Overview of Skilled Nursing Facility and Medicare Part A


Skilled Nursing Facility: Outline and Medicare Coverage

A patient is skilled when they required daily nursing or we have and this is on a daily basis meaning from a nursing perspective, that's seven days a week. From a rehab perspective, skilled under Medicare means five to seven days per week.

So patient went out to the hospital. They had a hip fracture, they had surgical repair, they come in to the skilled nursing facility and the facility says, “Well, there is rehab.” Well, they went into an acute hospital with a medical issue.

And when they come back to the skilled nursing facility, they are going to have a surgical wound that's going to need care. Therapy really isn't responsible for that. That's a nursing issue. Therapies will do their thing. And it's fabulous, everything that can be accomplished through physical and occupational therapy specific to a hip fracture.

But once therapy is done with their treatment, there are still maybe 20, 22 hours left in the day that nursing is caring for them. So you should always have a skilled nursing note everyday talking about the skilled services which were provided.

And this is exactly why we're talking about what is skilled care so that both nursing and rehab understand what is skilled care therefore, you can understand what you should have in your documentation that Medicare can recognize a skilled care.

So the 262 talks about that the patient will receive skilled nursing and/or rehab on a daily basis. And the services are reasonable and necessary and physical ordered.

Now, reasonable and necessary is very interesting because what does that mean? There's no further clarifying definition of reasonable and necessary. What that means is that on a weekly basis when you're having your Medicare meeting that you will discuss, is this person have they met all of their goals with therapies? Are they at the highest practical level of wellbeing which is Medicare terminology and is there medical regime essentially stabilized based on them requiring skilled nursing?

If a medical regime appears essentially stabilized, then no. They would not need to have skilled nursing on a daily basis but that's what you're looking for. Services that are reasonable and necessary, that's sort of part of that definition if you will.

And that’s up to the skilled nursing facility to determine which is what is so exciting about the Medicare program versus a commercial insurance program. Medicare allows the facility the authority and the lateral decision making to decide is this person still skilled, are they not? And the way you prove your clinical reasoning or your thought process is through your documentation to support why you continue to keep this individual at a skilled level of care.

And then physician ordered self therapies which to have a physician order and the physician also need to just certify the Medicare Part A services. And we meet with and talk with many facilities who don’t understand the urgency of the physician certification.

Extremely important that upon admission then is also obtained a physician certification form can be signed or it could be a note that's written by the physician but it's in a format that supports that the physician is certifying that the patient requires skilled care and what the skilled care is going to entail. So upon admission at 14 days and then every 30 days after that as long as the person is under their skilled benefit up to their 100 days.

So skilled care consist of care from a licensed person, a licensed person being a physician, a nurse or a therapist. That is the person who needs to intervene with the patient on a daily basis.

And the services need to be provided either directly or under general supervision which is Medicare terminology. What is general supervision? Well, that's important for a facility to understand especially when you have a patient who has come off of skilled therapies but still requires daily skilled nursing.

And oftentimes, a skilled nursing facility will not recognize that the patient continues to be at a skilled level because there's that general supervision definition that people don’t understand meaning that if a patient is on your unit and maybe they are post hip fracture with surgical repair, use our same patient and that nurse is aware that the patient has maybe hip precautions in terms of being able to flex or extend up the hip or maybe you have a patient who had a repair and they have touched down a weight bearing precautions.

Well the nurse doesn’t need to be next to that patient to be enforcing hip precautions or weight bearing precautions throughout the entire day but that nurse is aware and instructs the nursing assistant who's working with the patient. That nurse also could be in visual. The patient could be within the visual gates of the nurse and the nurse might note, “Oh, that patient is leaning over in their wheelchair. Shouldn't be doing that. I need to intervene or get somebody to intervene with the patient to prevent that from happening, to prevent their – from being a medical complication with the surgical repair.”

Furthermore, they could be a patient who has respiratory issues. Maybe that patient also has cognitive issues and they forget to keep their oxygen on. Or general supervision would mean that that nurse who is aware that the patient requires the oxygen continuously throughout the day could identify “Oh, Mr. Jones, walking down the hall removed his oxygen. We need an intervention to make sure that he keeps his oxygen on, has a reminder so that he does not go into some type of respiratory distress.” So it is important to understand that general supervision piece.

So initial direction and periodic inspection of the activity or of the patient to ensure promote healing and ensure medical safety. So you're looking for medical stability until you can document that there's to medical stability, that person remain skilled and you need to clearly convey to the staff who is documenting for that patient everyday, what other skilled areas that we're addressing.


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