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Skilled Nursing Facility Manual
Chapter 2 - Coverage of Services


Table of Contents
Definitions

201 SKILLED NURSING FACILITY (SNF) DEFINED
201.1 Distinct Part of an Institution as an SNF
201.2 Transfer Agreements
201.3 Hospital Providers of Extended Care Services
202. CHRISTIAN SCIENCE SANATORIUM
203. HOSPITAL DEFINED
203.1 Psychiatric and Tuberculosis Hospitals
203.2 Hospital for Emergency Purposes
205. PARTICIPATING PROVIDERS OF SERVICES
206. UNDER ARRANGEMENTS

Requirements for Coverage of Extended
Care Services Under Hospital Insurance

210. REQUIREMENTS--GENERAL
212. PRIOR HOSPITALIZATION AND TRANSFER REQUIREMENTS
212.1 Three-Day Prior Hospitalization
212.2 Three-Day Prior Hospitalization--Foreign Hospital
212.3 Thirty-Day Transfer
A 212.3 AMENDMENT SUPPLEMENT-COVERAGE OF SERVICES
214. COVERED LEVEL OF CARE - GENERAL
214.1 Skilled Nursing and Skilled Rehabilitation Services
214.2 Direct Skilled Nursing Services to Patients
214.3 Direct Skilled Rehabilitation Services to Patients
214.4 Nonskilled Supportive or Personal Care Services.
214.5 Daily Skilled Services--Defined
214.6 Services Provided on an Inpatient Basis as a "Practical Matter"
214.7 Prohibition Against Use of "Rules of Thumb" in Medicare Review Determinations

Certification and Recertification by
Physicians for SNF Services

220. PHYSICIAN CERTIFICATION AND RECERTIFICATION
220.1 Who May Sign Certification or Recertification
220.2 Certification
220.3 Recertification
220.4 Timing of Recertifications
220.5 Delayed Certifications and Recertifications
220.6 Disposition of Certification and Recertification Statements

Extended Care Services Covered Under
Hospital Insurance

230. COVERED EXTENDED CARE SERVICES
230.1 Nursing Care Provided by or under the Supervision of a Registered Professional Nurse
230.2 Bed and Board
230.3 Physical, Speech, and Occupational Therapy Furnished by the Skilled Nursing Facility or by Others under Arrangements with the Facility and under its Supervision
230.4 Medical Social Services to Meet the Patient's Medically Related Social Needs
230.5 Drugs and Biologicals
230.6 Blood
230.7 Supplies, Applicances, and Equipment
230.8 Medical Services of an Intern or Resident-in-Training
230.9 Other Diagnostic or Therapeutic Services Provided by Hospital
230.10 Other Services

Duration of Extended Care Services
Under Hospital Insurance

240. BENEFIT PERIOD
242. EXTENDED CARE BENEFIT DAYS
242.1 Counting Inpatient Days
242.2 Late Discharge
242.3 Leave of Absence
242.4 Discharge or Death on First Day of Entitlement or Participation
244. SERVICES COUNTING TOWARD MAXIMUMS
246. COINSURANCE--EXTENDED CARE SERVICES
247. BASIS FOR DETERMINING THE COINSURANCE AMOUNTS
249. PART A - DEDUCTIBLE AND COINSURANCE AMOUNTS

SNF Services Covered Under Part B

260. MEDICAL AND OTHER HEALTH SERVICES FURNISHED TO PATIENTS OF PARTICIPATING SNFs
260.1 Diagnostic X-Ray and Clinical Laboratory Tests
260.2 X-Ray, Radium, and Radioactive Isotope Therapy
260.3 Surgical Dressings, and Splints, Casts, and Other Devices Used for Reduction of Fractures and Dislocations
260.4 Prosthetic Devices.
260.5 Leg, Arm, Back, and Neck Braces, Trusses, and Artificial Legs, Arms, and Eyes.
261. TOTAL PARENTERAL NUTRITION AND ENTERAL NUTRITION FURNISHED TO INDIVIDUALS WHO ARE NOT INPATIENTS
262. AMBULANCE SERVICE
262.1 Vehicle and Crew Requirements
262.2 Necessity and Reasonableness.--To be covered, ambulance service must be medically necessary and reasonable.
262.3 Destination.
264. RENTAL AND PURCHASE OF DURABLE MEDICAL EQUIPMENT
264.1 Definition of Durable Medical Equipment
264.2 Necessary and Reasonable.
264.3 Repairs, Maintenance, Replacement, and Delivery
264.4 Coverage of Supplies and Accessories
264.5 Miscellaneous Issues Included in the Coverage of Equipment
264.6 Definition of Beneficiary's Home
264.7 Payment for Durable Medical Equipment

Outpatient Physical Therapy, Occupational Therapy, and
Speech Pathology Services Covered Under Medical Insurance

270. COVERAGE OF INPATIENT PART B AND OUTPATIENT PHYSICAL THERAPY, OCCUPATIONAL THERAPY, AND SPEECH PATHOLOGY SERVICES
270.1 Services Furnished under Arrangements with Providers
271. CONDITIONS FOR COVERAGE OF OUTPATIENT PHYSICAL THERAPY, OCCUPATIONAL THERAPY, AND SPEECH PATHOLOGY SERVICES
271.1 Physician's Certification and Recertification for Outpatient Physical Therapy, Occupational Therapy, and Speech Pathology Services
271.2 Outpatient Must be Under the Care of a Physician
271.3 Outpatient Physical Therapy, Occupational Therapy or Speech Pathology Services Furnished Under a Plan
271.4 Requirement that Services be Furnished on an Outpatient Basis.

Facility Based Physicians

275. FACILITY-BASED PHYSICIAN'S SERVICES

General Exclusions from Coverage

280. GENERAL EXCLUSIONS.
280.1 Services Not Reasonable and Necessary
280.2 No Legal Obligation to Pay for or Provide Services.
280.3 Items and Services Furnished, Paid For or Authorized by Governmental Entities--Federal, State Or Local Governments
280.4 Services Resulting From War
280.5 Personal Comfort Items
280.6 Routine Services and Appliances
280.7 Supportive Devices for Feet
280.8 Excluded Foot Care Services
280.9 Custodial Care
280.10 Cosmetic Surgery
280.11 Charges Imposed by Immediate Relatives of the Patient or Members of His/Her Household
280.12 Dental Services Exclusion.
280.13 Items and Services under a Workers' Compensation Law
280.14 Services Not Provided Within United States

AMENDMENT SUPPLEMENT, COVERAGE OF SERVICES

09-00    COVERAGE OF SERVICES    201.2

Definitions

201.    SKILLED NURSING FACILITY (SNF) DEFINED

An SNF is an institution or a distinct part of an institution (see §201.1), such as a skilled nursing home or rehabilitation center, which has a transfer agreement in effect with one or more participating hospitals (see §201.2 for transfer agreements and §205 for definition of a participating hospital) and which:

  1. Is primarily engaged in providing skilled nursing care and related services for residents who require medical or nursing care; or rehabilitation services for the rehabilitation of injured, disabled, or sick persons, and

  2. Meets the requirements for participation in §1819 of the Social Security Act and in regulations in 42 CFR part 483, subpart B.

A qualified SNF is one that meets all the requirements in the above definition.

For Medicare purposes, the term SNF does not include any institution which is primarily for the care and treatment of mental diseases or tuberculosis. (This restriction does not apply to title XIX (Medicaid).) Also, the term SNF does not include swing bed hospitals authorized to provide and be reimbursed for SNF level services. Swing bed hospitals must meet many of the same requirements that apply to SNFs. (For more details regarding swing bed hospitals, see §201.3.)

201.1    Distinct Part of an Institution as an SNF.--The term “distinct part” refers to a portion of an institution or institutional complex (e.g., a nursing home or a hospital) that is certified to provide SNF and/or NF services. A distinct part must be physically distinguishable from the larger institution and fiscally separate for cost reporting purposes. An institution or institutional complex can only be certified with one distinct part SNF and/or one distinct part NF. A hospital-based SNF is by definition a distinct part. Multiple certifications within the same institution or institutional complex are strictly prohibited. The distinct part must consist of all beds within the designated area. The distinct part can be a wing, separate building, a floor, a hallway, or one side of a corridor. The beds in the certified distinct part area must be physically separate from (that is, not commingled with) the beds of the institution or institutional complex in which it is located. However, the distinct part need not be confined to a single location within the institution or institutional complex's physical plant. It may, for example, consist of several floors or wards in a single building or floors or wards that are located throughout several different buildings within the institutional complex. In each case, however, all residents of the distinct part would have to be located in units that are physically separate from those units housing other patients of the institution or institutional complex. Where an institution or institutional complex owns and operates a SNF and/or a NF distinct part, that SNF and/or NF distinct part is a single distinct part even if it is operated at various locations throughout the institution or institutional complex. The aggregate of the SNF and/or NF locations represents a single distinct part subprovider, not multiple subproviders, and must be assigned a single provider number.

201.2    Transfer Agreements.--To participate in the program, an SNF must have a written transfer agreement with one or more participating hospitals (see §205) providing for the transfer of patients between the hospital and the SNF, and for the interchange of medical and other information. If an otherwise qualified SNF has attempted in good faith, but without success, to enter into a transfer agreement, this requirement may be waived by the State agency. (See 42 CFR 483.75(n) for the detailed requirements for transfer agreements.)



Next page is 2-6.1




Rev. 367/Page 2-5


07-88     COVERAGE OF SERVICES    201.3

201.3    Hospital Providers of Extended Care Services.--In order to address the shortage of rural SNF beds for Medicare patients, effective July 20, 1982, rural hospitals with fewer than 50 beds could be reimbursed under Medicare for furnishing post hospital extended care services to Medicare beneficiaries. Such a hospital, known as a swing bed hospital, can "swing" its beds between hospital and SNF levels of care, on an as needed basis, if it has obtained a swing bed approval from the Department of Health and Human Services. Under §4005(b)(2) of the Omnibus Budget Reconciliation Act of 1987, effective for agreements entered into after March 31, 1988, rural hospitals with fewer than 100 beds must make application and request approval to be a swing bed hospital from the Regional office. In order to obtain a swing bed approval, the hospital must:

  • as noted above, be located in a rural area (i.e., located outside of an "urbanized area," as defined by the Census Bureau and based on the most recent census) and have fewer than 100 beds (excluding beds for newborns and intensive care-type units);

  • have a Medicare provider agreement, as a hospital;

  • be granted any necessary certificate of need for the provision of extended care services, as required by the State;

  • be substantially in compliance with the SNF conditions of participation for patient rights, 42 CFR 405.1121(k)(2), (3), (4), (7), (8), (10), (11), (13) and (14); specialized rehabilitative services, 42 CFR 405.1126(a), (b) and (c); dental services, 42 CFR 405.1129; social services, 42 CFR 405.1130; patient activities, 42 CFR 405.1131; and discharge planning, 42 CFR 405.1137(h); (most other SNF conditions would be largely met by virtue of the facility's compliance with comparable hospital conditions);

  • not have in effect a 24-hour nursing waiver granted under 42 CFR 405.1910(c); and

  • not have had a swing bed approval terminated within the 2 years previous to application for swing bed participation.

However, the Department may grant a swing bed approval, on a demonstration basis, with hospitals meeting all of the statutory requirements except bed size and geographic location.

When a hospital has a swing bed approval from the Department, it may provide and be reimbursed by Medicare Part A for providing extended care or SNF-type services. When a swing bed hospital provides extended care services, Medicare reimbursement for those services will be based on the average State Medicaid rate paid for SNF services in the prior calendar year. This rate is set under explicit statutory conditions and is described at 42 CFR 405.434 and 405.452.

When a hospital is providing extended care services, it will be treated as a SNF for purposes of applying coverage rules. This means that those services are subject to the same Part A coverage, physician certification/recertification, deductible and coinsurance provisions that are applicable to SNF extended care services.

Rev. 268/Page 2-6.1


201.3 (Cont.)    COVERAGE OF SERVICES    07-88

Under §4005(b)(2) of the Omnibus Budget Reconciliation Act of 1987, effective for swing-bed agreements entered into after March 31, 1988, rural hospitals with more than 49 beds (but less than 100 beds) are subject to the following:

  • If there is an available SNF bed in the geographic region, the extended care patient must be transferred within 5 days of the availability date (excluding weekends and holidays) unless the patient's physician certifies, within that 5-day period, that transfer of that patient to that facility is not medically appropriate on the availability date. In order to do this, hospitals need to identify all SNFs in their geographic region and enter into agreements with them for the transfer of extended care patients under which SNFs are to notify the hospitals of the availability of beds and the dates these beds will be available for extended care patients; and

  • The 5 week day transfer requirement and the 15 percent payment limitation do not apply for Medicaid reimbursement purposes.

