Issue 2006-2, February 2006

Skilled vs. Non-Skilled Services in a Skilled Nursing Facility

Defining Skilled Services (Pub 100-2):
Skilled services are “those services, furnished pursuant to physician order, that:

• Require the skills of qualified technical or professional health personnel such as registered nurses, licensed practical (vocational) nurses, physical therapists, occupational therapists, and speech language pathologists or audiologists;

And

• Must be provided directly by or under the general supervision of these skilled nursing or skilled rehabilitation personnel to assure the safety of the patient and to achieve the medically desired result.”

Determining Whether a Service Is Skilled (Pub 100-2):
Principals for deciding whether or not a service is skilled would include the determination of the “inherent complexity of a service prescribed for a patient” and whether the service can be performed “safely and/or effectively” only “by or under the general supervision of the skilled nursing or skilled rehabilitation personnel” as listed above.

“The nature of the service and the skills required for safe and effective delivery of the service should be considered.”

The diagnosis/prognosis of the patient should not be the “sole factor” in deciding that a service is skilled or not skilled.

The importance of a particular service to an individual patient, or the frequency with which it must be performed, does not, by itself, make it a skilled service.

Examples of Skilled Nursing Services (Pub 100-2):

• Intravenous or intramuscular injections and intravenous feeding
• Enteral feeding that comprises at least 26 percent of daily calorie requirements and provides at least 501 milliliters of fluid per day
• Nasopharangeal and tracheostomy aspiration
• Insertion, sterile irrigation, and replacement of suprapubic catheters
• Application of dressing involving prescription medications and aseptic techniques
• Treatment of decubitus ulcers, of a severity rated at Stage 3 or worse, or a widespread skin disorder
• Heat treatments which have been specifically ordered by a physician as part of active treatment and which require observation by skilled nursing personnel to evaluate the patient’s progress adequately
• Rehabilitation nursing procedures, including the related teaching and adaptive aspects of nursing, that are part of active treatment and require the presence of skilled nursing personnel; e.g., the institution and supervision of bowel and bladder training programs
• Initial phases of a regimen involving administration of medical gases such as bronchodilator therapy
• Care of colostomy during the early postoperative period in the presence of associated complications

Examples of Nonskilled Nursing Services (Pub 100-2): (unless rendered under circumstances detailed in Section 30.2)

• Administration of routine oral medications, eye drops and ointments
• General maintenance care of colostomy and ileostomy
• Routine services to maintain satisfactory functioning of indwelling bladder catheters (emptying and cleaning containers and clamping tubing)
• Changes of dressings for uninfected postoperative 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
• 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.) See Pub 100-2 for more detail.

Documenting Skilled Services :
All skilled services must be clearly documented and signed by appropriate personnel from the point of initiation throughout care.

It is the responsibility of the health care professional providing the services or education to document any changes throughout the course of treatment.

Remember: When submitting documentation for review:

• Refer to the ADR (Additional Development Request) or Letter of Request for documentation.
• Submit any and all documentation that may support the services documented.

When, Why and Where to Document Skilled Services :

When:
Daily documentation of care provided is not mandated. However, the patient who requires daily skilled care usually necessitates documentation on a daily basis. In fact, documentation for a patient requiring skilled services usually requires more frequent charting, such as every few hours or each shift. Documentation should occur any time the patient experiences unusual signs or symptoms, any time an assessment is done, and any time treatment has been rendered.

Why:
Empire Medicare Services Medical Review and Appeals departments determine skilled care based on the documentation submitted. Therefore, documentation from all modalities (therapy, nursing, nursing assistants, and physician) should ALL clearly illustrate the same clinical picture of the patient.

Where:
Documentation that is requested and reviewed that may support the need for daily skilled care includes (but is not limited to):

• Original M.D. orders
• All M.D., nursing, and therapy notes
• Care plans
• Evaluations
• Discharge summaries
• Labs/diagnostic exams
• MDS
• M.D. certification, and treatment flow sheets/minutes for therapy
• 30-day look back period information
• All records for any services billed for the dates of service in question

Reminder:
The PUB 100-2 can now be accessed via the Empire Medicare Services Web site at www.empiremedicare.com by utilizing the following instructions:

Click on:

• Part A
• CMS Links
• Medicare Program Manuals
• Internet Only Manuals
• PUB 100-2 Medicare Benefit Policy