(Medicare Benefit Policy Manual)

These modalities must always be performed by or under the supervision of a qualified physical therapist.   G.  Hot Packs, Infra- Red Treatments, Paraffin Baths, and Whirlpool Baths   Heat treatments and baths of this type ordinarily do not require the skills of a qualified physical therapist.  However, the skills, knowledge, and judgment of a qualified physical therapist might be required in the giving of such treatments or baths in a particular case, e.g., where the patients condition is complicated by circulatory deficiency, areas of desensitization, open wounds, fractures, or other complications.  There must be clear documentation in the medical record of the special medical complic ations that describe the need for the skilled therapy provided by the therapist.  30.4.2 - Speech -Language Pathology  (Rev. 179, Issued: 01- 14-14, Effective: 01 -07-14, Implementation: 01- 07-14)  See Pub. 100- 02, Medicare Benefit Policy Manual, Chapter 1, Inpatient Hospital Services.   See 30.4.1.2.E. Maintenance Therapy for the specific circumstances in which speech -language pathology therapy is appropriate in connection with a maintenance program.   30.4.3 - Occupational Therapy  (Rev. 179, Issued: 01-14-14, Effective: 01-07-14, Implementation: 01-07-14) A3-3132.3.C, SNF-214.3.C  See Pub. 100-02, Medicare Benefit Policy Manual, Chapter 1, Inpatient Hospital Services.   See 30.4.1.2.E. Maintenance Therapy for the specific circumstances in which occupational therapy is appropriate in connection with a maintenance program.  30.5 - Nonskilled Supportive or Personal Care Services  (Rev. 1, 10-01-03)  A3-3132.4, SNF-214.4  The following services are not skilled services unless rendered under circumstances detailed in 30.2:   Administration of routine oral medications, eye drops, and ointments (the fact that patients cannot be relied upon to take such medications themselves or that State law requires all medications to be dispensed by a nurse to institutional patients would not change this service to a skilled service);   General maintenance care of colostomy and ileostomy;   Routine services to maintain satisfactory functioning of indwelling bladder catheters (this would include emptying and cleaning containers and clamping the tubing);   Changes of dressings for uninfected post-operative or chronic conditions;   Prophylactic and palliative skin care, including bathing and application of creams, or treatment of minor skin problems;   Routine care of the incontinent patient, including use of diapers and protective sheets;    General maintenance care in connection with a plaster cast (skilled supervision or observation may be required where the patient has a preexisting skin or circulatory condition or requires adjustment of traction);   Routine care in connection with braces and similar devices;    Use of heat as a palliative and comfort measure, such as whirlpool or steam pack;    Routine administration of medical gases after a regimen of therapy has been established (i.e., administration of medical gases after the patient has been taught how to institute therapy);    Assistance in dressing, eating, and going to the toilet;    Periodic turning and positioning in bed; and   General supervision of exercises, which have been taught to the patient and the performance of repetitious exercises that do not require skilled rehabilitation personnel for their performance.  (This includes the actual carrying out of maintenance programs  where the performances of repetitive exercises that may be required to maintain function do not necessitate a need for the involvement and services of skilled rehabilitation personnel.  It also includes the carrying out of repetitive exercises to improve gait, maintain strength or endurance; passive exercises to maintain range of motion in paralyzed extremities which are not related to a specific loss of function; and assistive walking.)  (See Medicare Benefit Policy Manual, Chapter 1, Inpatient Hospital Services.)   30.6 - Daily Skilled Services Defined  (Rev. 249, Issued: 11- 02-18, Effective: 12 -04-18, Implementation: 12- 04-18)  Skilled nursing services or skilled rehabilitation services (or a combination of these services) must be needed and provided on a daily basis, i.e., on essentially a 7- days-a-week basis.  A patient whose inpatient stay is based solely on the need for ski lled rehabilitation services would meet the daily basis requirement when they need and receive those services on at least 5 days a week.  (If therapy services are provided less than 5 days a week, the daily requirement would not be met.)   This requirement should not be applied so strictly that it would not be met merely because there is an isolated break of a day or two during which no skilled rehabilitation services are furnished and discharge from the facility would not be practical.  EXAMPLE:   A patient who normally requires skilled rehabilitation services on a daily basis  may exhibit extreme fatigue, which results in suspending therapy sessions for a day or two.  Coverage may continue for these days since discharge in such a case would not be practical.   In instances when a patient requires a skilled restorative nursing program to positively affect his functional well -being, the expectation is that the program be rendered at least 6 days a week.  (Note that when a patients skilled status is based on a res torative program, medical evidence must be documented to justify the services.  In most instances, it is expected that a skilled restorative program will be, at most, only a few weeks in duration.)   The daily basis requirement can be met by furnishing a single type of skilled service every day, or by furnishing various types of skilled services on different days of the week that collectively add up to daily skilled services.  However, arbitrarily st aggering the timing of various therapy modalities through the week, merely in order to have some type of therapy session occur each day, would not satisfy the SNF coverage requirement for skilled care to be needed on a daily basis.  To meet this requirem ent, the patient must actually need  skilled rehabilitation services to be furnished on each of the days that the facility makes such services available.   It is not sufficient for the scheduling of therapy sessions to be arranged so that some therapy is furnished each day, unless the patient's medical needs indicate that daily therapy is required.  