Hospitals have fewer than 50 and rural hospitals which entered into agreements before March 31, 1988 (i.e., those which were licensed for more than 49 beds but who were operating as a 50 or less bed facility) are not subject to the 5 week day transfer requirement or the payment limitation for extended care days. (See §2230.7 of the Provider Reimbursement Manual for the explanation of the payment limitation.)

"Geographic region" is an area which includes the SNFs with which a hospital has traditionally arranged transfers and all other SNFs within the same proximity to the hospital. In the case of a hospital without existing transfer practices upon which to base a determination, the geographic region is an area which includes all the SNFs within 50 miles of the hospital unless the hospital can demonstrate that the SNFs are inaccessible to its patients. In the event of a dispute as to whether an SNF is within this region or the SNF is inaccessible to hospital patients, the HCFA regional office shall make a determination.

Page 2-6.2/Rev. 268


06-79    COVERAGE OF SERVICES    203

202.    CHRISTIAN SCIENCE SANATORIUM

A Christian Science sanatorium operated or listed and certified by the First Church of Christ, Scientist, Boston, Massachusetts, may qualify as both a hospital and skilled nursing facility. Inpatient care in such an institution can begin or prolong a benefit period (§240).

Payment may be made in the same benefit period for inpatient hospital services furnished in a regular hospital and such services furnished by a Christian Science sanatorium in its capacity as a hospital. However, the total days of covered care cannot exceed the maximum of 90 days in a benefit period (§110.2). In addition, each beneficiary has a lifetime reserve of 60 additional days of inpatient hospital services which may be provided by a regular hospital or sanatorium in its capacity as a hospital. This lifetime reserve can be drawn upon whenever the beneficiary has used 90 days of inpatient hospital services in a benefit period, but cannot exceed total of 60 days.

Payment for sanatorium services as extended are services may be made for up to 30 days in each benefit period, instead of the 100 days applicable to extended care services generally.

Payment for sanatorium extended care services may be made only if the patient elects to treat such services as extended care services rather than hospital inpatient services. The election must be in writing and signed by the individual of proper party on his behalf.

Stays in Christian Science sanatoriums are excluded for the purpose of satisfying the prior inpatient stay requirement for SNF services not provided in a Christian Science sanatorium or for posthospital home health services. (See §212.1.)

Payment may not be made for posthospital extended care services furnished to an inpatient of an SNF which is not a Christian Science sanatorium after he has been furnished covered sanatorium extended services during the same benefit period. similarly, payment may not be made on behalf of an individual for sanatatorium extended care services furnished him after he has been furnished covered posthospital extended care services during the same benefit period as an inpatient of a participating SNF which is not a Christian Science sanatorium.

203.    HOSPITAL DEFINED

A hospital (other than tuberculosis or psychiatric) is an institution which:

  1. Is primarily engaged in providing to inpatients, by or under the supervision of physicians,

    1. Diagnostic and therapeutic services for medical diagnosis, treatment, and care of injured, disabled, or sick persons, or

    2. Rehabilitation services for the rehabilitation of injured disabled, or sick persons;

Rev. 165/Page 2-7


203.2    COVERAGE OF SERVICES    06-79

  1. Maintain clinical records on all patients;

  2. Has bylaws in effect concerning its staff of physicians;

  3. Requires that ever patient must be under the care of a physician;

  4. Provides 24-hour nursing services rendered by or supervised by a registered professional nurse, and has a licensed practical nurse or register professional nurse on duty at all times;

  5. Has in effect a hospital utilization review plan;

  6. Is licensed or is approved by the State or local licensing agency as meeting the standards established for such licensing;

  7. Meets other health and safety requirements found necessary by the Secretary of Health, Education, and Welfare. (These additional requirements may not be higher than comparable ones prescribed for accreditation by the Joint Commission on Accreditation of Hospitals with certain exceptions specified in the law.);

  8. Is not primarily for the care and treatment of mental diseases or tuberculosis.

203.l    Psychiatric and Tuberculosis Hospitals.--A psychiatric hospital is an institution which is primarily engaged in providing by or under the supervision of a physician, psychiatric services for the diagnosis and treatment of mentally ill persons.

A tuberculosis hospital is an institution which is primarily engaged in providing by or under the supervision of a physician, medical services for the diagnosis and treatment of tuberculosis.

To be eligible for participation in the program, a psychiatric or tuberculosis hospital must be accredited by the Joint Commission on Accreditation of Hospitals, have in effect a utilization review plan, and meet additional staffing and medical record requirements necessary to carry out an active program of treatment and intensive care.

A distinct part of a psychiatric or tuberculosis institution may qualify as a psychiatric or tuberculosis hospital independently of the institution of which it is a part, if the part meets certain specified requirements.

203.2    Hospital for Emergency Purposes.--An emergency services hospital is a nonparticipating hospital which meets the requirements of the law's definition of a "hospital" relating to full-time nursing services and licensure under State or applicable local law. (See § 203 E and G.) (A Federal hospital need not be licensed under state or local licensing laws to meet the definition of emergency hospital.) In addition, the hospital must be primarily engaged in providing, under the supervision of doctors of medicine or osteopathy, services of the type that 203A describes in defining the term hospital, and must not be primarily engaged in providing skilled nursing care and related services for patients who require medical or nursing care. (See requirement "A" of the definition of an SNF in §201.)

Page 2-8/Rev. 165


11-87    COVERAGE OF SERVICES    206

Psychiatric hospitals that meet these requirements can qualify as emergency hospitals. A nonparticipating hospital within the United States may receive payment for covered emergency inpatient and outpatient hospital services if it meets at least these requirements. Coverage continues only as long as the emergency continues.

Stays in hospitals that meet these requirements also satisfy the 3 day hospital stay requirement for coverage of posthospital services.

Inpatient hospital services outside the United States can be covered under limited conditions.

205.    PARTICIPATING PROVIDERS OF SERVICES

For purposes of §1866 of the Act, the term provider of services (or provider) means a hospital, skilled nursing facility, home health agency and, for the limited purpose of furnishing outpatient physical therapy, occupational therapy, or speech pathology services, a clinic, rehabilitation agency or public health agency which meets the applicable eligibility provisions of Title XVIII of the Act and regulations issued thereunder (i.e., the conditions of participation).

To be a participating provider under Medicare, a provider must be in compliance with the applicable provisions of title VI of the Civil Rights Act of 1964 and must enter into an agreement under §1866 of the Act which provides that it:

  • will not charge any individual or other person for items and services covered by the health insurance program other than allowable charges and deductibles and coinsurance amounts; and

  • will return any money incorrectly collected from the individual or other person on his behalf or make other disposition. (See §§318ff.)

206.    UNDER ARRANGEMENTS

A skilled nursing facility may have others furnish certain covered items and services to its patients through arrangements, under which receipt of payment by the facility for the services discharges the liability of the beneficiary or any other person to pay for the services.

In permitting skilled nursing facilities to furnish services under arrangements, it was not intended that the facility merely serve as a billing mechanism for the other party. For services provided under arrangements to be covered, the SNF must exercise professional responsibility over the arranged-for services.

Rev. 258/Page 2-9


212.1    COVERAGE OF SERVICES    11-87

The facility's professional supervision over arranged-for services requires application of many of the same quality controls as are applied to services furnished by salaried employees. The SNF must accept the patient for treatment in accordance with its admission policies; maintain a complete and timely clinical record of the patient which includes diagnosis, medical history, physician's orders, and progress notes relating to all services received; maintain liaison with the attending physician on the progress of the patient and the need for revised orders or, in the case of outpatient physical therapy, occupational therapy, or speech pathology services, to assure that the required plan of treatment is periodically reviewed by the physician; secure from the physician the required certifications and recertifications; and see to it that the medical necessity of such services is reviewed on a sample basis by its utilization review committee.

Requirements for Coverage of Extended
Care Services under Hospital Insurance

210.    REQUIREMENTS--GENERAL

Posthospital extended care services furnished to inpatients of a skilled nursing facility are covered under the hospital insurance program. Patients with hospital insurance coverage are entitled to have payment made on their behalf for the reasonable cost of covered extended care services furnished by the facility, by others under arrangements with the facility, or by a hospital with which the facility has a transfer agreement.

212.    PRIOR HOSPITALIZATION AND TRANSFER REQUIREMENTS

In order to have payment made for posthospital extended care services, the individual must have been an inpatient of a hospital for a medically necessary stay of at least 3 consecutive calendar days. In addition, the individual must have been transferred to a participating skilled nursing facility within 30 days after discharge from the hospital, unless the exception in section 212.3B applies.

212.1    Three-Day Prior Hospitalization.--The hospital discharge must have occurred on or after the first day of the month in which the individual attains age 65 or becomes entitled to health insurance benefits under the disability or chronic renal disease provisions of the law. The 3 consecutive calendar days requirement can be met by stays totalling 3 consecutive days in one or more hospitals. In determining whether the requirement has been met, the day of admission, but not the day of discharge, is counted as a hospital inpatient day.

To be covered, the extended care services must be needed for a condition which was treated during the patient's qualifying hospital stay, or by a condition which arose while he was in the facility for treatment of a condition for which he was previously treated in the hospital. In addition, the qualifying hospital stay must have been medically necessary. The intermediary will determine whether this requirement is met; where the situation warrants it, by checking with the attending physician and the hospital.

Page 2-10/Rev. 258


07-81    COVERAGE OF SERVICES    212.3

The 3-day hospital stay need not be in a hospital with which the SNF has a transfer agreement. However, the hospital must be: (a) a participating general, psychiatric, or tuberculosis hospital; or (b) an institution which meets at least the conditions of participation for hospitals described in section 203E. and G., i.e., an emergency service hospital. A nonparticipating psychiatric or tuberculosis hospital need not meet the special requirements applicable to psychiatric and tuberculosis hospitals (section 203.1). Stays in Christian Science Sanatoriums (section 202) are excluded for the purpose of satisfying the 3-day period of hospitalization. (See section 410 for prohibition on use of waiver of liability days in meeting 3-day requirement.)

NOTE: While a 3-day stay in a psychiatric hospital satisfies the prior hospital stay requirement, institutions which primarily provide psychiatric treatment cannot participate in the program as skilled nursing facilities. Therefore, a patient with only a psychiatric condition who is transferred from a psychiatric hospital to a participating SNF is likely to receive only noncovered care. In the SNF, the term "noncovered care" refers to any level of care which is less intensive and skilled than the SNF level of care which is covered under the program. (See section 214ff).

212.2    Three-Day Prior Hospitalization--Foreign Hospital.-- A stay of 3 or more days in a hospital outside the United States may satisfy the prior inpatient stay requirement for posthospital extended care services within the United States if the foreign hospital is qualified as an "emergency hospital." (See section 414, Item 12F, for documentation requirements. The intermediary will advise the SNF whether the prior inpatient stay requirement is met and whether Part A benefits are payable.

212.3    Thirty-Day Transfer.--

  1. General.--Posthospital extended care services represent an extension of care for a condition for which the individual received inpatient hospital services. Extended care services are "posthospital" if initiated within 30 days after discharge from a hospital stay which included at least 3 consecutive days of medically necessary inpatient hospital services. (In certain circumstances the 30-day period may be extended, as described in B below). For SNF admissions occurring after October 29, 1972, but before December 5, 1980, see section D below.

In determining the 30-day transfer period, the day of discharge from the hospital is not counted in the 30 days. For example, a patient discharged from a hospital on August l and admitted to an SNF on August 31 was admitted within 30 days. The
30-day period begins to run on the day following actual discharge from the hospital and continues until the individual is admitted to a participating SNF, and requires and receives a covered level of care. Thus, an individual who is admitted to an SNF within 30 days after discharge from a hospital, but does not require a covered level of care until more than 30 days after such discharge, does not meet the 30-day requirement. (See B below for an exception under which such services may be covered.)

Rev. 185/Page 2-11


212.3 (Cont.)    COVERAGE OF SERVICES    07-81

If an individual whose SNF stay was covered upon admission is thereafter determined not to require a covered level of care for a period of more than 30 days, payment could not be resumed for any extended care services he may subsequently require even though he has remained in the facility. Such services could not be deemed to be "posthospital" extended care services. (For exception, see B below.)

  1. Medical Appropriateness Exception.--An elapsed period of more than 30 days is permitted for SNF admissions where the patient's condition makes it medically inappropriate to begin an active course of treatment in an SNF within 30 days after hospital discharge, and it is medically predictable at the time of the hospital discharge that he will require covered care within a predeterminable time period. The fact that a patient enters an SNF within 30 days of discharge from a hospital, for either covered or noncovered care, does not necessarily negate coverage at a later date, assuming the subsequent covered care was medically predictable.

    1. Medical Needs Are Predictable.--In determining the type of case which this exception is designed to handle, it is necessary to recognize the intent of the extended care benefit itself. The extended care benefit covers relatively short-term care when a patient requires skilled nursing or skilled rehabilitation services as a continuation of treatment begun in the hospital. The requirement that covered extended care services be provided in an SNF within 30 days after hospital discharge is one means of assuring that the SNF care is related to the prior hospital care.

