally predictable period of time; or, the services must be necessary for the establishment  of a safe and effective maintenance program;  or, the services must require the skills of a qualified therapist for the performance of a safe and effective maintenance program.  NOTE:   See Section E. Maintenance Therapy for more guidance regarding when skilled therapy services are necessary for the performance of a safe and effective maintenance program.    The services must be considered under accepted standards of medical practice to be specific and effective treatment for the patients condition; and,    The services must be reasonable and necessary for the treatment of the patients condition; this includes the requirement that the amount, frequency, and duration of the services must be reasonable.   EXAMPLE 1:   An 80- year old, previously ambulatory, post -surgical patient has been bed -bound for 1 week, and, as a result, had developed muscle atrophy, orthostatic hypotension, joint stiffness and lower extremity edema.  To the extent that the patient requires a brief  period of daily skilled physical therapy to restore lost functions, those services are reasonable and necessary and must be documented in the medical record (see 30.2.2.1).  EXAMPLE 2:   A patient with congestive heart failure also has diabetes and previously had both legs amputated above the knees.  Consequently, the patient does not have a reasonable potential to achieve ambulation, but still requires daily skilled physical therapy to le arn bed mobility and transferring skills, as well as functional activities at the wheelchair level.  If the patient has a reasonable potential for achieving those functions in a reasonable period of time in view of the patients total condition, the physic al therapy services are reasonable and necessary and must be documented in the medical record (see 30.2.2.1).  Physical therapy services are not reasonable and necessary and would not be covered if the expected results are insignificant in relation to the extent and duration of physical therapy services that would be required to achieve those results.  Some SNF inpatients do not require skilled physical therapy services but do require services, which are routine in nature.  When services can be safely and effectively performed by supportive personnel, such as aides or nursing personnel, without the super vision of a physical therapist, they do not constitute skilled physical therapy.  Additionally, services involving activities for the general good and welfare of the patient (e.g., general exercises to promote overall fitness and flexibility and activities  to provide diversion or general motivation) do not constitute skilled physical therapy.   30.4.1.2 - Application of Guidelines  (Rev. 179, Issued: 01- 14-14, Effective: 01 -07-14, Implementation: 01- 07-14) A3-3132.3.A.2, SNF -214.3.A.2  Some of the more common skilled physical therapy modalities and procedures are:   A.  Assessment   The skills of a physical therapist are required for the ongoing assessment of a patients rehabilitation needs and potential.  Skilled rehabilitation services concurrent with the management of a patients care plan include tests and measurements of range o f motion, strength, balance, coordination, endurance, and functional ability.  B.  Therapeutic Exercises   Therapeutic exercises, which must be performed by or under the supervision of the qualified physical therapist, due either to the type of exercise employed or to the condition of the patient.  C.  Gait Training   Gait evaluation and training furnished to a patient whose ability to walk has been impaired by neurological, muscular, or skeletal abnormality often require the skills of a qualified physical therapist.  Repetitious exercises to improve gait, or to maintain strength and endurance, and assistive walking can be appropriately provided by supportive personnel, e.g., aides or nursing personnel, and would not necessarily require the skills of a physical therapis t.  Thus, such services are not inherently skilled.  However, see 30.2.2. for the specific circumstances in which an ordinarily nonskilled service can nevertheless be considered skilled.  Documentation of the patients condition in the medical record must  describe the circumstances which delineate the need for skilled rather than unskilled services during gait training.   D.  Range of Motion   Only the qualified physical therapist may perform range of motion tests and, therefore, such tests  are skilled physical therapy.  Range of motion exercises  constitute skilled physical therapy only if they are part of active treatment for a specific disease state which has resulted in a loss or restriction of mobility (as evidenced by physical therapy notes showing the degree of motion lost, the degree to be restored and the impact on mobility and/or function).   Generally, range of motion exercises which are not related to the restoration of a specific loss of function may be provided safely by supportive personnel, such as aides or nursing personnel, and as such would not necessarily require the skills of a physi cal therapist.  Passive exercises to maintain range of motion in paralyzed extremities that can be carried out by aides or nursing personnel would not be considered skilled care.  However, see 30.2.2. for the specific circumstances in which an ordinarily nonskilled servi ce can nevertheless be considered skilled.  Documentation of the patients condition in the medical record must describe the circumstances which delineate the need for skilled rather than unskilled services during range of motion training.  E.  Maintenance Therapy   Therapy services in connection with a maintenance program 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 qualified therapist.  (See 42CFR 409.32)  If all  other requirements for coverage under the SNF benefit are met, skilled therapy services are covered when an individualized assessment of the patients clinical condition demonstrates that the specialized judgment, knowledge, and skills of a qualified ther apist are necessary for the performance of a safe and effective maintenance program.  Such a maintenance program to maintain the patients current condition or to prevent or slow further deterioration is covered so long as the beneficiary requires skilled care for the safe and effective performance of the program.  When, however, the individualized assessment does not demonstrate such a necessity for skilled care, including when the performance of a maintenance program does not require the skills of a thera pist because it could safely and effectively be accomplished by the patient or with the assistance of non-therapists, including unskilled caregivers, such maintenance services do not constitute a covered level of care.   A service is not considered a skilled therapy service merely because it is furnished by a therapist or by a therapist/therapy assistant under the direct supervision of a therapist.  If a service can be self -administered or safely and effectively furnished by an unskilled person, without the direct supervision of a therapist, the service cannot be regarded as a skilled therapy service even when a therapist actually furnishes the service.  Similarly, the unavailability of a competent person to provide a non- skilled service, regardless of the importance of the service to the patient, does not make it a skilled service when a therapist furnishes the service.   However, even though it would not otherwise require the skills of a therapist, the performance of a maintenance program may nevertheless require such skills under certain circumstances.  Specifically, skilled therapy services are necessary for the performance of a safe and effective maintenance program only when (a) the particular patients special medical complications require the skills of a qualified therapist to perform a therapy service that would otherwise be considered non- skilled; or (b) the needed therapy procedures are of such complexity that the skills of a qualified therapist are required to perform the procedure.   If the specialized knowledge and judgment of a qualified therapist are required, the establishment or design of a maintenance program by a qualified therapist, the instruction of the beneficiary or appropriate caregiver by a qualified therapist regarding a  maintenance program, and the necessary periodic reevaluations by a qualified therapist of the beneficiary and maintenance program are considered skilled therapy services, to the extent provided by regulation.  EXAMPLE:  A patient with Parkinsons disease may require the services of a physical therapist to determine the type of exercises that are required to maintain his present level of function.  The initial evaluation of the patients needs, the designing of a maintenance program which is appropriate to the capacity and tolerance of the patient and the treatment objectives of the physician, the instruction of the patient or supportive personnel (e.g., aides or nursing personnel) in the carrying out of the progr am, would constitute skilled physical therapy and must be documented in the medical record (see 30.2.2.1).  While a patient is receiving a skilled physical therapy program, the physical therapist should regularly reevaluate the patients condition and adjust any exercise program the patient is expected to carry out independently or with the aid of supportive per sonnel to maintain the function being restored.  Consequently, by the time it is determined that no further skilled therapy services are needed, i.e., by the end of the last skilled session, the physical therapist will have already designed any maintenance  program required and instructed the patient or supportive personnel in the carrying out of the program.  F.  Ultrasound, Shortwave, and Microwave Diathermy Treatments