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 t