This exception to the 30-day requirement recognizes that for certain conditions SNF care can serve as a necessary and proper continuation of treatment initiated during the hospital stay, although it would be inappropriate from a medical standpoint to begin such treatment within 30 days after hospital discharge. Since the exception is intended to apply only where the SNF care constitutes a continuation of care provided in the hospital, it will be applicable only where, under accepted medical practice, the established pattern of treatment for a particular condition indicates that a covered level of SNF care will be required within a predeterminable time frame. Accordingly, to qualify for this exception it must be medically predictable at the time of hospital discharge that a covered level of skilled nursing facility care will be required within a predictable period of time for the treatment of a condition for which hospital care was received and the patient must begin receiving such care within that time frame.

An example of the type of care for which this provision was designed is a hip fracture case. Under the established pattern of treatment of hip fractures it is known that skilled therapy services will be required subsequent to hospital care, and that they can normally begin within 4-6 weeks after hospital discharge, when weight bearing can be tolerated. Under the exception to the 30-day rule, the admission of a hip fracture patient to an SNF within 4-6 weeks after his hospital discharge for skilled care, which as a practical matter can only be provided on an inpatient basis by an SNF, would be considered a timely admission.

Page 2-12/Rev. 185


07-81    COVERAGE OF SERVICES    212.3 (Cont.)

  1. Medical Needs Are Not Predictable.--When a patient's medical needs and the course of treatment are not predictable at the time of hospital discharge because the exact pattern of care which he will require and the time frame in which it will be required is dependent on the developing nature of his condition, his admission to an SNF more than 30 days after discharge from the hospital could not be justified under this exception to the 30-day rule. For example, in some situations the prognosis for a patient diagnosed as having cancer is such that it can reasonably be expected that he will require additional care at some time in the future. However, at the time of his discharge from the hospital it is difficult to predict the actual services which will be required or the time frame in which the care will be needed. Similarly it is not known in what setting any future necessary services will be required; i.e., whether he will require the life-supporting services found only in the hospital setting, the type of care covered in an SNF, the intermittent type of care which can be provided by a home health agency, or custodial care which may be provided either in a nursing home or his place of residence. In some instances such patients may require care immediately and continuously; others may not require any skilled care for much longer periods, perhaps measured in years. Since in such cases it is not medically predictable at the time of the hospital discharge that the individual will require covered SNF care within a predeterminable time frame, such cases do not fall within the 30-day exception.

  2. SNF Stay Prior to Beginning of Deferred Covered Treatment.--In some cases where it is medically predictable that a patient will require a covered level of SNF care within a predeterminable time frame, the individual will also have a need for a covered level of SNF care within 30 days of hospital discharge. In such situations, this need for covered SNF care does not negate further coverage at a future date even if there is a noncovered interval of more than 30 days between the two stays, provided all other requirements are met. (See example No. l below.) However, this rule applies only where part of the care required involves deferred care which was medically predictable at the time of hospital discharge. If the deferred care is not medically predictable at the time of hospital discharge, then coverage may not be extended to include SNF care following an interval of more than 30 days of noncovered care. (see example No. 2). Where it is medically predictable that a patient will require a covered level of SNF care within a specific time frame, the fact that an individual enters an SNF immediately upon discharge from the hospital for noncovered care does not negate coverage at a later date, assuming the requirements of the law are met (see example No. 3).

EXAMPLE NO.  l: A patient who has had an open reduction of a fracture of the neck of the femur and has a history of diabetes mellitus and angina pectoris is discharged from the hospital on January 30, 1981, and admitted immediately to an SNF. He requires among other services careful skin care, appropriate oral medications, a diabetic diet, a therapeutic exercise program to preserve muscle tone and body condition, and observation to detect signs of deterioration in his condition or

Rev. 185/Page 2-13


212.3 (Cont.)    COVERAGE OF SERVICES    07-81

   complications resulting from his restricted mobility, which necessitates skilled management of his care to ensure his safety and recovery. It is also medically predictable that when he reaches weight bearing, skilled rehabilitative services will be required. After he is in the SNF for two days, he becomes unhappy and at his request is released to his home in the care of a full-time private duty nurse. Five weeks later when he reaches weight bearing he is readmitted to the SNF for the needed rehabilitative care. The patient would be eligible for coverage under the program for the care furnished him during both of these stays.

EXAMPLE NO.  2: An individual is admitted to an SNF for daily skilled rehabilitative care which as a practical matter can only be provided on an inpatient basis in an SNF. After three weeks the therapy is discontinued because the patient's condition has stabilized and daily skilled services are no longer required. Six weeks later, however, as a result of an unexpected change in the patient's condition, daily skilled services are again required. Since the second period of treatment did not constitute care which was predictable at the time of hospital discharge and could not thus be considered as care which was deferred until medically appropriate, it would not represent an exception to the 30-day rule. Therefore, since more than 30 days of noncovered care had elapsed between the last period of covered care and the reinstitution of skilled services, reimbursement could not be made under the extended care benefit for the latter services.

EXAMPLE NO.  3: A patient whose right leg was amputated was discharged from the hospital and admitted directly to an SNF on January 30, 1981. Although upon admission to the SNF the patient required help with meeting his activities of daily living, he did not require daily skilled care. Subsequently, however, after the stump had healed, daily skilled rehabilitative services designed to enable him to use a prosthesis were required. Since at the time of the patient's discharge from the hospital it was medically predictable that at a predeterminable time interval, covered SNF care would be required, and since such care was initiated when appropriate, the patient would be entitled to extended care benefits for the period during which such care was provided.

  1. Effect of Delay in Initiation of Deferred Care.--As indicated, where the required care commences within the anticipated time frame the transfer requirement would be considered met even though more than 30 days have elapsed. However, situations may occur where complications necessitate delayed initiation of the required care and treatment beyond the usual anticipated time frame (e.g., skilled rehabilitative services which will enable an amputee patient to use a prosthetic device must be deferred due to an infection in the stump). In such situations, the 30-day transfer requirement may still be met even though care is not started within the usual anticipated time frame, if the care is begun as soon as medically possible and the care at that time is still reasonable and necessary for the treatment of a condition for which the patient received inpatient hospital care.

Page 2-14/Rev. 185


12-87    COVERAGE OF SERVICES    212.3 (Cont.)

    1. Effect on Spell of Illness.--In the infrequent situation where the patient has been discharged from the hospital to his home more than 60 days before he is ready to begin a course of deferred care in an SNF, a new spell of illness begins with the day the beneficiary enters the SNF thereby regenerating another 100 days of extended care benefits. Another qualifying hospital stay would not be required, providing the care furnished is clearly related to the hospital stay in the previous spell of illness and represents care for which the need was predicted at the time of discharge from such hospital stay.

  1. Readmission to an SNF.--If an individual who is receiving covered posthospital extended care leaves a skilled nursing facility and is readmitted to the same or any other participating skilled nursing facility for further covered care within 30 days, the 30-day transfer requirement is considered to be met. Thus, the period of extended care services may be interrupted briefly and then resumed, if necessary, without hospitalization preceding the readmission to an SNF. (See B.3 above for situations where a period of more than 30 days between SNF discharge and readmission, or more than 30 days of noncovered care in an SNF, is followed by later covered care.)

  2. Transfer Rules for SNF Admissions Subsequent to October 29, 1972 and Prior to December 5, 1980.

    1. General.--Under the transfer rules in effect during this time frame an individual must have been admitted to a participating SNF, and have required and received a covered level of care within 14 days after discharge from a qualifying hospital stay, unless one of the exceptions in D.2 or D.3 below applies.

    2. Nonavailability of Appropriate Bed Space in a Participating SNF.-Intervals of up to 28 days are permitted where transfer to a participating SNF (for this purpose a "participating SNF" includes only those facilities participating under title XVIII) was deferred under the following conditions:

      1. The individual required within the 14-day period after the hospital discharge, and continued to require through admission to the SNF, a covered level of SNF care for a condition for which he received inpatient hospital care, and he met all other extended care requirements, and either b or c below applied;

      2. There is no bed available in the facilities ordinarily utilized in the geographic area in which the beneficiary resided. (A private room is considered an "available bed" for this purpose and is subject to reimbursement per sections 230.2ff.) The geographic area in which a beneficiary resides should be defined in such a way that a patient would not be taken away from his family and transported over great distances;

      3. There was an available bed in an SNF but it did not constitute appropriate bed space for the patient. In determining whether appropriate bed space was available, consideration should be given only to whether the facility in which a vacant bed was available had the capacity to meet the individual's medical needs, i.e., was capable of providing the required skilled services. Such nonmedical considerations as the individual's or his physician's preference for a particular SNF should not be considered.

Rev. 262/Page 2-15


214    COVERAGE OF SERVICES    12-87

  1. Medical Appropriateness.--An elapsed period of more than 14 days was permitted for skilled nursing facility admissions where the patient's condition makes it medically inappropriate to begin an active course of treatment in an SNF within 14 days after hospital discharge, and it was medically predictable at the time of the hospital discharge that he would require covered care within a predeterminable time period. The fact that a patient entered an SNF immediately upon discharge from a hospital, for either covered or noncovered care, does not necessarily negate coverage at a later date, assuming the subsequent covered care was medically predictable.

  2. Readmission to an SNF.--If an individual who was receiving covered posthospital extended care left an SNF and was readmitted to the same or any other participating SNF for further covered care within 14 days, the
    14-day transfer requirement was considered to be met. Thus, the period of extended care services could be interrupted briefly and then resumed, if necessary, without hospitalization preceding the readmission to an SNF. (See 3 above for situations where a period of more than 14 days between SNF discharge and readmission, or more than 14 days of noncovered care in an SNF, was followed by later covered care.)

214.    COVERED LEVEL OF CARE - GENERAL

Care in a SNF is covered if all of the following three factors are met:

  • The patient requires skilled nursing services or skilled rehabilitation services, i.e., services that must be performed by or under the supervision of professional or technical personnel (see §§214.1 - 214.3);

  • The patient requires these skilled services on a daily basis (see §214.5); and

  • As a practical matter, considering economy and efficiency, the daily skilled services can be provided only on an inpatient basis in an SNF. (See §214.6.)

If any one of these three factors is not met, a stay in an SNF, even though it might include the delivery of some skilled services, is not covered. For example, payment for an SNF level of care could not be made if a patient needs an intermittent rather than daily skilled service.

In determining whether the level of care requirements are met, the first consideration should be whether a patient needs skilled care. If a need for a skilled service does not exist, then the "daily" and "practical matter" requirements do not have to be addressed.

In addition, the services must be furnished pursuant to a physician's orders and be reasonable and necessary for the treatment of a patient's illness or injury, i.e., be consistent with the nature and severity of the individual's illness or injury, his particular medical needs, and accepted standards of medical practice. The services must also be reasonable in terms of duration and quantity.

EXAMPLE: Even though the irrigation of a catheter may be a skilled nursing service, daily irrigations may not be "reasonable and necessary" for the treatment of a patient's illness or injury.

Page 2-16/Rev. 262


12-87    COVERAGE OF SERVICES    214.1

214.1    Skilled Nursing and Skilled Rehabilitation Services

  1. Skilled Services--Defined.--Skilled nursing and/or skilled rehabilitation services are those services, furnished pursuant to physician orders, that:

    • Require the skills of qualified technical or professional health personnel such as registered nurses, licensed practical (vocational) nurses, physical therapists, occupational therapists, and speech pathologists or audiologists; and

    • Must be provided directly by or under the general supervision of these skilled nursing or skilled rehabilitation personnel to assure the safety of the patient and to achieve the medically desired result.

NOTE: "General supervision" requires initial direction and periodic inspection of the actual activity. However, the supervisor need not always be physically present or on the premises when the assistant is performing services.

Assume that skilled services provided by a participating SNF are furnished by or under the general supervision of the appropriate skilled nursing or skilled rehabilitation personnel.

  1. Principles for Determining Whether a Service is Skilled

    • If the inherent complexity of a service prescribed for a patient is such that it can be performed safely and/or effectively only by or under the general supervision of skilled nursing or skilled rehabilitation personnel, the service is a skilled service; e.g., the administration of intravenous feedings and intramuscular injections; the insertion of catheters; and ultrasound, shortwave, and microwave therapy treatments.

    • The nature of the service and the skills required for safe and effective delivery of that service are considered in deciding whether a service is a skilled service. While a patient's particular medical condition is a valid factor in deciding if skilled services are needed, a patient's diagnosis or prognosis should never be the sole factor in deciding that a service is not skilled.

EXAMPLE: Even where a patient's full or partial recovery is not possible, a skilled service still could be needed to prevent deterioration or to maintain current capabilities. A cancer patient, for instance, whose prognosis is terminal may require skilled services at various stages of his illness in connection with periodic "tapping" to relieve fluid accumulation and nursing assessment and intervention to alleviate pain or prevent deterioration. The fact that there is no potential for such a patient's recovery does not alter the character of the services and skills required for their performance.