For example, if physical therapy is furnished on 3 days each week and occupational therapy is furnished on 2 other days each week, the daily basis requirement would b e satisfied only if there is a valid medical reason why both cannot be furnished on the same day.  The basic issue here is not whether the services are needed, but when  they are needed.  Unless there is a legitimate medical need for scheduling a therapy session each day, the daily basis requirement for SNF coverage would not be met.  30.7 - Services Provided on an Inpatient Basis as a Practical Matter  (Rev. 261, Issued: 10- 04-19, Effective: 11 -05-19, Implementation: 11- 05-19) A3-3132.6, SNF -214.6   In determining whether the daily skilled care needed by an individual can, as a practical matter, only be provided in a SNF on an inpatient basis, the A/B MAC (A) considers the individuals physical condition and the availability and feasibility of using more economical alternative facilities or services.   As a practical matter, daily skilled services can be provided only in a SNF if they are not available on an outpatient basis in the area in which the individual resides or transportation to the closest facility would be:    An excessive physical hardship;    Less economical; or    Less efficient or effective than an inpatient institutional setting.   The availability of capable and willing family or the feasibility of obtaining other assistance for the patient at home should be considered.  Even though needed daily skilled services might be available on an outpatient or home care basis, as a practical matter, the care can be furnished only in the SNF if home care would be ineffective because the patient would have insufficient assistance at home to reside there safely.   EXAMPLE: A patient undergoing skilled physical therapy can walk only with supervision but has a reasonable potential to learn to walk independently with further training.  Further daily skilled therapy is available on an outpatient or home care basis, but the patie nt would be at risk for further injury from falling, because sufficient supervision and assistance could not be arranged for the patient in his home.  In these circumstances, the physical therapy services as a practical matter can be provided effectively only in the inpatient setting.   30.7.1 - The Availability of Alternative Facilities or Services  (Rev. 261, Issued: 10- 04-19, Effective: 11 -05-19, Implementation: 11- 05-19) A3-3132.6.A, SNF -214.6.A   Alternative facilities or services may be available to a patient when health care providers such as home health agencies are utilized.  These alternatives are not always available in all communities and even where they exist they may not be available when needed.   EXAMPLE: Where the residents of a rural community generally utilize the outpatient facilities of a hospital located some distance from the area, the hospital outpatient department constitutes an alternative source of care that is available to the community.  Roads in winter, however, may be impassable for some periods of time and in special situations institutionalization might be needed.   In determining the availability of more economical care alternatives, the coverage or noncoverage of that alternative care is not a factor to be considered.  Home health care for a patient who is not homebound, for example, may be an appropriate alternative in some cases.  The fact that Medicare cannot cover such care is irrelevant.   The issue is feasibility and not whether coverage is provided in one setting and not provided in another.  For instance, an individual in need of daily skilled physical therapy might be able to receive the services needed on a more economical basis from an  independently practicing physical therapist.  However, the fact that Medicare payment could not be made for the services because an expense limitation (if applicable) to the services of an independent physical therapist had been exceeded or because the pa tient was not enrolled in Part B, would not be a basis for determining that, as a practical matter, the needed care could only be provided in a SNF.   In determining the availability of alternate facilities or services, whether the patient or another resource can pay for the alternate services is not a factor to be considered.   30.7.2 - Whether Available Alternatives Are More Economical in the Individual Case  (Rev. 261, Issued: 10- 04-19, Effective: 11 -05-19, Implementation: 11- 05-19) A3-3132.6.B, SNF -214.6.B   If the A/B MAC (A) determines that an alternative setting is available to provide the needed care, it considers whether the use of the alternative setting would actually be more economical in the individual case.   EXAMPLE 1:   If a patient's condition requires daily transportation to the alter native source of care (e.g., a hospital outpatient depart ment) by ambulance, it might be more economical from a health care delivery viewpoint to provide the needed care in the SNF setting.  EXAMPLE 2:   If needed care could be provided in the home, but the patients residence is so isolated that daily visits would entail inordinate travel costs, care in a SNF might be a more economical alternative.    30.7.3 - Whether the Patients Physical Condition Would Permit Utilization of an Available, More Economical Care Alternative  (Rev. 1, 10- 01-03)  A3-3132.6.C, SNF -214.6.C   In determining the practicality of using more economical care alternatives, the A/B MAC (A) considers the patients medical condition.  If the use of those alternatives would adversely affect the patients medical condition, the A/B MAC (A) concludes that as a practical matter the daily skilled services can only be provided by a SNF on an inpatient basis.   If the use of a care alternative involves transportation of the individual on a daily basis, the A/B MAC (A) considers whether daily transportation would cause excessive physical hardship.  Determinations on whether a patients condition would be adversely affected if an available, more economical care alternative were utilized should not be based solely on the fact that the patient is nonambulatory.  There are individuals confined to wheelchairs who, though nonambulatory, could be transported daily by auto mobile from their homes to alternative care sources without any adverse impact.  Conversely, there are instances where an individuals condition would be adversely affected by daily transportation to a care facility, even though the individual is able to a mbulate to some extent.