Q:
We have a patient with a stage IV pressure injury to the ankle that is being treated with a wound vac, which is changed 3x/week. Does this meet the criteria for skilled coverage under Medicare Part A in the SNF?
A:
The Medicare Benefit Manual Chapter 8 section 30.3 provides the following examples of direct daily skilled nursing services related to the treatment of wounds:
- Application of dressings involving prescription medications and aseptic techniques (see §30.5 for exception);
- Treatment of decubitus ulcers, of a severity rated at Stage 3 or worse, or a widespread skin disorder (see §30.5 for exception);
In the example provided, the treatment of a stage IV pressure injury would meet the skilled coverage criteria in the SNF; however, to be covered under Medicare, the patient must need and receive these skilled services on a daily basis, which for nursing is defined as 7 days per week. The manual further clarifies that even though the care may include the delivery of some skilled services, payment for a SNF level of care could not be made if the patient needs an intermittent rather than daily skilled service. Since the treatment to the stage IV pressure injury is being provided three times per week and not daily, the coverage criteria would not be met when the sole factor considered is the treatment of the stage IV pressure injury.
When making a coverage decision it is important to complete an individualized case by case coverage determination considering the inherent complexity of the patient’s condition and services provided to determine whether the patient’s level of care meets the criteria for coverage under the “indirect” skilled nursing care and not make a blanket decision. If for example, the patient has multiple co-morbidities that require skilled nursing care plan management to promote recovery and ensure the safety of the patient, the care may be coverable under Medicare Part A. 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.
Examples of considerations under “indirect” skilled nursing may include, but are not limited to the following:
- A patient with a diagnosis of diabetes that requires close management due to a wound which may cause this condition to be unstable with fluctuating blood sugars.
- Determine the root cause of the pressure injury and consider interventions to mitigate them (i.e. immobility – determine if patient is appropriate for therapy or restorative nursing.) Also, consider possible complications as result of the condition (i.e. is the patient at risk for PNA as a result of the bed bound status due to the pressure injury?)
- Is pain management an issue that requires care plan management to adjust medications and implement appropriate non medications intervention to manage?
- For a patient with an existing pressure injury who is at risk of the development of further ulcers, consider interventions beyond the wound vac to promote healing and prevent complications (i.e. specific turning and repositioning program, nutrition interventions to promote healing, etc.)
- Patient/caregiver teaching and training related to the care of the wound vac and dressing changes, as well as pressure injury prevention interventions to enable safe transition to a lower level of care as appropriate.
Christine Twombly, RN-BC, RAC-MT, RAC-MTA, HCRM, CHC
Clinical Consultant
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