When rehabilitation services are the primary services, the key issue is whether the skills of a therapist are needed. The deciding factor is not the patient's potential for recovery, but whether the services needed require the skills of a therapist or whether they can be carried out by nonskilled personnel. (See §214.3.A.)

Rev. 262/Page 2-16.1


214.1 (Cont.)    COVERAGE OF SERVICES    12-87

  • A service that is ordinarily considered nonskilled could be considered a skilled service in cases in which, because of special medical complications, skilled nursing or skilled rehabilitation personnel are required to perform or supervise it or to observe the patient. In these cases, the complications and special services involved must be documented by physicians' orders and nursing or therapy notes.

EXAMPLE: The existence of a plaster cast on an extremity generally does not indicate a need for skilled care. However, a patient with a preexisting acute skin problem, preexisting peripheral vascular disease, or a need for special traction of the injured extremity might need skilled nursing or skilled rehabilitation personnel to observe for complications or to adjust traction.
EXAMPLE: Whirlpool baths do not ordinarily require the skills of a qualified physical therapist. However, the skills, knowledge, and judgment of a qualified physical therapist might be required where the patient's condition is complicated by circulatory deficiency, areas of desensitization, or open wounds.

  • In determining whether services rendered in an SNF constitute covered care, it is necessary to determine whether individual services are skilled, and whether, in light of the patient's total condition, skilled management of the services provided is needed even though many or all of the specific services were unskilled.

EXAMPLE: An 81-year-old woman who is aphasic and confused, suffers from hemiplegia, congestive heart failure, and atrial fibrillation, has suffered a cerebrovascular accident, is incontinent and has a Grade 1 decubitus ulcer, and is unable to communicate and make her needs known. Even though no specific service provided is skilled, the patient's condition requires daily skilled nursing involvement to manage a plan for the total care needed, to observe the patient's progress, and to evaluate the need for changes in the treatment plan.

  • The importance of a particular service to an individual patient, or the frequency with which it must be performed, does not, by itself, make it a skilled service.
EXAMPLE: A primary need of a nonambulatory patient may be frequent changes of position in order to avoid development of decubitus ulcers. However, since such changing of position does not ordinarily require skilled nursing or skilled rehabilitation personnel, it would not constitute a skilled service, even though such services are obviously necessary.

The possibility of adverse effects from the improper performance of an otherwise unskilled service does not make it a skilled service unless there is documentation to support the need for skilled nursing or skilled rehabilitation personnel. Although the act of turning a patient normally is not a skilled service, for some patients the skills of a nurse may be necessary to assure proper body alignment in order to avoid contractures and deformities. In all such cases, the reasons why skilled nursing or skilled rehabilitation personnel are essential must be documented in the patient's record.

Page 2-16.2/Rev. 262


12-87    COVERAGE OF SERVICES    214.1 (Cont.)

  1. Specific Examples of Some Skilled Nursing or Skilled Rehabilitation Services

    1. Management and Evaluation of a Patient Care Plan.--The development, management, and evaluation of a patient care plan, based on the physician's orders, constitute skilled nursing services when, in terms of the patient's physical or mental condition, these services require the involvement of skilled nursing personnel to meet the patient's medical needs, promote recovery, and ensure medical safety. However, the planning and management of a treatment plan that does not involve the furnishing of skilled services may not require skilled nursing personnel; e.g., a care plan for a patient with organic brain syndrome who requires only oral medication and a protective environment. Skilled management would be required where the sum total of unskilled services which are a necessary part of the medical regimen, when considered in light of the patient's overall condition, makes the involvement of skilled nursing personnel necessary to promote the patient's recovery and medical safety.

EXAMPLE 1: An aged patient with a history of diabetes mellitus and angina pectoris is recovering from an open reduction of the neck of the femur. He requires, among other services, careful skin care, appropriate oral medications, a diabetic diet, a therapeutic exercise program to preserve muscle tone and body condition, and observation to notice signs of deterioration in his condition or complications resulting from his restricted (but increasing) mobility. Although any of the required services could be performed by a properly instructed person, that person would not have the capability to understand the relationship among the services and their effect on each other. Since the nature of the patient's condition, his age and his immobility create a high potential for serious complications, such an understanding is essential to assure the patient's recovery and safety. The management of this plan of care requires skilled nursing personnel until the patient's treatment regimen is essentially stabilized, even though the individual services involved are supportive in nature and do not require skilled nursing personnel.
EXAMPLE 2: An aged patient is recovering from pneumonia, is lethargic, is disoriented, has residual chest congestion, is confined to bed as a result of his debilitated condition, and requires restraints at times. To decrease the chest congestion, the physician has prescribed frequent changes in position, coughing, and deep breathing. While the residual chest congestion alone would not represent a high risk factor, the patient's immobility and confusion represent complicating factors which, when coupled with the chest congestion, could create high probability of a relapse. In this situation, skilled overseeing of the nonskilled services would be reasonable and necessary, pending the elimination of the chest congestion, to assure the patient's medical safety.

  1. Observation and Assessment of Patient's Condition.--Observation and assessment are skilled services when the likelihood of change in a patient's condition requires skilled nursing or skilled rehabilitation personnel to identify and evaluate the patient's need for possible modification of treatment or initiation of additional medical procedures, until the patient's treatment regimen is essentially stabilized.

Rev. 262/Page 2-17


214.1 (Cont.)    COVERAGE OF SERVICES    12-87

EXAMPLE 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.

EXAMPLE 2: A patient has undergone peripheral vascular disease treatment including revascularization procedures (bypass) with open or necrotic areas of skin on the involved extremity. Skilled observation and monitoring of the vascular supply of the legs is required.

EXAMPLE 3: A patient has undergone hip surgery and has been transferred to an SNF. Skilled observation and monitoring of the patient for possible adverse reaction to the operative procedure, development of phlebitis, skin breakdown, or need for the administration of subcutaneous Heparin, is both reasonable and necessary.

EXAMPLE 4: A patient has been hospitalized following a heart attack and, following treatment but before mobilization, is transferred to the SNF. Because it is unknown whether exertion will exacerbate the heart disease, skilled observation is reasonable and necessary as mobilization is initiated, until the patient's treatment regimen is essentially stabilized.

EXAMPLE 5: A frail 85-year-old man was hospitalized for pneumonia. The infection was resolved, but the patient, who had previously maintained adequate nutrition, will not eat or eats poorly. The patient is transferred to an SNF for monitoring of fluid and nutrient intake, assessment of the need for tube feeding and forced feeding if required. Observation and monitoring by skilled nursing personnel of the patient's oral intake is required to prevent dehydration.

If a patient was admitted for skilled observation but did not develop a further acute episode or complication, the skilled observation services still are covered so long as there was a reasonable probability for such a complication or further acute episode. "Reasonable probability" means that a potential complication or further acute episode was a likely possibility.

Skilled observation and assessment may also be required for patients whose primary condition and needs are psychiatric in nature or for patients who, in addition to their physical problems, have a secondary psychiatric diagnosis. These patients may exhibit acute psychological symptoms such as depression, anxiety or agitation, which require skilled observation and assessment such as observing for indications of suicidal or hostile behavior. However, these conditions often require considerably more specialized, sophisticated nursing techniques and physician attention than is available in most participating SNFs. (SNFs that are primarily engaged in treating psychiatric disorders are precluded by law from participating in Medicare.) Therefore, these cases must be carefully documented.

Page 2-17.1/Rev. 262


12-87    COVERAGE OF SERVICES     214.2

    1. Teaching and Training Activities.--Teaching and training activities which require skilled nursing or skilled rehabilitation personnel to teach a patient how to manage his treatment regimen would constitute skilled services. Some examples are:

      • Teaching self-administration of injectable medications or a complex range of medications;

      • Teaching a newly diagnosed diabetic to administer insulin injections, to prepare and follow a diabetic diet, and to observe foot-care precautions;

      • Teaching self-administration of medical gases to a patient;

      • Gait training and teaching of prosthesis care for a patient who has had a recent leg amputation;

      • Teaching patients how to care for a recent colostomy or ileostomy;

      • Teaching patients how to perform self-catheterization and self-administration of gastrostomy feedings;

      • Teaching patients how to care for and maintain central venous lines, such as Hickman catheters;

      • Teaching patients the use and care of braces, splints and orthotics, and any associated skin care; and

      • Teaching patients the proper care of any specialized dressings or skin treatments.

  1. Questionable Situations.--There must be specific evidence that daily skilled nursing or skilled rehabilitation services are required and received if:

    • The primary service needed is oral medication; or

    • The patient is capable of independent ambulation, dressing, feeding, and hygiene.

214.2    Direct Skilled Nursing Services to Patients.--Some examples of direct skilled nursing services are:

  • Intravenous, intramuscular or subcutaneous injections and hypodermoclysis or intravenous feeding (although giving an insulin injection is considered a skilled service, it is customary to teach patients to self-administer such an injection; if self-injection cannot be learned, however, insulin injection is a skilled service);

  • Nasogastric tube, gastrostomy, and jejunostomy feedings;

  • Naso-pharyngeal and tracheotomy aspiration;

Rev. 262/Page 2-17.2


214.3    COVERAGE OF SERVICES    12-87

  • Insertion, sterile irrigation, and replacement of catheters; care of a suprapubic catheter and, in selected patients, urethral catheter (the mere presence of a urethral catheter, particularly one placed for convenience or the control of incontinence, does not justify a need for skilled nursing care. On the other hand, the insertion and maintenance of a urethral catheter as an adjunct to the active treatment of disease of the urinary tract may justify a need for skilled nursing care. In such instances, the need for a urethral catheter must be justified and documented in the patient's medical record; i.e., it must be established that it is reasonable and necessary for the treatment of the patient's condition.);

  • Application of dressings involving prescription medications and aseptic techniques (see §214.4 for exception);

  • Treatment of decubitus ulcers, of a severity rated at Grade 3 or worse, or a widespread skin disorder (see §214.4 for exception);

  • Heat treatments which have been specifically ordered by a physician as part of active treatment and which require observation by skilled nursing personnel to adequately evaluate the patient's progress (see §214.4 for exception);

  • Rehabilitation nursing procedures, including the related teaching and adaptive aspects of nursing, that are part of active treatment and require the presence of skilled nursing personnel; e.g., the institution and supervision of bowel and bladder training programs;

  • Initial phases of a regimen involving administration of medical gases such as bronchodilator therapy; and

  • Care of a colostomy during the early postoperative period in the presence of associated complications. The need for skilled nursing care during this period must be justified and documented in the patient's medical record.

214.3    Direct Skilled Rehabilitation Services to Patients

  1. Skilled Physical Therapy

    1. General.--Skilled physical therapy services must meet all of the following conditions:

      • The services must be directly and specifically related to an active written treatment plan designed by the physician after any needed consultation with a qualified physical therapist;

      • The services must be of a level of complexity and sophistication, or the condition of the patient must be of a nature that requires the judgment, knowledge, and skills of a qualified physical therapist;

Page 2-17.3/Rev. 262


12-87    COVERAGE OF SERVICES    214.3 (Cont.)

  • The services must be provided with the expectation, based on the assessment made by the physician of the patient's restoration potential, that the condition of the patient will improve materially in a reasonable and generally predictable period of time, or the services must be necessary for the establishment of a safe and effective maintenance program;

  • The services must be considered under accepted standards of medical practice to be specific and effective treatment for the patient's condition; and

  • The services must be reasonable and necessary for the treatment of the patient's condition; this includes the requirement that the amount, frequency, and duration of the services must be reasonable.

EXAMPLE 1: An 80-year-old, previously ambulatory, post-surgical patient has been bedbound for one week and, as a result, has developed muscle atrophy, orthostatic hypotension, joint stiffness and lower extremity edema. To the extent that the patient requires a brief period of daily skilled physical therapy services to restore lost functions, those services are reasonable and necessary.

EXAMPLE 2: A patient with congestive heart failure also has diabetes and previously had both legs amputated above the knees. Consequently, the patient does not have a reasonable potential to achieve ambulation, but still requires daily skilled physical therapy to learn bed mobility and transferring skills, as well as functional activities at the wheelchair level. If the patient has a reasonable potential for achieving those functions in a reasonable period of time in view of the patient's total condition, the physical therapy services are reasonable and necessary.

If the expected results are insignificant in relation to the extent and duration of physical therapy services that would be required to achieve those results, the physical therapy would not be reasonable and necessary, and thus would not be covered skilled physical therapy services.

Many SNF inpatients do not require skilled physical therapy services but do require services which are routine in nature. Those services can be performed by supportive personnel; e.g., aides or nursing personnel, without the supervision of a physical therapist. Such services, as well as services involving activities for the general good and welfare of patients (e.g., general exercises to promote overall fitness and flexibility and activities to provide diversion or general motivation) do not constitute skilled physical therapy.

