Evidence-based criteria for determining whether services are skilled

Editorial Note: This post is an excerpt from HCPro’s title Long-Term Care Skilled Services: How to Document for Proper Medicare Reimbursement by Elizabeth McLaren.

Chapter 8 of the Medicare Benefit Policy Manual, Section 30.2.2 (“Principles for Determining Whether a Service is Skilled”) starts to look more closely at the criteria for assessing a skilled need. The regulation states, “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.” It goes on to state that a condition that would not ordinarily require skilled services may still qualify for skilled care if there are “special medical complications.”

Let’s review two different examples that highlight this clarification. This situation would qualify as skilled care:

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 patient’s 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.

This situation, however, would NOT qualify as skilled care:

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 would not constitute a skilled service, even though such services are obviously necessary.

There are always exceptions to the rule. Bottom line: All services have to be evaluated to determine whether they meet the skilled services criteria; there is no magic bullet. In the example above regarding positioning, there may be a situation in which there are concerns about proper body alignment while positioning to avoid contractures. In such a case, the record must document the reasons why skilled personnel are vital, if that fact contributes to the qualification for skilled services.

Have more questions? Expert speaker Elizabeth McLaren will answer them on Wednesday, April 12 during her 90-minute webinar, Breaking Down the Skilled Services Process: Avoid Costly Gaps in Pre-Admission and Admission, including:

  • Who is eligible for Medicare in a SNF
  • How enrollment in other programs may impact eligibility
  • How hospitalizations, benefit periods, and prior SNF stays tie into a facility’s ability to accept a Medicare admission.

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