Clinical UM Guideline
|Subject:||Skilled Nursing Facility Services|
|Guideline #:||CG-MED-31||Current Effective Date:||10/08/2013|
|Status:||Reviewed||Last Review Date:||08/08/2013|
A skilled nursing facility (SNF) is an institution (or a distinct part of an institution) that mainly provides inpatient skilled nursing and related services to individuals requiring convalescent and rehabilitative care. The facility or program must be licensed, certified or otherwise authorized, pursuant to the laws of the state in which it is situated, as a skilled nursing home.
This document addresses services provided in a skilled nursing facility. Please see the following documents for additional information regarding skilled and non-skilled services in other settings:
Skilled nursing facility (SNF) services are medically necessary when ALL of the following criteria in Section A are met and one or more of the criteria in Section B are met:
Respiratory Therapy (RT)
NOTE: The need for respiratory therapy, either by a nurse or by a respiratory therapist, does not alone qualify an individual for skilled nursing facility (SNF) care.
Not Medically Necessary
A skilled nursing facility (SNF) setting is considered not medically necessary when any one of the following is present:
The following services are examples of services that do not require the skills of a licensed nurse or rehabilitation personnel and are therefore considered to be not medically necessary in the skilled nursing facility setting unless there is documentation of comorbidities and complications that require individual consideration.
The following codes for treatments and procedures applicable to this document are included below for informational purposes. A draft of future ICD-10 Coding (effective 10/01/2014) related to this document, as it might look today, is included below for your reference. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.
|0022||Skilled nursing facility prospective payment system|
|ICD-10 Diagnosis||ICD-10-CM draft codes; effective 10/01/2014|
A skilled nursing facility (SNF) is an institution (or a distinct part of an institution) that mainly provides inpatient skilled nursing and related services to individuals requiring convalescent and rehabilitative care. Such care is given by or under the supervision of physicians. A skilled nursing facility is not a place that provides:
The facility or program must be licensed, certified or otherwise authorized, pursuant to the laws of the state in which it is situated, as a skilled nursing home to provide the skilled nursing services.
Skilled nursing services, furnished pursuant to physician orders, require the skills of qualified technical or professional health personnel such as registered nurses, physical therapists, occupational therapists and speech pathologists or audiologists. These services must be provided directly by or under the general supervision of these skilled nursing or skilled rehabilitation personnel to assure the safety of the individual and to achieve the medically desired result.
Pressure Ulcer (National Pressure Ulcer Advisory Panel, 2007)
A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated.
Pressure Ulcer Stages
Suspected Deep Tissue Injury:
Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.
Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment.
Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area.
The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Stage I may be difficult to detect in individuals with dark skin tones. May indicate "at risk" persons (a heralding sign of risk)
Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.
Presents as a shiny or dry shallow ulcer without slough or bruising.* This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation.
*Bruising indicates suspected deep tissue injury
Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.
The depth of a stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep stage III pressure ulcers. Bone/tendon is not visible or directly palpable.
Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling.
The depth of a stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable.
Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.
Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as "the body's natural (biological) cover" and should not be removed.
Government Agency, Medical Society, and Other Authoritative Publications:
|Reviewed||08/08/2013||Medical Policy & Technology Assessment Committee (MPTAC) review. References updated.|
|Reviewed||08/09/2012||MPTAC review. Websites updated.|
|Reviewed||08/18/2011||MPTAC review. Definitions, references and websites updated.|
|Revised||08/19/2010||MPTAC review. Clarified that medically necessary criteria covers initial admission as well as subsequent stay in a SNF. Combined duplicate not medically necessary criteria. Websites and references updated.|
|Reviewed||08/27/2009||MPTAC review. Removed place of service, case management and discharge plan sections. References updated.|
|Revised||08/28/2008||MPTAC review. Formatting change to clarify rehabilitation criteria. Title updated to include "Services".|
|Reviewed||08/23/2007||MPTAC review. Updated Discussion section by adding information on the definition and staging of pressure ulcers. Minor wording changes.|
|Revised||09/14/2006||MPTAC review. Clarified criteria.|
|New||03/23/2006||MPTAC initial guideline development.|
Last Review Date
|Anthem BCBS Midwest|
|MA-020||Skilled Nursing Facility Setting, Skilled and Custodial Services Defined|
|WellPoint Health Networks, Inc.|