  1. Application of Guidelines.--Some of the more common physical therapy modalities and procedures are:

    1. Assessment.--The skills of a physical therapist are required for the ongoing assessment of a patient's rehabilitation needs and potential. Skilled rehabilitation services concurrent with the management of a patient's care plan include tests and measurements of range of motion, strength, balance, coordination, endurance, and functional ability.

Rev. 262/Page 2-17.4


214.3 (Cont.)    COVERAGE OF SERVICES    12-87

  1. Therapeutic Exercises.--Therapeutic exercises which must be performed by or under the supervision of the qualified physical therapist, due either to the type of exercise employed or to the condition of the patient, constitute skilled physical therapy.

  2. Gait Training.--Gait evaluation and training furnished a patient whose ability to walk has been impaired by neurological, muscular, or skeletal abnormality require the skills of a qualified physical therapist and constitute skilled physical therapy if they reasonably can be expected to improve significantly the patient's ability to walk.

    Repetitious exercises to improve gait, or to maintain strength and endurance, and assistive walking are appropriately provided by supportive personnel, e.g., aides or nursing personnel, and do not require the skills of a physical therapist. Thus, such services are not skilled physical therapy.

  3. Range of Motion.--Only the qualified physical therapist may perform range of motion tests and, therefore, such tests are skilled physical therapy. Range of motion exercises constitute skilled physical therapy only if they are part of active treatment for a specific disease state which has resulted in a loss or restriction of mobility (as evidenced by physical therapy notes showing the degree of motion lost and the degree to be restored).

    Range of motion exercises which are not related to the restoration of a specific loss of function often may be provided safely by supportive personnel, such as aides or nursing personnel, and may not require the skills of a physical therapist. Passive exercises to maintain range of motion in paralyzed extremities that can be carried out by aides or nursing personnel would not be considered skilled care.

  4. Maintenance Therapy.--The repetitive services required to maintain function sometimes involve the use of complex and sophisticated therapy procedures and, consequently, the judgment and skill of a physical therapist might be required for the safe and effective rendition of such services. (See §214.1.B.) The specialized knowledge and judgment of a qualified physical therapist may be required to establish a maintenance program intended to prevent or minimize deterioration caused by a medical condition, if the program is to be safely carried out and the treatment aims of the physician achieved. Establishing such a program is a skilled service.
EXAMPLE: A Parkinson's patient who has not been under a restorative physical therapy program may require the services of a physical therapist to determine what type of exercises are required for the maintenance of his present level of function. The initial evaluation of the patient's needs, the designing of a maintenance program which is appropriate to the capacity and tolerance of the patient and the treatment objectives of the physician, the instruction of the patient or supportive personnel (e.g., aides or nursing personnel) in the carrying out of the program, and such infrequent reevaluations as may be required, would constitute skilled physical therapy.

While a patient is under a restorative physical therapy program, the physical therapist should regularly reevaluate his condition and adjust any exercise program the patient is expected to carry out himself or with the aid of supportive personnel to maintain the

Page 2-18/Rev. 262


12-87    COVERAGE OF SERVICES    214.4

function being restored. Consequently, by the time it is determined that no further restoration is possible, i.e., by the end of the last restorative session, the physical therapist will have already designed the maintenance program required and instructed the patient or supportive personnel in the carrying out of the program.

    1. Ultrasound, Shortwave, and Microwave Diathermy Treatments.--These modalities must always be performed by or under the supervision of a qualified physical therapist and are skilled physical therapy.

    2. Hot Packs, Infra-Red Treatments, Paraffin Baths and Whirlpool Baths.--Heat treatments and baths of this type ordinarily do not require the skills of a qualified physical therapist. However, the skills, knowledge, and judgment of a qualified physical therapist might be required in the giving of such treatments or baths in a particular case, e.g., where the patient's condition is complicated by circulatory deficiency, areas of desensitization, open wounds, fractures or other complications.

  1. Speech Pathology.--See §230.3.B.

  2. Occupational Therapy.--See §230.3.C.

214.4    Nonskilled Supportive or Personal Care Services.--The following services are not skilled services unless rendered under circumstances detailed in §214.1.B:

  • Administration of routine oral medications, eye drops, and ointments (the fact that a patient cannot be relied upon to take such medications himself or that State law requires all medications to be dispensed by a nurse to institutional patients would not change this service to a skilled service);

  • General maintenance care of colostomy and ileostomy;

  • Routine services to maintain satisfactory functioning of indwelling bladder catheters (this would include emptying containers and cleaning them, and clamping tubing);

  • Changes of dressings for noninfected postoperative or chronic conditions;

  • Prophylactic and palliative skin care, including bathing and application of creams, or treatment of minor skin problems;

  • Routine care of the incontinent patient, including use of diapers and protective sheets;

  • General maintenance care in connection with a plaster cast (skilled supervision or observation may be required where the patient has a preexisting skin or circulatory condition or needs to have traction adjusted);

  • Routine care in connection with braces and similar devices;

Rev. 262/Page 2-19


214.5    COVERAGE OF SERVICES    12-87

  • Use of heat as a palliative and comfort measure, such as whirlpool or steam pack;

  • Routine administration of medical gases after a regimen of therapy has been established (i.e., administration of medical gases after the patient has been taught how to institute therapy);

  • Assistance in dressing, eating, and going to the toilet;

  • Periodic turning and positioning in bed; and

  • 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. (This includes the actual carrying out of maintenance programs where the performance of repetitive exercises that may be required to maintain function do not necessitate a need for the involvement and services of skilled rehabilitation personnel. It also includes the carrying out of repetitive exercises to improve gait, maintain strength or endurance; passive exercises to maintain range of motion in paralyzed extremities which are not related to a specific loss of function; and assistive walking.) (See §230.3.A.2(d).)

214.5    Daily Skilled Services--Defined.--Skilled nursing services or skilled rehabilitation services (or a combination of these services) must be needed and provided on a "daily basis," i.e., on essentially a 7-day-a-week basis. However, if skilled rehabilitation services are not available on a 7-day-a-week basis, a patient whose inpatient stay is based solely on the need for skilled rehabilitation services would meet the "daily basis" requirement when he needs and receives those services on at least 5 days a week. Accordingly, if a facility provides physical therapy on only 5 days a week and a patient in the facility requires and receives physical therapy on each of those days, the requirement that skilled rehabilitation services be provided on a daily basis is met. (If the services are available less than 5 days a week, though, the "daily" requirement would not be met.)

This requirement should not be applied so strictly that it would not be met merely because there is an isolated break of a day or two during which no skilled rehabilitation services are furnished and discharge from the facility would not be practical.

EXAMPLE: A patient who normally requires skilled rehabilitation services on a daily basis may exhibit extreme fatigue which results in suspending therapy sessions for a day or two. Coverage may continue for these days since discharge in such a case would not be practical.

214.6    Services Provided on an Inpatient Basis as a "Practical Matter".--In determining whether the daily skilled care needed by an individual can, as a "practical matter," only be provided in an SNF on an inpatient basis, the individual's physical condition and the availability and feasibility of using more economical alternative facilities or services are considered.

As a "practical matter," daily skilled services can be provided only in an SNF if they are not available on an outpatient basis in the area in which the individual resides or transportation to the closest facility would be:

Page 2-20/Rev. 262


12-87    COVERAGE OF SERVICES    214.6 (Cont.)

  • An excessive physical hardship;

  • Less economical; or

  • Less efficient or effective than an inpatient institutional setting.

The availability at home of capable and willing family or the feasibility of obtaining other assistance for the patient should be considered. Even though needed daily skilled services might be available on an outpatient or home care basis, as a practical matter, the care can be furnished only in the SNF if home care would be ineffective because the patient would have insufficient assistance at home to reside there safely.

EXAMPLE: A patient undergoing restorative physical therapy can walk only with supervision but has a reasonable potential to learn to walk independently with further training. Further daily skilled therapy is available on an outpatient or home care basis, but the patient would be at risk of further injury from falling, of dehydration or of malnutrition because insufficient supervision or assistance could be arranged for the patient in his home. In these circumstances, the physical therapy services as a practical matter can be provided effectively only in the inpatient setting.

  1. The Availability of Alternative Facilities or Services.--Alternative facilities or services may be available to a patient if health care providers such as home health agencies were utilized. These alternatives are not always available in all communities and even where they exist they may not be available when needed.

EXAMPLE: Where the residents of a rural community generally utilize the outpatient facilities of a hospital located some distance from the area, the hospital outpatient department constitutes an alternative source of care that is available to the community. Roads in winter, however, may be impassable for some periods of time and in special situations institutionalization might be needed.

In determining the availability of more economical care alternatives, the coverage or noncoverage of that alternative care is not a factor to be considered. Home health care for a patient who is not homebound, for example, may be an appropriate alternative in some cases. The fact that such care cannot be covered by Medicare is irrelevant.

The issue is feasibility and not whether coverage is provided in one setting and not provided in another. For instance, an individual in need of daily skilled physical therapy might be able to receive the services needed on a more economical basis from an independently practicing physical therapist. However, the fact that Medicare reimbursement could not be made for the services because the $500 expense limitation applicable to the services of an independent physical therapist had been exceeded or because the patient was not enrolled in Part B, would not be a basis for determining that, as a practical matter, the needed care could only be provided in a SNF.

Rev. 262/Page 2-21


214.6 (Cont.)    COVERAGE OF SERVICES    12-87

In determining the availability of alternate facilities or services, whether the patient or another resource can pay for the alternate services is not a factor to be considered.<>

  1. Whether Available Alternatives are More Economical in the Individual Case.--If a generally more economical care alternative is available to provide the needed care, whether the use of the alternative actually would be more economical in the individual case is considered.

EXAMPLE 1: If a patient's condition requires daily transportation to the alternative source of care (e.g., a hospital outpatient department) by ambulance, it might be more economical from a health care delivery viewpoint to provide the needed care in the SNF setting.

EXAMPLE 2: If needed care could be provided in the home, but the patient's residence is so isolated that daily visits would entail inordinate travel costs, care in an SNF might be a more economical alternative.

  1. Whether the Patient's Physical Condition Would Permit Him to Utilize an Available, More Economical Care Alternative.--In determining the practicality of using more economical care alternatives, the patient's medical condition should be considered. If the use of those alternatives would adversely affect the patient's medical condition, then as a practical matter the daily skilled services can only be provided by an SNF on an inpatient basis.

If the use of a care alternative involves transportation of the individual on a daily basis, whether daily transportation would cause excessive physical hardship is considered. Determinations on whether a patient's condition would be adversely affected if an available, more economical care alternative were utilized should not be based solely on the fact that the patient is nonambulatory. There are individuals confined to wheelchairs who, though nonambulatory, could be transported daily by automobile from their homes to alternative care sources without any adverse impact. Conversely, there are instances where an individual's condition would be adversely affected by daily transportation to a care facility, even though he is able to ambulate to some extent.

EXAMPLE: A 75-year-old woman has suffered a cerebrovascular accident and cannot climb stairs with safety. The patient lives alone in a second-floor apartment accessible only by climbing a flight of stairs. She requires physical therapy and occupational therapy on alternate days, and they are only available in a CORF one mile away from her apartment. However, because of her inability to negotiate the stairs, the daily skilled services she requires cannot, as a practical matter, be provided to the patient outside the SNF.

Page 2-22/Rev. 262


09-92    COVERAGE OF SERVICES    214.7

Do not interpret the "practical matter" criterion so strictly that it results in the automatic denial of coverage for patients who have been meeting all of the SNF level of care requirements but who have occasion to be away from the SNF for a brief period of time. While most beneficiaries requiring an SNF level of care find that they are unable to leave the facility for even the briefest of time, the fact that a patient is granted an outside pass, or short leave of absence, for the purpose of attending a special religious service, holiday meal or family occasion, for going on a ride or for a trial visit home, is not by itself evidence that the individual no longer needs to be in a SNF to receive required skilled care. Very often special arrangements, not feasible on a daily basis, have had to be made to allow for absence from the facility. Where frequent or prolonged periods away from the SNF become possible, however, then questions as to whether the patient's care can, as a practical matter, only be furnished on an inpatient basis in an SNF may be raised. Base decisions in these cases on information reflecting the care needed and received by the patient while in the SNF and on the arrangements needed for the provision, if any, of this care during any absences. (See §242.3 for counting inpatient days during a leave of absence.)

A conservative approach to retain the presumption for waiver of liability may lead a facility to notify patients that leaving the facility will result in denial of coverage. Such a notice is not appropriate. If an SNF determines that covered care is no longer needed, the situation does not change whether the patient actually leaves the facility or not. (See §356.2.)

214.7    Prohibition Against Use of "Rules of Thumb" in Medicare Review Determinations.--Do not notify patients that services are not covered by Medicare because of "rules of thumb" such as lack of restoration potential, ability to walk a certain number of feet, degree of stability, or because of general inferences about patients with similar diagnosis or general data related to utilization. A decision as to whether care is covered by Medicare must be made based on thorough analysis of the patient's total condition and individual need for care.

