Clinical UM Guideline



Subject: Skilled Nursing Facility Services
Guideline #:  CG-MED-31 Current Effective Date:    06/28/2017
Status: Reviewed Last Review Date:    05/04/2017

Description

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:

Clinical Indications

Medically Necessary

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:

Section A:  

  1. The individual requires skilled nursing or skilled rehabilitation services that must be performed by, or under the supervision of, professional or technical personnel; and
  2. 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
  3. As a practical matter, the daily skilled services can be provided only on an inpatient basis in a skilled nursing facility (SNF) setting; and
  4. 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
  5. 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:
    1. 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
    2. There must be a significant probability that complications would arise without skilled supervision of the treatment plan by a licensed nurse; and
    3. 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
    4. Updated care plans must document the outcome of the planned interventions; and
    5. There must be daily documentation of the individual's progress or complications.

Section B:  

  1. Observation, assessment and monitoring of a complicated or unstable condition.
    1. 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.
    2. There must be a high likelihood of a change in an individual's condition due to complications or further exacerbations.
    3. Daily nursing or therapy notes must give evidence of the individual's condition and documentation must indicate the results of monitoring.
      OR
  2. Complex teaching services to the individual or caregiver requiring 24-hour SNF setting vs. intermittent home health care setting.
    1. The teaching itself is the skilled service. The activity being taught may or may not be considered skilled.
    2. 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.
      OR
  3. Complex medication regimen
    1. 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.
    2. Documentation required to authorize initial admission and extensions must include the individual's unstable condition, medication changes and continuing probability of complications.
      OR
  4. Initiation of tube feedings
    1. Nasogastric tube and percutaneous tubes (including gastrostomy and jejunostomy tubes).
      OR
  5. Active weaning of ventilator dependent individuals
    1. These individuals are considered skilled due to their complex care.
      OR
  6. Wound care (including decubitus/pressure ulcers or pressure injury)
    Note: Skilled nursing facility placement solely for the purpose of wound care should be rare.
    All of the following criteria must be met:
    1. Wound care must be ordered by a physician; and
    2. 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
    3. 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:

  1. Services do not meet the medically necessary criteria above; or
  2. The individual's condition has changed such that skilled medical or rehabilitative care is no longer needed; or
    1. 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
    2. 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
    3. The individual refuses to participate in the recommended treatment plan; or
    4. Care is initially or has become custodial; or
    5. 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.

Coding

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
   
ICD-10 Diagnosis  
  All diagnoses
   
Discussion/General Information

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.

Definitions

Custodial Care:

Note: For examples of custodial care services refer to CG-MED-19 Custodial Care

Pressure Injury Stages (National Pressure Ulcer Advisory Panel, 2016)

A pressure injury is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to medical or other devices. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and conditions of soft tissue.

Pressure Injury Stages

Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visible changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury.

Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (for example, skin tears, burns, abrasions).

Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an unstageable Pressure Injury.

Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an unstageable Pressure Injury.

Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (that is, dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed.

Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions.

References

Government Agency, Medical Society, and Other Authoritative Publications:

  1. Centers for Medicare and Medicaid Services. The Skilled Nursing Facility Manual. Revised October 13, 2016. Available at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/index.html?redirect=/Manuals/PBM/list.asp. Accessed on March 9, 2017.
  2. National Pressure Ulcer Advisory Panel. Pressure injury staging system. Revised April 2016. Available at: http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/. Accessed on March 9, 2017.
  3. The Wound, Ostomy and Continence Nurse (WOCN). Position statement: pressure ulcer staging. Revised April 2011. Available at: http://www.wocn.org/?page=library. Accessed on March 9, 2017.
History

Status

Date

Action

Reviewed 05/04/2017 Medical Policy & Technology Assessment Committee (MPTAC) review. Updated Definitions and References sections.
Revised 08/04/2016 MPTAC review. Revised MN clinical indication for wound care. Updated formatting in Clinical Indications section. Updated Definitions and References sections. Removed ICD-9 codes from Coding section.
Revised 08/06/2015 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.
Pre-Merger Organizations

Last Review Date

Document Number

Title

Anthem, Inc.

 

N/A  
Anthem BCBS Midwest

05/27/2005

MA-020 Skilled Nursing Facility Setting, Skilled and Custodial Services Defined
WellPoint Health Networks, Inc.

 

N/A