The Landscape of Skilled Service Justification in Skilled Nursing Facilities
Compliance and accountability related to justifying skilled services is more important than ever. In Part 2 of this blog addressing justification of SNF Skilled Care, we’ll take a deeper look at specific skilled nursing and therapy skilled service case examples, providing targeted tips for supportive documentation that justifies the decision to “skill” in order to fortify compliance and success under payer audits.
Check out Part 1 of this 2 part blog for a brief overview of the SNF data analytics and audit landscape, along with the fundamental guidelines for skilled documentation as outlined in Chapter 8 of the Medicare Benefit Policy Manual. The guidance goes on to outline direct skilled nursing services to patients (section 30.3), direct skilled therapy services to patients (section 30.4), along with additional examples of skilled nursing and rehabilitation services (section 30.2.3). Attention to the detail of these sections in the manual is vital, as it not only supports compliance with regulatory standards but also plays a crucial role in securing appropriate reimbursement and justifying the need for skilled services.
Direct Nursing Skill
Nursing services are considered skilled when they are so inherently complex that they can be safely and effectively performed only by, or under the supervision of, a registered nurse or, when provided by regulation, a licensed practical (vocational) nurse. (See 42CFR §409.32) The nature of the service and the skills required for safe and effective delivery of that service in deciding whether a service is a skilled service.
Examples include but are not limited to:
- IV or IM injections, and IV feeding;
- Tube feeding (at least 26% of daily calorie requirements and 501 mL of fluid per day);
- Application of dressings involving prescription medications and aseptic techniques;
- Treatment of decubitus ulcers, of a severity rated at Stage 3 or worse, or a widespread skin disorder
Indirect Nursing Skill
If all other requirements for coverage under the SNF benefit are met, skilled nursing services are covered when an individualized assessment of the patient’s clinical condition demonstrates that the specialized judgment, knowledge, and skills of a nurse are necessary. Skilled nursing services would be covered where such skilled nursing services are necessary to maintain the patient’s current condition or prevent or slow further deterioration, so long as the beneficiary requires skilled care for the services to be safely and effectively provided. A condition that would not ordinarily require skilled nursing services may nevertheless require them under certain circumstances.
Indirect skilled nursing services fall into the following categories:
- Management and Evaluation of the Care Plan: Development, management, and evaluation of a patient care plan, based on the physician’s orders and supporting documentation, constitute skilled nursing services when they require the involvement of skilled nursing personnel to meet the patient’s medical needs, promote recovery, and ensure medical safety.
- Observation and Assessment of the Patient’s Condition: Skilled services when the likelihood of change in condition requires skilled personnel to identify and evaluate the need for modification or initiation of additional medical procedures until the patient’s condition is essentially stabilized
- Teaching and Training Activities: Skilled services when they require skilled nursing or skilled rehabilitation personnel to teach a patient how to manage their treatment regimen.
Direct Skilled Therapy Services to Patients
Coverage for skilled therapy services is based on the beneficiary’s need for skilled care, rather than their potential for improvement from therapy (Jimmo v. Sebelius Settlement Agreement Fact Sheet). Rehab services are classified as skilled when they are so complex that they must be performed by, or under the supervision of, a qualified therapist. These skilled services may be necessary to enhance the patient’s current condition, maintain their status, or prevent or slow further decline. When all other coverage criteria under the SNF benefit are met, skilled therapy services are eligible for coverage if an individualized assessment indicates that the specialized judgment, knowledge, and skills of a qualified therapist are required for the delivery of rehabilitation services in order to achieve discharge goals.
Following the initial evaluation, therapists must closely analyze the patient’s response to skilled interventions and adjust treatments, strategies, and techniques accordingly as the rehab course progresses. The patient’s positive outcomes alone will not support ongoing medically necessary services for an extended length of stay if services seemingly become rote or routine. Documentation must prove that the complexity and sophistication of a licensed therapist is required to deliver the services and could not be trained to family or non-skilled staff to facilitate the same progress toward the patient’s discharge goals.
Further, the services must be provided with the expectation that the condition of the patient will improve in a reasonable and generally predictable amount of time. The services must also be considered under accepted standards of medical practice to be specific and effective treatment for the patient’s condition. Additionally, the services must be reasonable and necessary for the treatment of the patient’s condition; this includes the amount, frequency, and duration of the services. And finally, services involving activities for the general good and welfare of the patient (e.g., general exercises to promote overall fitness and flexibility and activities to provide diversion or general motivation) do not constitute skilled physical therapy.
Examples of services that don’t typically require the skills of a therapist:
- Repetitious exercises to improve gait, or to maintain strength and endurance, and assistive walking
- Passive exercises to maintain range of motion in paralyzed extremities where exercises can be carried out by aides or nursing personnel
- 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.