(next page is 2-24.1)


Rev. 315/Page 2-23


09-91    COVERAGE OF SERVICES    220.2

220.    PHYSICIAN CERTIFICATION AND RECERTIFICATION

Payment for covered posthospital extended care services is made if a physician certifies and, where services are furnished over a period of time, recertifies the need for them.

Obtain and retain the physician certification and recertification statements. Your intermediary may request them. Determine how to obtain the physician's certification and recertification statements. There is no requirement for a specific procedure or form as long as the approach permits a verification that the certification and recertification requirement is met. They may be entered or included in forms, notes, or other records a physician normally signs in caring for a patient, or on a separate form. Except as otherwise specified (see §220.5), each certification and recertification is to be signed by a physician.

If your failure to obtain a certification or recertification is not due to a question of the necessity for the services, but to the physician's refusal to certify on other grounds (e.g., he/she objects in principle to the concept of certification and recertification), do not charge the beneficiary for covered items or services. Your provider agreement precludes you from doing so.

If a physician refuses to certify because, in his/her opinion, the patient does not need, on a daily basis, skilled nursing or rehabilitation services, which as a practical matter can only be provided in an SNF on an inpatient basis, for either a condition for which he/she received inpatient hospital services, or for a condition which arose after transfer while in the SNF for treatment of a condition for which he/she received inpatient hospital services, the services are not covered. Document the reason for the physician's refusal to certify in your records. Adequate documentation consists of a statement in your records, signed by a physician or a responsible official, indicating that the patient's physician feels that the patient does not need, on a daily basis, skilled nursing or rehabilitation services for a condition for which he/she received inpatient hospital services.

220.1    Who May Sign Certification or Recertification.--A certification or recertification statement is signed by the attending physician or a physician on the staff who has knowledge of the case.

A doctor of podiatric medicine is a physician for purposes of certification and recertification of the medical necessity of covered services provided that the performance of these functions is consistent with the scope of the professional services as authorized under applicable State law.

220.2    Certification.--The certification must clearly indicate that posthospital extended care services were required on an inpatient basis because of the individual's need on a daily basis, for skilled nursing or rehabilitation services, for either a condition for which he/she received inpatient hospital services prior to the transfer to the SNF, or for a condition which arose after transfer while he/she was still in the SNF for treatment of a condition for which he/she received inpatient hospital services. Certifications must be

Rev. 304/Page 2-24.1


03-02
GENERAL INFORMATION ABOUT THE PROGRAM
220.4

obtained at the time of admission, or as soon thereafter as is reasonable and practicable. The routine admission procedure followed by a physician would not be sufficient certification of the necessity for posthospital extended care services for purposes of the program.

If ambulance service is furnished by an SNF, and additional certification is required, it may be furnished by any physician who has sufficient knowledge of the patient's case including the physician who requested the ambulance or the physician who examines the patient upon his arrival at the facility. The physician must certify that the ambulance service was medically required.

In addition, physician's certifications are required for the rental and purchase of durable medical equipment (see §264) and outpatient physical therapy and outpatient speech pathology services. (See §271.1.)

220.3    Recertification.--The recertification statement must meet the following standards as to its contents: it must contain an adequate written record of the reasons for continued need for extended care services, the estimated period of time the patient will need to remain in the facility, and any plans, where appropriate, for home care. The recertification statement made by the physician has to meet the content standards, unless, for example, all of the required information is in fact included in progress notes, in which case the physician's statement could indicate that the individual medical record contains the required information and that continued posthospital extended care services are medically necessary. A statement reciting only that continued extended care services are medically necessary is not, in and of itself, sufficient.

A certification may be mailed, faxed or completed when the physician is onsite.

If the circumstances require it, the first recertification must state that the continued need for a condition requiring such services which arose after the transfer from the hospital and while the patient was still in the facility for treatment of the condition(s) for which he had received inpatient hospital services.

Where the requirements for the second or subsequent recertification are satisfied by review of a stay of extended duration, pursuant to the utilization review (UR) plan, a separate recertification statement is not required. It is sufficient if the records of the UR committee show consideration was given to the recertification content standards. See §251B for requirements regarding certification for presumed coverage cases.

220.4    Timing of Recertifications.--The first recertification must be made no later than the 14th day of inpatient extended care services. An SNF can, at its option, provide for the first recertification to be made earlier, or it can vary the timing of the first recertification within the 14-day period by diagnostic or clinical

Rev. 372
  
2-25

220.5
GENERAL INFORMATION ABOUT THE PROGRAM
03-02

categories. Subsequent recertifications must be made at intervals not exceeding 30 days. Such recertifications may be made at shorter intervals as established by the UR committee and the SNF.

At the option of the SNF, review of a stay of extended duration, pursuant to the facility's utilization review plan, may take the place of the second and any subsequent physician recertifications. The SNF should have available in its files a written description of the procedure it adopts with respect to the timing of recertifications. The procedure should specify the intervals at which recertifications are required, and whether review of long-stay cases by the UR committee serves as an alternative to recertification by a physician in the case of the second or subsequent recertifications.

220.5    Delayed Certifications and Recertifications.--SNFs are expected to obtain timely certification and recertification statements. However, delayed certifications and recertifications will be honored where, for example, there has been an oversight or lapse.

In addition to complying with the content requirements, delayed certifications and recertifications must include an explanation for the delay and any medical or other evidence which the SNF considers relevant for purposes of explaining the delay. The facility will determine the format of delayed certification and recertification statements, and the method by which they are obtained. A delayed certification and recertification may appear in one statement; separate signed statements for each certification and recertification would not be required as they would if timely certification and recertification had been made.

220.6    Disposition of Certification and Recertification Statements.--Except for "presumed coverage" cases (see §250), skilled nursing facilities do not have to transmit certification and recertification statements to the intermediary or the Centers for Medicare and Medicaid Services (CMS). Instead, they must be maintained in the SNF medical record.

Extended Care Services Covered Under Hospital Insurance

230.    COVERED EXTENDED CARE SERVICES

  1. Payment for Extended Care Services.--Patients covered under hospital insurance are entitled to have payment made on their behalf for covered extended care services furnished by the facility, by others under arrangements with the facility, or by a hospital with which the facility has a transfer agreement. Effective with the start of the first cost reporting period on or after July 1, 1998, inpatient SNF services are paid under a prospective payment system. (See §211.) If the items or

2-26
  
Rev. 372

06-83    COVERAGE OF SERVICES    230.l

services were requested by the patient, the facility may charge him the difference between the amount customarily charged for the services requested and the amount customarily charged for covered services.

  1. Inpatient Defined.--An inpatient is a person who has been admitted to a skilled nursing facility or a swing bed hospital for bed occupancy for purposes of receiving inpatient services. A person is considered an inpatient if formally admitted as an inpatient with the expectation that he will remain at least overnight and occupy a bed even though it later develops that he can be discharged and does not actually use a bed overnight.

NOTE 1: When patients requiring inpatient hospital services occupy beds in an SNF, they are considered inpatients of the SNF. In such cases, the services furnished in the SNF may not be considered inpatient hospital services, and payment may not be made under the program for such services. Such a situation may arise where the SNF is a distinct part of an institution the remainder of which is a hospital, and either there is no bed available in the hospital or for any other reason the institution fails to place the patient in the appropriate bed. The same rule applies where the SNF is a separate institution. For the same reason, where patients who require extended care services are admitted to beds in a hospital, payment cannot be made on their behalf for the services furnished to them in the hospital unless the services are extended care services furnished pursuant to a swing bed approval granted to the hospital by the Secretary of Health and Human Services. (See sections 201.3.)

NOTE 2: When patients who require SNF services are placed in a noncertified part of an institution which contains a participating "distinct part" SNF, the services may be paid under certain conditions, based on an interpretation of the waiver of liability provisions. (See §§ 351.4 - 351.5B.)

230.l    Nursing Care Provided by or under the Supervision of a Registered Professional Nurse.--

NOTE: The services of a private-duty nurse or other private-duty attendant are not covered. Private-duty nurses or private-duty attendants are registered professional nurses, licensed practical nurses, or any other trained attendant whose services ordinarily are rendered to, and restricted to, a particular patient by arrangement between the patient and the private-duty nurse or attendant. Such persons are engaged or paid by an individual patient or by someone acting on his behalf, including an SNF that initially incurs the cost and looks to the patient for reimbursement for such noncovered services.

Where the SNF acts on behalf of a patient, the services of the private-duty nurse or other attendant under such an arrangement are not extended care services regardless of the control which the SNF may exercise with respect to the services rendered by such private-duty nurse or attendant.

Rev. 205/Page 2-27


230.2    COVERAGE OF SERVICES    06-83

230.2    Bed and Board.--

  1. Accommodations--General.--Regulations of the Department of Health and Human Services provide for apportionment of routine service costs on the basis of average per diem cost under both the Departmental and the Combination methods of cost apportionment. Thus, the program pays the same amount for routine services whether the patient has a private room not medically necessary, a private room medically necessary (Medicare does not pay for deluxe accommodations), or ward accommodations, if its ward accommodations are consistent with program purposes. (See F below.)

    A skilled nursing facility having both private and semiprivate accommodations may nevertheless charge a differential for a private room if:

    1. The private room is not medically necessary; and

    2. The patient (or relative or other person acting on his behalf) has requested the private room, and the SNF informs him at the time of the request of the amount of the charge.

The private room differential may not exceed the difference between the customary charge for the accommodations furnished and the most prevalent semiprivate accommodation rate at the time of the patient's admission.

When the SNF bills for a private room as a covered service, i.e., shows the charge for the room as a covered charge on the HCFA-1453, the intermediary will deem the private room to be medically necessary. Where the provider, on the other hand, shows a private room differential as a noncovered charge, the intermediary will assume that the private room is not medically necessary.

Where it is necessary to develop the medical necessity of a private room, the guidelines in subsections B and C will apply.

  1. Medical Necessity: Need for Isolation.--A private room is medically necessary where isolation of a beneficiary is required to avoid jeopardizing his health or recovery, or that of other patients who are likely to be alarmed or disturbed by the beneficiary's symptoms or treatment or subjected to infection by the beneficiary's communicable disease. For example, communicable diseases, heart attacks, cerebrovascular accidents, and psychotic episodes may require isolation of the patient for certain periods. (See C below concerning medical necessity not based on the need for isolation.)

Page 2-28/Rev. 205


6-79    COVERAGE OF SERVICES    230.2 (Cont.)

In establishing the medical necessity for isolation, the date of the physician's written statement is not controlling, nor is the presence of a written statement. The crucial question is whether a private room was ordered by the physician because it is necessary for the health of the patient himself or of other patients. In the absence of such an order, a patient who requested the room with knowledge of the amount of the charge may be charged appropriately, even though a physician subsequently submits a statement that the room was medically necessary. There may be cases in which the physician's written statement of medical necessity, though dated after admission or even after discharge, merely confirms an order may informally at or before the time the beneficiary was admitted to the private room (e.g., the physician made arrangements by phone for the patient's admission, gave the diagnosis, and stated the beneficiary would need a private room). In such cases, assuming that the private room was medically necessary, the lack of a written statement by the physician, or the fact that the written statement was prepared after discharge, would not be controlling. The patient may not be charged.

  1. Medical Necessity: Admission Required and Only Private Rooms Available.--Medical necessity is considered to exist if an SNF where semiprivate and ward accommodations are unavailable and admission cannot be deferred until such accommodations become available because it would endanger the beneficiary's health or recovery, require that the beneficiary's hospitalization be prolonged after he is ready for discharge to an SNF, or require that he forfeit program coverage by delaying admission beyond the applicable transfer period. (See §212.3.)

It need not be considered whether semiprivate or ward accommodations were available in some other accessible SNF. Where medical necessity exists, the provider may not charge the beneficiary a private-room differential until semiprivate or ward accommodations become available. Thereafter the provider may transfer the patient to the nonprivate accommodations, or allow him to continue occupancy of the private room, subject to an appropriate differential charge (described in A above) if he requests the private room with knowledge of the amount of the charge.

If the admission could be deferred until semiprivate or ward accommodations become available, the beneficiary should be informed of the amount of the differential he must pay for a private room if he wishes to be admitted immediately; the beneficiary may be charge the specified differential if he has been admitted to the private room at his request (or at the request of his representative) with knowledge of the amount of the charge.

