HI 00601.140 Daily Skilled Service
Skilled nursing services or skilled rehabilitation services must be required and provided on a “daily basis”—i.e., on essentially a 7-day-a-week basis. However, if skilled rehabilitation services are not available on a 7-day-a-week basis, a patient whose inpatient stay is based solely on the need for skilled rehabilitation services would meet the “daily basis” requirement where he needs and receives such services on at least 5 days a week. Accordingly, where a facility provides physical therapy on only 5 days a week and the patient in such a facility requires and receives physical therapy on each of the days on which such is available, the requirement that skilled rehabilitation services be provided on a daily basis would be met. A break of a day or two during which no skilled rehabilitation services are furnished and discharge from the facility would not be practical would not violate the requirement. For example, a patient who normally requires skilled rehabilitation services on a daily basis exhibits extreme fatigue which causes his physician to suspend therapy sessions for a day or two. Payment would be made for these days since discharge in such a case would not be practical.
A. Skilled services defined
For Medicare purposes, a skilled service is one which must be furnished by or under the general supervision of skilled personnel to assure the safety of the patient and achieve the medically desired result.
In determining whether skilled care was needed and provided, the intermediary's medical staff keeps in mind that the patient's eligibility for benefits depends on his need for skilled care and not on his potential for recovery. If a beneficiary requires daily skilled services to prevent deterioration of his condition or to sustain his current capabilities and such services as a practical matter can only be provided by an SNF on an inpatient basis, the beneficiary would be eligible for extended care benefits even though he may have very little or no rehabilitation potential. For example, a terminal cancer patient requiring daily skilled services on an inpatient basis may be eligible for extended care benefits even though his life expectancy may be no more than a few months. Such a patient, who may require palliative treatment, periodic “tapping” to relieve fluid accumulation, and careful skin care and hygiene to minimize discomfort, is receiving a covered level of care. Thus, the controlling factor in determining whether a person is receiving covered care is the level of care and medical supervision that the patient requires, rather than considerations such as diagnosis, type of conditions, or degree of functional limitation.
B. Skilled nursing services defined
A skilled nursing service is one which must be furnished by or under the general supervision of licensed nursing personnel and under the general direction of a physician in order to assure the safety of the patient and achieve the medically desired result.
C. Guidelines for determining need for skilled nursing care
Where a beneficiary's claim for extended care benefits is based on a need for skilled nursing care the guidelines set forth below are used to determine whether the care constitutes skilled services.
1. Assessment of the total needs of the patient and planning and management of a patient care plan
Ordinarily, the planning and management of a treatment plan which does not involve the furnishing of skilled services requires the skills of a nurse only where the facts of the case establish that the aggregate of such unskilled services, when considered in light of the patient's condition, necessitates the regular daily involvement of a licensed nurse to ensure the patient's recovery and/or medical safety.
For example, an aged patient with a history of diabetes mellitus and angina pectoris is recovering from an open reduction of a fracture of the neck of the femur. He requires, among other services, careful skin care, appropriate oral medication, 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 mobility. Although any one of the required services could be performed by a properly instructed unskilled person, such a person would not have the capability of understanding the relationship among the services and their effect on each other. Since the nature of the patient's condition, his age, and his immobility create a high potential for serious complications, such an understanding is essential to assure the patient's recovery and safety.
Under these circumstances, the management of such a plan requires the skills of a nurse, even though each individual service it involves is normally unskilled.
2. Observation and monitoring of the patient's response to care and treatment
Observation is a skilled nursing service when the unstabilized condition of the patient requires the skills of a licensed nurse to detect and evaluate the patient's need for possible modification of treatment or institution of medical procedures. For example, pending stabilization of the condition, a patient suffering from arteriosclerotic heart disease may require close observation by skilled nurses for signs of decompensation and loss of fluid balance in order to determine whether the digitalis dosage should be changed or other therapeutic measures should be taken.
Similarly, in some cases, surgical patients (including postoperative cataract patients) are transferred from a hospital to an SNF while still in the immediate unstabilized postoperative period during which the possibility of adverse reaction to anesthesia and other aspects of the operative procedure necessitates close skilled monitoring.
3. Complexity of service
The classification of a particular service as skilled is based on the technical or professional health training required to effectively perform or supervise the service. In many instances a service may be classified as a skilled service on the basis of the complexity alone, e.g., intravenous and intramuscular injections or insertion of catheters. On the other hand, a patient following instructions can normally take a daily vitamin pill. Consequently, the act of giving the vitamin pill to a patient who is too senile to take it himself is not a skilled service. Similarly, State law may require that all institutional patients receive medication only from a licensed nurse. This fact does not make administration of a medication a skilled nursing service if such medication can be prescribed for administration at home without the presence of a licensed nurse.
4. Services generally nonskilled may require skilled performance
Any generally nonskilled service could, because of special medical complications, require skilled performance, supervision, or observation. In such cases, the complications and special services involved must be documented by physician orders and/or nursing notes. For example, the existence of a plaster cast on an extremity would not generally indicate a need for skilled care. However, a preexisting acute skin problem and a need for special traction of the injured extremity might require the presence of professional health personnel in order to properly observe for complications and adjust traction accordingly. Such procedures should be undertaken only on specific physician orders and should be documented in the patient's clinical record. 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.