(Medicare Benefit Policy Manual)

Skilled nursing and/or skilled rehabilitation services are those services, furnished pursuant to physician orders, that:    Require the skills of qualified technical or professional health personnel such as registered nurses, licensed practical (vocational) nurses, physical therapists, occupational therapists, and speech- language pathologists or audiologists; and    Must be provided directly by or under the general supervision of these skilled nursing or skilled rehabilitation personnel to assure the safety of the patient and to achieve the medically desired result.   NOTE:   General supervision requires initial direction and periodic inspection of the actual activity.  However, the supervisor need not always be physically present or on the premises when the assistant is performing services.  Skilled care may be necessary to improve a patients current condition, to maintain the patients current condition, or to prevent or slow further deterioration of the patients condition.  30.2.2 - Principles for Determining Whether a Service is Skilled  (Rev. 179, Issued: 01- 14-14, Effective: 01 -07-14, Implementation: 01- 07-14) A3-3132.1.B, SNF -214.1.B    If the inherent complexity of a service prescribed for a patient is such that it can be performed safely and/or effectively only by or under the general supervision of skilled nursing or skilled rehabilitation personnel, the service is a skilled service; e.g., the administration of intravenous feedings and intramuscular injections; the insertion of suprapubic catheters; and ultrasound, shortwave, and microwave therapy treatments.    The A/B MAC (A) considers the nature of the service and the skills required for safe and effective delivery of that service in deciding whether a service is a skilled service.  While a patients particular medical condition is a valid factor in deciding if skilled services are needed, a patients diagnosis or prognosis should never be the sole factor in deciding that a service is not skilled.  EXAMPLE:  When rehabilitation services are the primary services, the key issue is whether the skills of a therapist are needed.  The deciding factor is not the patients potential for recovery, but whether the services needed require the skills of a therapist or whether they can be provided by nonskilled personnel.  (See 30.5.)   A service that is ordinarily considered nonskilled could be considered a skilled service in cases in which, because of special medical complications, skilled nursing or skilled rehabilitation personnel are required to perform or supervise it or to observe the patient.  In these cases, the complications and special services involved must be documented by physicians' orders and notes as well as nursing or therapy notes.  EXAMPLE:   Whirlpool baths do not ordinarily require the skills of a qualified physical therapist.  However, the skills, knowledge, and judgment of a qualified physical therapist might be required where the patients condition is complicated by circulatory deficiency, areas of desensitization, or open wounds.  The documentation needs to support the severity of the circulatory condition that requires skilled care (see section 30.2.2.1).   In determining whether services rendered in a SNF constitute covered care, it is necessary to determine whether individual services are skilled, and whether, in light of the patients total condition, skilled management of the services provided is needed even though many or all of the specific services were unskilled.  EXAMPLE:   An 81- year-old woman who is aphasic and confused, suffers from hemiplegia, congestive heart failure, and atrial fibrillation, has suffered a cerebrovascular accident, is incontinent, has a Stage 1 decubitus ulcer, and is unable to communicate and make her needs known.  Even though no specific service provided is skilled, the patients condition requires daily skilled nursing involvement to manage a plan for the total care needed, to observe the patients progress, and to evaluate the need for changes in the treatment plan.  As discussed in section 30.2.2.1 below, the medical condition of the patient must be described and documented to support the goals for the patient and the need for skilled nursing services.   The importance of a particular service to an individual patient, or the frequency with which it must be performed, does not, by itself, make it a skilled service.  EXAMPLE:   A primary need of a nonambulatory patient may be frequent changes of position in order to avoid development of decubitus ulcers.  However, since such changing of position does not ordinarily require skilled nursing or skilled rehabilitation personnel, it w ould not constitute a skilled service, even though such services are obviously necessary.    The possibility of adverse effects from the improper performance of an otherwise unskilled service does not make it a skilled service unless there is documentation to support the need for skilled nursing or skilled rehabilitation personnel.  Although the a ct of turning a patient normally is not a skilled service, for some patients the skills of a nurse may be necessary to assure proper body alignment in order to avoid contractures and deformities.  In all such cases, the reasons why skilled nursing or skill ed rehabilitation personnel are essential must be documented in the patients record.   30.2.2.1  Documentation to Support Skilled Care Determinations  (Rev. 179, Issued: 01- 14-14, Effective: 01 -07-14, Implementation: 01- 07-14)  Claims for skilled care coverage need to include sufficient documentation to enable a reviewer to determine whether    Skilled involvement is required in order for the services in question to be furnished safely and effectively; and    The services themselves are, in fact, reasonable and necessary for the treatment of a patients illness or injury, i.e., are  consistent with the nature and severity of the individuals illness or injury, the individuals particular medical needs, and accepted standards of medical practice.  The documentation must also show that the services are appropriate in terms of duration and quantity, and that the services promote the documented therapeutic goals.  Such determinations would be made from the perspective of the patients condition when the services were ordered and what was, at that time, reasonably expected to be appropriate treatment for the illness or injury.  Thus, when a service appears reasonable  and necessary from that perspective, it would not then be appropriate to deny the service retrospectively merely because the goals of treatment have not yet been achieved.  