This document addresses skilled nursing facility (SNF) services in 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.
Note: 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:
- The individual requires skilled nursing or skilled rehabilitation services that must be performed by, or under the supervision of, professional or technical personnel; and
- The individual requires these skilled services on a daily basis; (note: if skilled rehabilitation services are not available on a 7-day-a-week basis, an individual whose inpatient stay is based solely on the need for skilled rehabilitation services would meet the "daily basis" requirement when he/she needs and receives those services at least 5 days a week); and
- As a practical matter, the daily skilled services can be provided only on an inpatient basis in a skilled nursing facility (SNF) setting; and
- SNF services must be furnished pursuant to a physician's orders and be reasonable and necessary for the treatment of an individual's illness or injury (that is, be consistent with the nature and severity of the individual's illness or injury, his particular medical needs and accepted standards of medical practice); and
- Initial admission and subsequent stay in a SNF for skilled nursing services or rehabilitation services must include development, management and evaluation of a plan of care as follows:
- The involvement of skilled nursing personnel is required to meet the individual's medical needs, promote recovery and ensure medical safety (in terms of the individual's physical or mental condition); and
- There must be a significant probability that complications would arise without skilled supervision of the treatment plan by a licensed nurse; and
- Care plans must include realistic nursing goals and objectives for the individual, discharge plans and the planned interventions by the nursing staff to meet those goals and objectives; and
- Updated care plans must document the outcome of the planned interventions; and
- There must be daily documentation of the individual's progress or complications.
- Observation, assessment and monitoring of a complicated or unstable condition.
- A complex or unstable condition of the individual must require the skills of a licensed nurse or rehabilitation personnel in order to identify and evaluate the individual's need for possible modification of the treatment plan or initiation of additional medical procedures.
- There must be a high likelihood of a change in an individual's condition due to complications or further exacerbations.
- Daily nursing or therapy notes must give evidence of the individual's condition and documentation must indicate the results of monitoring.
- Complex teaching services to the individual or caregiver requiring 24-hour SNF setting vs. intermittent home health care setting.
- The teaching itself is the skilled service. The activity being taught may or may not be considered skilled.
- Documentation should include the reasons why the teaching was not completed in the hospital, as well as the individual's or caregiver's capability of compliance.
- Complex medication regimen
- The individual must have a complex range of new medications (including oral medications) following a hospitalization where there is a high probability of adverse reactions or a need for changes in the dosage or type of medication.
- Documentation required to authorize initial admission and extensions must include the individual's unstable condition, medication changes and continuing probability of complications.
- Initiation of tube feedings
- Nasogastric tube and percutaneous tubes (including gastrostomy and jejunostomy tubes).
- Active weaning of ventilator dependent individuals
- These individuals are considered skilled due to their complex care.
- Wound care (including decubitus/pressure ulcers)
Note: Skilled nursing facility placement solely for the purpose of wound care should be rare.
All of the following criteria must be met:
- Wound care must be ordered by a physician; and
- The individual must require extensive wound care (for example, packing, debridement or irrigation of multiple stage II, or one or more stage III or IV wounds); and
- Skilled observation and assessment of a wound must be documented daily and should reflect any changes in wound status to support the medical necessity for continued observation.
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:
- Services do not meet the medically necessary criteria above; or
- The individual's condition has changed such that skilled medical or rehabilitative care is no longer needed; or
- Physical medicine therapy or rehabilitation services in which there is not a practical improvement in the level of functioning within a reasonable period of time; or
- Services that are solely performed to preserve the present level of function or prevent regression of functions for an illness, injury or condition that is resolved or stable; or
- The individual refuses to participate in the recommended treatment plan; or
- Care is initially or has become custodial; or
- The services are provided by a family member or another non-medical person. When a service can be safely and effectively self-administered or performed by the average non-medical person without the direct supervision of a nurse, the service cannot be regarded as a skilled service.
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.
