Q:
Is it appropriate to skill every resident that tests positive for COVID-19? Does the waiver allow us to skill any resident who tests positive?
A:
There has been quite a bit of confusion surrounding the use of the waivers, especially when it comes to current long-term care residents and the ability to admit to skilled services “in-house” without a qualifying hospital stay. CMS addressed this questions in their FAQ (updated 8/16/2022): COVID-19 Frequently Asked Questions (FAQs) on Medicare Fee-for-Service (FFS) Billing (cms.gov) In their response to a similar question CMS clarified A COVID-19 diagnosis would not in and of itself automatically serve to qualify a beneficiary for coverage under the Medicare Part A SNF benefit. The diagnosis and/or resident condition is not the determining factor in whether Medicare Coverage criteria are met. The primary question that needs to be answered and supported in the diagnosis is whether the beneficiary needs and will receive a skilled level of care on daily basis that can only be provided as a practical matter in a SNF. When utilizing the waiver to skill beneficiaries who test positive for COVID-19 it is not a blanket decision that applies to all residents, but instead an individual case by case determination that should be made based on whether or not the resident meets skilled coverage criteria. The coverage criteria under the Medicare Part A are detailed in Chapter 8 Section 30 of the Medicare benefit policy manual, which is the definitive resource for Medicare coverage in the SNF. These coverage criteria have not been modified by the waiver, and include:
- Services must require the skills of a qualified technical or professional health personnel and;
- Must be provided directly by or under the supervision of these personnel
- The patient requires skilled services on a daily bases; and
- Services delivered are reasonable and necessary for the treatment of a patient’s illness or injury.
- The services must also be reasonable in terms of duration and quantity.
The inherent complexity of services 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. A resident’s diagnosis or prognosis should not be the sole factor in determining whether a service is or is not skilled.
Observation and assessment are skilled services when the likelihood of change in a patient’s condition requires skilled nursing or skilled rehabilitation personnel to identify and evaluate the patient’s need for possible modification of treatment or initiation of additional medical procedures, until the patient’s condition is essentially stabilized. It is important that documentation support the provision of skilled services that require the involvement of nursing personnel to promote the patient’s recovery and medical safety in view of the patient’s overall condition, to maintain the patient’s current condition, or to prevent or slow further deterioration in the patient’s condition.
Please also note that the PHE and related waivers will expire on May 11, 2023
Jessica Cairns, RN, RAC-CT, CMAC
Clinical Consultant
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