HI 00601.155 Questionable Situations

A. Psychiatric treatment

The situation is usually questionable where the primary diagnosis or the primary needs of the patient are psychiatric rather than medical. An institution primarily engaged in treating psychiatric disorders cannot participate as an SNF. This type of active psychiatric treatment requires considerably more sophisticated nursing techniques and physician attention than are available in the usual SNF; therefore, the type of mental condition which could be adequately handled in most SNF's would be one which requires only a supportive environment without daily skilled services. However, in some cases a patient suffering from mental illness may need the type of services which constitute extended care because the mental condition was secondary to another more acute medical disorder.

B. Post-cataract surgery convalescence

Uncomplicated post-cataract surgery convalescence, after the immediate postoperative period, usually does not require skilled nursing services since application of eye drops and ointments can generally be performed by any person with brief instructions. Other services usually furnished to such persons are protective in nature and primarily concerned with meeting the activities of daily living since the patient's mobility is restricted.

However, where a patient is transferred from a hospital to an SNF within one or two days following surgery, the patient is still in the immediate unstabilized postoperative period during which the possibility of adverse reaction to anesthesia and other aspects of the operative procedures necessiates close skilled monitoring. During this immediate postsurgical period, the services provided may be skilled nursing services.

C. Other questionable situations

When any of the following circumstances exist, there must be evidence that skilled nursing service is also concurrently required and received:

  1. The primary service is one or more of the following:

    1. Oral medication

    2. Skin care to prevent decubiti

    3. Restraints

    4. Frequent laboratory tests

  2. The patient is capable of independent ambulation, dressing, feeding, and hygiene;

  3. The patient has outside privileges;

  4. The diagnosis shown is not of a type which is sufficiently specific to indicate skilled treatment regimen; i.e., the diagnosis is chronic brain syndrome, senility, arteriosclerosis, “old” CVA, etc.

  5. Return to a hospital preceding the SNF stay occurred shortly after the expiration of 60 days from the last discharge from hospital or SNF;

  6. Long-term hospitalization (60 days or longer) occurred prior to the SNF admission;

  7. Discharge from the SNF occurred after about 100 days of care (or there have been many discharges from the SNF after nearly 100 days);

  8. Transfer occurred from an SNF to a hospital for three, four, or five days followed by an immediate admission to an SNF.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0600601155