- Routine services directed toward the prevention of injury or illness
- Routine or maintenance medication administration. SNF admissions solely for the administration of routine or maintenance medications, including intravenous (IV), intramuscular (IM) and subcutaneous (SQ) medications are not considered skilled. Parenteral medication administration in medically stable members is most often managed in the home setting by a home health or home infusion therapy provider.
- Care solely for the administration of oxygen, IPPB (intermittent positive pressure breathing) treatments and nebulizer treatments
- Routine enteral feedings
- Routine colostomy care
- Custodial care by a licensed practical nurse (LPN) or registered nurse (RN)
- Emotional support or counseling
- Suctioning of the nasopharynx or nasotrachea. Suctioning daily or as needed (PRN) with occurrences less frequently than every four hours is not considered skilled.
- Administration of suppositories or enemas
- Routine foot and nail care
- Medically stable ventilator care that can be safely provided in an alternative setting
- Urinary catheters. The presence of a stable indwelling or suprapubic catheter, the need for routine intermittent straight catheterization or ongoing intermittent straight catheterization for chronic condition, catheter replacement or routine catheter irrigation does not qualify an individual for SNF placement unless other skilled needs exist.
- Heat treatment – wet or dry
- Whirlpool baths, paraffin baths or heat lamp treatments do not qualify an individual for care in a SNF.
- There may be a rare instance when a severely compromised individual with desensitizing neuropathies or severe burns requires skilled observation during the above treatments. These cases are to be reviewed on an individual basis. Documentation must support the medical necessity for such observation.
The following codes for treatments and procedures applicable to this document are included below for informational purposes. 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.
|Revenue Code|| |
|0022||Skilled nursing facility prospective payment system|
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|ICD-10 Diagnosis||[For dates of service on or after 10/01/2015]|
| ||All diagnoses|
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|ICD-9 Diagnosis||[For dates of service prior to 10/01/2015]|
| ||All diagnoses|
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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:
- custodial, ambulatory or part-time care;
- treatment for mental health disorders, substance abuse or pulmonary tuberculosis.
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.
- Custodial care is that care which is primarily for the purpose of assisting the individual in the activities of daily living or in meeting personal rather than medical needs, which is not specific therapy for an illness or injury and is not skilled care.
- Custodial care serves to assist an individual in the activities of daily living, such as assistance in walking, getting in and out of bed, bathing, dressing, feeding, using the toilet, preparation of special diets, and supervision of medication that usually can be self-administered.
- Custodial care essentially is personal care that does not require the continuing attention or supervision of trained, medical or paramedical personnel.
- Custodial care is maintenance care provided by family members, health aides or other unlicensed individuals after an acute medical event when an individual has reached the maximum level of physical or mental function.
- In determining whether an individual is receiving custodial care, the factors considered are the level of care and medical supervision required and furnished. The decision is not based on diagnosis, type of condition, degree of functional limitation or rehabilitation potential.
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:
- Centers for Medicare and Medicaid Services. The Skilled Nursing Facility Manual. Revised September 2005. Available at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/index.html?redirect=/Manuals/PBM/list.asp. Accessed on June 21, 2015.
- National Pressure Ulcer Advisory Panel. Pressure ulcer staging system. Revised February 2007. Available at: http://www.npuap.org/resources/educational-and-clinical-resources/. Accessed on June 21, 2015.
- The Wound, Ostomy and Continence Nurse (WOCN). Position statement: pressure ulcer staging. Revised April 2011. Available at: http://c.ymcdn.com/sites/www.wocn.org/resource/collection/E3050C1A-FBF0-44ED-B28B-C41E24551CCC/Position_Statement_-_Pressure_Ulcer_Staging_(2011).pdf. Accessed on June 21, 2015.
|Revised||08/06/2015||Medical Policy & Technology Assessment Committee (MPTAC) review. Clarified abbreviations in medically necessary criteria. Updated Websites.|
|Reviewed||08/14/2014||MPTAC review. Description and Websites updated.|
|Reviewed||08/08/2013||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.|