Rev. 165/Page 2-29


230.2 (Cont.)    COVERAGE OF SERVICES    6-79

  1. Charges for Deluxe Private Room.--A beneficiary found to need a private room (either because he needs isolation for medical reason or because he needs immediate admission when no other accommodations are available) may be assigned to any private room in the SNF. He does not have the right to insist on the private room of his choice, but his preference should be given the same consideration as if he were paying all SNF charges himself. The program does not, under any circumstances, pay for personal comfort items. Thus, the program does not pay for deluxe accommodations and/or services; these would include a suite, or a room substantially more spacious than is required for treatment, or specially equipped or decorated, or serviced for the comfort and convenience of persons willing to pay a differential for such amenities. If he (or his representative) requests such deluxe accommodations, the SNF should advise that there will be a charge, not covered by Medicare, of a specified amount per day (not exceeding the differential defined in the next sentence) and may charge him that amount for each day he occupies the deluxe accommodations. The maximum amount he may be charged for such accommodations is the differential between the most prevalent private room rate at the time of admission and the customary charge for the room occupied. The beneficiary may not be charge this differential if he (or his representative) does not request the deluxe accommodations.

    The beneficiary may not be charged such a differential in private room rates if that differential is based on factors other than personal comforts items. Such factors might include difference between older and newer wings, proximity to lounge, elevators or nursing stations, desirable view, etc. Such rooms are standard one-bed units and not deluxe rooms for purpose of this instruction, even though the SNF may call them deluxe and have a higher customary charge for them. No additional charge may be imposed upon the beneficiary who is assigned to a room which may be somewhat more desirable because of these factors.

  2. All-Private-Room Providers.--If the patient is admitted to a facility which has only private accommodations, and no semiprivate or ward accommodations, medical necessity will be deemed to exist for the accommodations furnished. Beneficiaries may not be subject to an extra charge for a private room in an all-private room SNF.

  3. Wards.--The law contemplates that Medicare patients should not be assigned to ward accommodations except at the patient's request or for a reasons consistent with the purposes of the health insurance program.

    When ward accommodations are furnished at the patient's request or for a reason determined to be consistent with the program's purposes, payment will be based on the average per diem cost of routine services. (See

Page 2-30/Rev. 165


03-80    COVERAGE OF SERVICES    230.2 (Cont.)

paragraph A above.) Where ward accommodations are assigned for other reasons, the law provides what may be a substantial penalty. (See 2 below.)

Any request by the patient (or his representative) for ward accommodations must be obtained by the provider in writing and kept in its files.

  1. Assignment Consistent With Program Purposes.--It is considered to be consistent with the program's purposes to assign the patient to ward accommodations if all semiprivate accommodations are occupied or the facility has no semiprivate accommodations. However, the patient must be moved to semiprivate accommodations if they become available during his stay.

  2. Assignment Not Consistent With Program Purposes.--It is not consistent with the purposes of the law to assign a patient ward accommodations on the basis of his social or economic status, his national origin, race, or religion, or his entitlement to benefits as a Medicare patient, or any other such discriminatory reason. It is also inconsistent with the purposes of the law to assign patients to ward accommodations merely for the convenience or financial advantage of the institution.

    If a ward assignment is neither made at the patient's request nor for a reason consistent with the purpose of the program, the reimbursement to the SNF for routine services is decreased by the difference between the institution's customary charges for semiprivate accommodations at the most prevalent rate (see G below) at the time of the patient's admission and the charge customarily made for the ward accommodations furnished the patient. The reduction in payment, when applicable, will be made at the end-of-year settlement.

EXAMPLE: The reasonable cost for routine services is $15 per day. The most prevalent customary charge for a semiprivate room is $17 per day, while $10 per day is the customary charge for ward accommodations. In such a case, development of the reason for the ward assignment will be necessary. If it is determined that the patient was assigned to a ward neither at his request nor for a reason consistent with the purposes of the program, the SNF will be paid only $8 per day for the ward accommodations, computed as follows: $17 (the reasonable cost for routine services) minus a differential of $7 (obtained by subtracting $10 from $17). However, if it is determined that the patient was assigned to the ward at his own request or for a reasons consistent with the purposes of the program, the SNF will be paid $15, i.e., the reasonable cost of routine services.

  1. Charges.--Customary charges means amounts which the skilled nursing facility is uniformly charging patients currently for specific services and accommodations. The most prevalent rate or charge is the rate which applies to the greatest number of semiprivate or private beds in the institution.

Rev. 174/Page 2-31


230.3    COVERAGE OF SERVICES    03-80

230.3    Physical, Speech, and Occupational Therapy Furnished by the Skilled Nursing Facility or by Others under Arrangements with the Facility and under its Supervision.--

  1. Physical Therapy.--

    1. General.--To be covered physical therapy services, the services must related directly and specifically to an active written treatment regimen established by the physician after any need consultation with the qualified physical therapist and must be reasonable and necessary to the treatment of the individual's illness or injury.

    2. Reasonable and Necessary.--To be considered reasonable and necessary the following conditions must be met:

      --    The services must be considered under accepted standards of medical practice to be a specific and effective treatment for the patient's condition,

      --    The services must be of such a level of complexity and sophistication or the condition of the patient must be such that the services required can be safely and effectively performed only by a qualified physical therapist or under his supervision. Services which do not require the performance or supervision of a physical therapist are not considered reasonable or necessary physical therapy services, even if they are performed or supervised by a physical therapist. When the intermediary determines the services furnished were of a type that could have been safely and effectively performed only by a qualified physical therapist or under his supervision, it will presume that such services were properly supervised. However, this assumption is rebuttable and if in the course of processing claims, the intermediary finds that physical therapy services are not being furnished under proper supervision, the intermediary will deny the claim and bring this matter to the attention of the Division of stet and Certification of the HCFA regional office.)

      --    There must be an expectation that the condition will improve significantly in a reasonable (and generally predictable) period of time based on the assessment made by the physician of the patient's restoration potential after any needed consultation with the qualified physical therapist or the services must be necessary to the establishment of a safe and effective maintenance program required in connection with a specific disease state, and

      --    The amount, frequency, and duration of the services must be reasonable.

NOTE: Claims for physical therapy services denied because they are not considered reasonable and necessary are excluded by section 1862(a)(l) and are thus subject to consideration under the waiver of liability provision in 1879 of the act. (See §§350ff.)

(a).    Restorative Therapy.--To constitute physical therapy a service must among other things be reasonable and necessary to the treatment of the individual's illness. If an individual's expected restoration potential would be insignificant in relation to the extent and duration of physical

Page 2-32/Rev. 174


03-80    COVERAGE OF SERVICES    230.3 (Cont.)

therapy services required to achieve such potential the physical therapy would not be considered reasonable and necessary. In addition, there must be an expectation that the patient's condition will improve significantly in a reasonable (and generally predictable) period of time. However, if at any point in the treatment of an illness it is determined that the expectations will not materialize, the services will no longer be considered reasonable and necessary; and they, therefore, should be excluded from coverage under section 1962(a)(1).

(b)    Maintenance Program.--The repetitive services required to maintain function generally do not involve complex and sophisticated physical therapy procedures, and consequently the judgment and skill of a qualified physical therapist are not required for safety and effectiveness. However, in certain instances the specialized knowledge and judgment of a qualified physical therapist may be required to establish an maintenance program. For example, a Parkinson patient who has not been under a restorative physical therapy program may require the services of a physical therapist to determine what type of exercises will contribute the most to maintain the patient's present functional level.

In such situations the initial evaluation of the patient's needs, the designing by the qualified physical therapist of a maintenance program which is appropriate to the capacity and tolerance of the patient and the treatment objectives of the physician, the instruction of the patient or supportive personnel, e.g., aides or nursing personnel (or family members where physical therapy is being furnished on an outpatient basis) in carrying out the program and such infrequent reevaluations as may be required would constitute physical therapy.

Where a patient has been under a restorative physical therapy program, the physical therapist should regularly be reevaluating the condition and adjusting any exercise program in which the patient is engaged. Consequently, when it is determined that no further restoration is possible, the physical therapist should have already designed the maintenance program required and instructed the patient or supportive personnel (or family members here physical therapy is being furnished on an outpatient basis) in the carrying out the program. Therefore, where a maintenance program is not established until after the restorative physical therapy program has been completed it would not be considered reasonable and necessary to the treatment of the patient's condition and would be excluded from coverage under
§1862(a)(l).

(c)    Application of Guidelines.--The following discussion illustrates the application of the above guidelines to the more common modalities and procedures utilized in the treatment of patients:

(1)    Hot Pack, Hydrocollator, Infra-Red Treatments, Paraffin Baths and Whirlpool Baths.--Heat treatments of this type and whirlpool baths do not ordinarily require the skills of a qualified physical therapist. However, in a particular case the skills, knowledge, and judgement of a qualified physical therapist might be required in such treatments or baths, e.g., where the

Rev. 174/Page 2-33


230.3 (Cont.)    COVERAGE OF SERVICES    03-80

patient's condition is complicated by circulatory deficiency, areas of desensitization, open wounds, or other complications. Also, if such treatments are given prior to but as an integral part of a skilled physical therapy procedure, they would be considered part of the physicial therapy service.

(2)    Gait Training.--Gait evaluation and training furnished a patient whose ability to walk has been impaired by neurological, muscular, or skeletal abnormality require the skills of a qualified physical therapist. However, if such gait evaluation and training cannot reasonable be expected to improve significantly the patient's ability to walk, such services would not be considered reasonable and necessary. Repetitious exercises to improve gait or maintain strength and endurance and assistive walking, such as provided in support for feeble or unstable patients are appropriately provided by supportive personnel, e.g., aides or nursing personnel, and do not require the skills of a qualified physical therapist.

(3)    Ultrasound, Shortwave, and Microwave Diathermy Treatments.--These modalities must always be performed by or under the supervision of a qualified physical therapist and therefore such treatments constitute physical therapy.

(4)    Range of Motion Tests.--Only the qualified physical therapist may perform range of motion tests and, therefore, such tests would constitute physical therapy.

(5)    Therapeutic Exercises.--Therapeutic exercises which must be performed by or under the supervision of the qualified physical therapist or by a qualified physical therapy assistant under the general supervision of a qualified physical therapist due either to the type of exercise employed or to the condition of the patient would constitute physical therapy. Range of motion exercises require the skills of a qualified physical therapist only when they are part of the active treatment of a specific disease which has resulted in a loss or restriction of mobility (as evidenced by physical therapy notes showing the degree of motion lost and the degree to be restored) and such exercises, either because of their nature or the condition of the patient, may only be performed safely and effectively by or under the supervision of a qualified physical therapist. Generally, range of motion exercises which are not related to the restoration of a specific loss of function but rather are related to the maintenance of function (see §230.3A2.2) do not require the skills of a qualified physical therapist. However, such services may, under some circumstances, be included in the physical therapy cost center (see §230.3A4.).

(d)    Routine Services.--Many skilled nursing facility inpatients who do not require physical therapy services do require services involving procedures which are routine in nature in the sense that they can be rendered by supportive personnel, e.g., aides or nursing personnel, without the supervision of a qualified physical therapist. Such services as well as services involving activities to promote over-all fitness and flexibility and activities to provide diversion or general motivation, can be reimbursed through the physical therapy cost center even though they do not constitute physical therapy for Medicare purposes, if:

Page 2-34/Rev. 174


08-89    COVERAGE OF SERVICES    230.3 (Cont.)

  • The services are medically necessary;

  • The treatment furnished is prescribed by a physician;

  • All services are provided by salaried employees of the physical therapy department of the provider;

  • The cost incurred is reasonable in amount (i.e., the employees' salaries are reasonably related to the level of skill and experience required to perform the services in question); and

  • Charges are equally imposed on all patients.

If all of the above conditions are met, routine restorative services can be billed as ancillary physical therapy services and their costs included in the physical therapy cost center for reimbursement purposes.

The services furnished beneficiaries must constitute physical therapy where the entitlement to benefits is at issue. Since the outpatient physical therapy benefit under Part B provides coverage only of physical therapy services, payment can be made only for those services which constitute physical therapy.

  1. Speech Pathology.--

    1. General.--Speech pathology services are those services necessary for the diagnosis and treatment of speech and language disorders which result in communication disabilities and for the diagnosis and treatment of swallowing disorders (dysphagia), regardless of the presence of a communication disability. They must relate directly and specifically to a written treatment regimen established by the physician after any needed consultation with the qualified speech pathologist.

    2. Reasonable and Necessary.--Speech pathology services must be reasonable and necessary to the treatment of the individual's illness or injury. To be considered reasonable and necessary, the following conditions must be met:

      • The services must be considered under accepted standards of practice to be a specific and effective treatment for the patient's condition;

      • The services must be of such a level of complexity and sophistication, or the patient's condition must be such that the services required can be safely and effectively performed only by or under the supervision of a qualified speech pathologist. (See 42 CFR 405.1202(u)(1)(2).) (When the intermediary determines the services furnished were of a type that could have been safely and effectively performed only by qualified speech pathologists or under the supervision of a qualified speech pathologist, it presumes that such services were properly supervised. However, this assumption is rebuttable and, if in the course of processing claims the intermediary finds that speech pathology services are not being furnished under proper supervision, it denies the claim and brings this matter to the attention of the Division of Health Standards and Quality of the RO.);

Rev. 285/Page 2-35


230.3 (Cont.)    COVERAGE OF SERVICES    08-89

  • There must be an expectation that the patient's condition will improve significantly in a reasonable (and generally predictable) period of time based on the assessment by the physician of the patient's restoration potential after any needed consultation with the qualified speech pathologist, or the services must be necessary to the establishment of a safe and effective maintenance program required in connection with a specific disease state; and

  • The amount, frequency, and duration of the services must be reasonable under accepted standards of practice. (The intermediary consults with local speech pathologists or the State chapter of the American Speech-Language-Hearing Association in the development of any utilization guidelines.)