However, if it becomes apparent at some point that the goal set for the patient is  no longer a reasonable one, then the treatment goal itself should be promptly and appropriately modified to reflect this, and the patient should then be reassessed to determine whether the treatment goal as revised continues to require the provision of skilled services.  By the same token, the treatment goal itself  cannot be modified retrospectively, e.g., when it becomes apparent that the initial treatment goal of restoration is no longer a reasonable one, the provider cannot retroactively alter the initi al goal of treatment from restoration to maintenance.  Instead, it would make such a change on a prospective basis only.  Although the presence of appropriate documentation is not, in and of itself, an element of the definition of a skilled service, such documentation serves as the means by which a provider would be able to establish and an A/B MAC (A) would be able to confirm that skilled care is, in fact, needed and received in a given case.   It is expected that the documentation in the patients medical record will reflect the need for the skilled services provided.  The patients medical record is also expected to provide important communication among all members of the care team regarding the development, course, and outcomes of the skilled observations, assessments, treatment, and training performed.  Taken as a whole, then, the documentation in the patients medical record should illustrate the degree to which the patient is accomplishing t he goals as outlined in the care plan. In this way, the documentation will serve to demonstrate why a skilled service is needed.   Thorough and timely documentation with respect to treatment goals can help clearly demonstrate a beneficiarys need for skilled care in situations where such need might not otherwise be readily apparent, as when the treatments purpose changes (for example , from restoration to maintenance), as well as in establishing the efficacy of care that serves to prevent or slow decline where, by definition, there would be no improvement to evaluate.  For example, when skilled services are necessary to maintain the patients current condition, the documentation would need to substantiate that the services of skilled personnel are, in fact, required to achieve this goal.  Similarly, establishing that a maintenance programs services are reasonable and necessary would involve regularly documenting the degree to which the programs treatment goals are being accomplished. In situations where the maintenance program is performed to maintain the patients current condition, such documentation would serve to demonstrate the programs effectiveness in achieving this goal.  When the maintenance program is intended to slow further deterioration of the patients condition, the efficacy of the services could be established by documenting that the natural progression of the patient s medical or functional decline has been interrupted. Assessments of all goals must be performed in a frequent and regular manner so that the resulting documentation provides a sufficient basis for determining the appropriateness of coverage.   Therefore the patients medical record must document as appropriate:    The history and physical exam pertinent to the patients care, (including the response or changes in behavior to previously administered skilled services);    The skilled services provided;    The patients response to the skilled services provided during the current visit;    The plan for future care based on the rationale of prior results.    A detailed rationale that explains the need for the skilled service in light of the patients overall medical condition and experiences;    The complexity of the service to be performed;    Any other pertinent characteristics of the beneficiary.   The documentation in the patients medical record must be accurate, and avoid vague or subjective descriptions of the patients care that would not be sufficient to indicate the need for skilled care.  For example, the following terminology does not suffic iently describe the reaction of the patient to his/her skilled care:    Patient tolerated treatment well   Continue with POC   Patient remains stable   Such phraseology does not provide a clear picture of  the results of the treatment, nor the next steps that are planned. Objective measurements of physical outcomes of treatment should be provided and/or a clear description of the changed behaviors due to education programs should be recorded so that all concerned can follow the results of the provided services.   30.2.3 - Specific Examples of Some Skilled Nursing or Skilled Rehabilitation Services (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 describe specific examples of skilled nursing or skilled rehabilitation services.  30.2.3.1 - Management and Evaluation of a Patient Care Plan  (Rev. 179, Issued: 01 -14-14, Effective: 01 -07-14, Implementation: 01- 07-14) A3-3132.1.C.1, SNF -214.1.C.1  The development, management, and evaluation of a patient care plan, based on the physicians orders and supporting documentation, constitute skilled nursing services when, in terms of the patients physical or mental condition, these services require the involvement of skilled nursing personnel to meet the patients medical needs, promote recovery, and ensure medical safety.  However, the planning and management of a treatment plan that does not involve the furnishing of skilled services may not require skilled nursing personnel; e.g., a care plan for a patient with organic brain syndrome who requires only oral medication and a protective environment.  The sum total of nonskilled services would only add up to the need for skilled management and evaluation when the condition of the beneficiary is such that there is an expectation that a change in condition is likely without that intervention.   The patients clinical record may not always specifically identify skilled planning and management activities as such.  Therefore, in this limited context, if the documentation of the patients overall condition substantiates  a finding that the patient s medical needs and safety can be addressed only if the total care, skilled or not, is planned and managed by skilled nursing personnel, it is appropriate to infer that skilled management is being provided, but only if the record as a whole clearly establi shes that there was a likely potential for serious complications without skilled management, as illustrated in the following Examples.  EXAMPLE 1:   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.