CMS also notes that service is not considered a skilled therapy service merely because it is furnished by a therapist or by a therapist/therapy assistant under the direct supervision of a therapist. They also note that the unavailability of a competent person to provide a non-skilled service does not make it a skilled service when a therapist furnishes the service.
Skilled Service Justification through Quality Documentation:
Claims for skilled coverage must be supported by documentation that demonstrates that skilled involvement is required for the services to be safely and effectively furnished and that the services are consistent with the nature and severity of the illness or injury, the medical needs of the patient and accepted standards of practice. The documentation must clearly illustrate that the services promote the documented goals and are appropriate in terms of duration and quantity.
The patient’s medical record must document as appropriate:
- The history and physical exam pertinent to the patient’s care, (including the response or changes in behavior to previously administered skilled services);
- The skilled services provided;
- The patient’s response to the skilled services provided during the current visit;
- The plan for future care based on the rationale of prior results;
- A detailed rationale that explains the need for the skilled service in light of the patient’s overall medical condition and experiences;
- The complexity of the service to be performed;
- Any other pertinent characteristics of the beneficiary.
Case Examples:
| The Medicare Benefit Policy Manual (chapter 8) provides the following example for a patient in which skilled observation and assessment could be supported: Ex. 1 A patient with arteriosclerotic heart disease with congestive heart failure requires close observation by skilled nursing personnel for signs of decompensation, abnormal fluid balance, or adverse effects resulting from prescribed medication. Skilled observation is needed to determine whether the digitalis dosage should be reviewed or whether other therapeutic measures should be considered, until the patient’s treatment regimen is essentially stabilized. In this case, the documentation must describe the skilled services that require the involvement of nursing personnel to promote the stabilization of the patient’s medical condition and safety. Clinicians should consider documentation that includes an assessment of the cardiac system, which includes vital signs, edema, abnormal weight changes, activity tolerance, shortness of breath, chest pain, cardiac medication effectiveness and or side effects. |
| Let’s review a sample nursing documentation entry for teaching and training a patient to care for a new colostomy below: Ex. 2 Resident was able to remove colostomy pouch without assist. Cueing was required to assure skin surrounding the stoma was dry before applying the clean ostomy pouch. Education provided regarding moisture associated skin damage. Assistance and cueing needed to secure the pouch to the skin due to his visual deficit. Magnified mirror obtained due to visual deficit to assist during next teaching session. As outlined in the Medicare Benefit Policy the supportive documentation in support of skilled teaching and training should describe all efforts that have been made to educate the patient/caregiver, and their responses to the training. The medical record should also describe the reason for failed educational attempts, if applicable. |
| Quality documentation for skilled rehabilitation services in the progress reports are key to justifying the medical necessity and duration of services. Support for skilled interventions must clearly demonstrate that treatment is evolving, based on the patient’s response to the treatment. Ex. 3 OT established a BUE AROM RNP with individualized training related to breathing techniques. Pt now utilizes yellow t-band for UE exercise to promote progress toward discharge goals outside therapy. Basic ADL tasks were analyzed, including hygiene & grooming while standing at the sink. Pt’s bathroom was adapted to promote safety during standing tasks with grab bar placed on dominant, non-affected side. Pt and caregivers were taught compensatory strategies for dressing to complete LB dressing tasks utilizing hemi techniques. It is often appropriate to transition procedures that are repetitive or reinforce previously learned skills to a restorative nursing program. In this case, the BUE exercises are trained with restorative aides to continue to promote progress outside of skilled OT. |
| Skilled Justification Guidelines & Considerations for Nursing | ||
| General guidelines |
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| Acute Infections |
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| Acute Neurologic |
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| Cancer |
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| Cardiovascular & Coagulations |
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| Medical Management |
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| Non-Orthopedic Surgery |
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| Orthopedic Surgery |
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| Pulmonary |
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Conclusion
Although the presence of appropriate documentation is not, in and of itself, an element of the definition of a “skilled” service, such documentation serves as the means by which a provider establishes that skilled care was necessary and provided. The documentation supports the communication among the interdisciplinary team regarding the development, course, and outcomes of the skilled observations, assessments, treatment, and training performed. Timely and thorough documentation is essential to supporting the provision of clinically appropriate skilled services in the SNF.
Don’t miss our upcoming Documentation in Depth series on November 19, 2024, where we’ll explore critical documentation for skilled care justification. Proactive also offers remote Quality Assurance audit solutions for skilled documentation compliance and reimbursement accuracy. Contact us today to learn more about audit services and Medical Review support assistance including ADR preparation and Appeals management.