Claims for speech pathology services which are not reasonable and necessary are denied under authority of §1862(a)(l) and, therefore, are subject to the waiver of liability provisions in §1879 of the Act. (See §§350ff.)

  1. Application of Guidelines.--The following discussion illustrates the application of the above guidelines to the more common situations in which the reasonableness and necessity of speech services furnished is a significant issue.

    1. Restorative Therapy.--If an individual's expected restoration potential is insignificant in relation to the extent and duration of speech pathology services required to achieve such potential, the services are not considered reasonable and necessary. In addition, there must be an expectation that the patient's condition will improve significantly in a reasonable (and generally predictable) period of time. If at any point in the treatment of an illness or injury it is determined that the expectations will not materialize, the services no longer constitute covered speech pathology services, as they are no longer reasonable and necessary for the treatment of the patient's condition and are excluded from coverage under §1862(a)(1).

    2. Maintenance Program.--After the initial evaluation of the extent of the disorder or illness, if the restoration potential is judged insignificant or, after a reasonable period of trial, the patient's response to treatment is judged insignificant or at a plateau, an appropriate functional maintenance program may be established. The specialized knowledge and judgment of a qualified speech pathologist may be required if the treatment aim of the physician is to be achieved; e.g., a multiple sclerosis patient may require the services of a speech pathologist to establish a maintenance program designed to fit the patient's level of function. In such a situation, the initial evaluation of the patient's needs, the designing by the qualified speech pathologist of a maintenance program which is appropriate to the capacity and tolerance of the patient and the treatment objectives of the physician, the instruction of the patient and supportive personnel (e.g., aides or nursing personnel, or family members where speech pathology is being furnished on an outpatient basis) in carrying out the program, and such infrequent reevaluations as may be required, constitute covered speech therapy. After the maintenance program has been established and instructions

Page 2-35.1/Rev. 285


06-86    COVERAGE OF SERVICES     230.3 (Cont.)

  1. have been given for carrying out the program, the services of the speech pathologist would no longer be covered, as they would no longer be considered reasonable and necessary for the treatment of the patient's condition and would be excluded from coverage under section 1862(a)(1).

    If a patient has been under a restorative speech pathology program, the speech pathologist should regularly reevaluate the condition and adjust the treatment program. Consequently, during the course of treatment the speech pathologist should determine when the patient's restorative potential will be achieved and, by the time the restorative program has been completed, should have designed the maintenance program required and instructed the patient, supportive personnel, or family members in the carrying out of the program. A separate charge for the establishment of the maintenance program under these circumstances would not be recognized. Moreover, where a maintenance program is not established until after the restorative speech pathology program has been completed, it would not be considered reasonable and necessary to the treatment of the patient's condition and would be excluded from coverage under section 1862(a)(1) since the maintenance program should have been established during the active course of treatment.

  2. Types of Services.--Speech pathology services can be grouped into two main categories: services concerned with diagnosis or evaluation and therapeutic services.

    1. Diagnostic and Evaluation Services.--Unless excluded by section 1862(a)(7) of the law, these services are covered if they are reasonable and necessary. The speech pathologist employs a variety of formal and informal language assessment tests to ascertain the type, causal factor(s), and severity of the speech and language disorders. Reevaluation would be covered only if the patient exhibited a change in functional speech or motivation, clearing of confusion, or the remission of some other medical condition which previously contraindicated speech pathology. However, monthly reevaluations, e.g., a Porch Index of Communicative Ability (PICA) for a patient undergoing a restorative speech pathology program, are to be considered a part of the treatment session and could not be covered as a separate evaluation for billing purposes.

    2. Therapeutic Services.--The following are examples of common medical disorders and resulting communication deficits which may necessitate active restorative therapy:

      (i)    Cerebrovascular disease such as cerebral vascular accidents presenting with dysphagia, aphasia/dysphasia, apraxia, and dysarthria;

      (ii)    Neurological disease such as Parkinsonism or Multiple Sclerosis may exhibit dysarthria, dysphagia, or inadequate respiratory volume/control;

      (iii)    Mental retardation with disorders such as aphasia or dysarthria; and

      (iv)    Laryngeal carcinoma requiring laryngectomy resulting in aphonia may warrant therapy of the laryngectomized patient so he can develop new communication skills through esophageal speech and/or use of the electrolarynx.

Rev. 243/Page 2-35.2


230.3 (Cont.)    COVERAGE OF SERVICES    06-86

NOTE: Many patients who do not require speech pathology services as defined above do require services involving nondiagnostic, nontherapeutic, routine, repetitive, and reinforced procedures or services for their general good and welfare; e.g., the practicing of word drills. Such services do not constitute speech pathology services for Medicare purposes and would not be covered since they do not require performance by or the supervision of a qualified speech pathologist.

  1. Occupational Therapy.--

    1. General.--Occupational therapy is medically prescribed treatment concerned with improving or restoring functions which have been impaired by illness or injury or, where function has been permanently lost or reduced by illness or injury, to improve the individual's ability to perform those tasks required for independent functioning. Such therapy may involve:

      1. the evaluation, and reevaluation as required, of a patient's level of function by administering diagnostic and prognostic tests;

      2. the selection and teaching of task-oriented therapeutic activities designed to restore physical function, e.g., use of wood-working activities on an inclined table to restore shoulder, elbow and wrist range of motion lost as a result of burns;

      3. the planning, implementing, and supervising of individualized therapeutic activity programs as part of an overall "active treatment" program for a patient with a diagnosed psychiatric illness, e.g., the use of sewing activities which require following a pattern to reduce confusion and restore reality orientation in a schizophrenic patient;

      4. the planning and implementing of therapeutic tasks and activities to restore sensory-integrative function, e.g., providing motor and tactile activities to increase sensory input and improve response for a stroke patient with functional loss resulting in a distorted body image;

      5. the teaching of compensatory technique to improve the level of independence in the activities of daily living, for example:

        • teaching a patient who has lost the use of an arm how to pare potatoes and chop vegetables with one hand.

        • teaching an upper extremity amputee how to functionally utilize a prosthesis.

        • teaching a stroke patient new techniques to enable him to perform feeding, dressing and other activities as independently as possible.

Page 2-36/Rev. 243


06-86    COVERAGE OF SERVICES     230.3 (Cont.)

    • teaching a hip fracture/hip replacement patient techniques of standing tolerance and balance to enable him or her to perform such functional activities as dressing and homemaking tasks.

  1. the designing, fabricating, and fitting of orthotic and self-help devices, e.g., making a hand splint for a patient with rheumatoid arthritis to maintain the hand in a functional position or constructing a device which would enable an individual to hold a utensil and feed himself independently; and

  2. vocational and prevocational assessment and training.

Only a qualified occupational therapist has the knowledge, training, and experience required to evaluate and, as necessary, reevaluate a patient's level of function, determine whether an occupational therapy program could reasonably be expected to improve, restore, or compensate for lost function and, where appropriate, recommend to the physician a plan of treatment. However, while the skills of a qualified occupational therapist are required to evaluate the patient's level of function and develop a plan of treatment, the implementation of the plan may also be carried out by a qualified occupational therapy assistant functioning under the general supervision of the qualified occupational therapist. ("General supervision" requires initial direction and periodic inspection of the actual activity; however, the supervisor need not always be physically present or on the premises when the assistant is performing services.)

Rev. 243/Page 2-36.1


6-79    COVERAGE OF SERVICES     230.3 (Cont.)

  1. Coverage Criteria.--To constitute covered occupational therapy for Medicare purposes the services furnished to a beneficiary must be (a) prescribed by a physician, (b) performed by a qualified occupational therapist or a qualified occupational therapy assistant under the general supervision of a qualified occupational therapist, and (c) reasonable and necessary for the treatment of the individual's illness or injury.

    Occupational therapy designed to improve functions considered reasonable and necessary for the treatment of the individual's illness or injury only where an expectation exists that the therapy will result in a significant practical improvement in the individual's level of functioning within a reasonable period of time. Where an individual's improvement potential is insignificant in relation to the extent and duration of occupational therapy services required to achieve improvement, such services would not be considered reasonable and necessary and would thus be excluded from coverage by 1862(a)(l). Where a valid expectation of improvement exists at the time the occupation therapy program is instituted, the services would be covered even though the expectation may not be realized. However, in such situations the services would be covered only up to the time at which it would have been reasonable to conclude that the patient is not going to improve. Once a patient has reached the point where no further significant practical improvement can be expected, the skills of an occupational therapist or occupational therapy assistant will not be required in the carrying out of any activity and/or exercise program required to maintain function at the level to which it has been restored. Consequently, while the services of an occupational therapist in designing a maintenance program and making infrequent but periodic evaluation if its effectiveness would be covered, the services of an occupation therapist or occupational therapy assistant in carrying out the program are not considered reasonable and necessary for the treatment of illness or injury and such services are excluded from coverage under section 1862(a)(l).

    Generally speaking, occupational therapy is not required to effect improvement or restoration of function where a patient suffers a temporary loss or a reduction of function (e.g., temporary weakness which may follow prolonged bedrest following major abdominal surgery) which could reasonably be expected to spontaneously improve as the patient gradually resumes normal activities. Accordingly, occupational therapy furnished in such situations would not be considered reasonable and necessary for the treatment of the individual's illness or injury and the services would be excluded from coverage by 1862(a)(l).

    Occupational therapy may also be required for a patient with a specific diagnosed psychiatric illness. Where such services are required they would be covered, assuming the coverage criteria set forth above are met. However, it should be noted that where an individual's motivational needs are not related to a specific diagnosed psychiatric illness, the meeting of such needs does not usually require an individualized therapeutic program. Rather, such needs can be met through general activity programs or the efforts of other professional personnel involved in the care of the patient, patient motivation being an appropriate and inherent function of all health disciplines which is interwoven

Rev. 165/Page 2-37


230.3 (Cont.)    COVERAGE OF SERVICES    6-79

  1. with other functions performed by such personnel for the patient. Accordingly, since the special skills of an occupational therapist or occupational therapy assistant are not required, an occupational therapy program for such individuals would not be considered reasonable and necessary for the treatment of an illness or injury, and services furnished under such a program would be excluded from coverage by 1862(a)(l). See §4 for discussion regarding coverage of patient activity programs.

    As indicated, occupational therapy includes vocational and prevocational assessment and training. When services provided by an occupational therapist or assistant are related solely to specific employment opportunities, work skills or work settings, they are not reasonable or necessary for the diagnosis or treatment of an illness or injury and are excluded from coverage under the program by 1862(a)(l). However, care should be exercised in applying this exclusion, because the assessment of level of function and the teaching of compensatory techniques to improve the level of function, especially in activities of daily living, are services which occupational therapists provide for both vocational and nonvocational purposes. For example, an assessment of sitting and standing tolerance might be nonvocational for a mother of young children or a retire individual living alone, but would be a vocational test for a sales clerk. Training an amputee in the use of a prosthesis for telephoning is necessary for every-day activities as well as for employment purposes. Major changes in life style may be mandatory for an individual with a substantial disability; the techniques of adjustment cannot be considered exclusively vocational or nonvocational.

  2. Supplies.--Occupational therapy frequently necessitates the use of various supplies, e.g., looms, ceramic tiles, leather, etc. The cost of such supplies may be included in the occupational therapy cost center.

  3. Patient Activity Program.--In the inpatient setting, organized patient activity programs are utilized to provide diversion and general motivation to inpatients. Although occupational therapists and occupational therapy assistants may be involved in directing and supervising such programs, these activity programs are part of a generalized effort directed to the health and welfare of all patients and such programs do not constitute occupational therapy and no ancillary charges may be recognized for such services. However, since these programs do constitute an integral part of good inpatient care they would be considered covered services related to the routine care of patients, providing: (a) the program is one ordinarily furnished by the SNF to its inpatients, and (b) it is of a type in which Medicare patients requiring a covered level of care may reasonably be expected to participate. For example, patients games such as checkers or chess, handicrafts such as sewing or weaving, and they might attend movies, etc. But, it would not be expected that such patients would be able to go on field trips, engage in strenuous athletics, or participate in other activities which are inappropriate for patients requiring the level of care covered under the program. (The capacities of physically health psychiatric patients would vary from those of patients whose ailments are physical.)

Page 2-38/Rev. 165


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Last Modified on Wednesday, October 23, 2002