Meeting Skilled Requirements Re-Visited

Some things have drastically changed in our Medicare world while others just need a little dusting off. One of the topics we are hearing a lot of lately is the importance of ensuring skilled criteria is being met now that we are shifting away from rehab days and minutes driving the bus – to truly the patient’s needs.



Let’s re-visit the 4 factors that must be in place to support a ‘skilled’ stay:

Taken from the Medicare Benefit Policy Manual Ch 8, Section 30

  • Patient requires skilled nursing or skilled rehabilitation services

• Performed by or under the supervision of professional or technical personnel – ‘to assure the safety of the patient and to achieve the medically desired result’

‘Skilled care may be necessary to improve a patient’s current condition, to maintain the patient’s current condition, or to prevent or slow further deterioration of the patient’s condition.’

• Ordered by a physician

• Services are rendered for a condition for which the patient received inpatient hospital services or for a condition that arose related to the inpatient hospital stay

  • Patient requires skilled services daily (7 x / week if nursing is skilling, 5x / week if rehab)

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

  • Services delivered are reasonable and necessary for the treatment of a patient’s illness or injury, i.e. are consistent with the nature and severity of the individual’s illness or injury, the particular medical needs, and accepted standards of medical practice. Services must also be reasonable in duration and quantity.


Now let’s look at the Principles for Determining Whether a Service is Skilled (30.2.2)

  • If the inherent complexity of a service prescribed 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 skilled

a. Consider and document medical complications requiring performance, observation or supervision by skilled personnel

b. Documentation of such complexities must be documented by physician’s orders and notes as well as nursing and or therapy notes

  • If skilled services are needed, a patient’s diagnosis or prognosis should never be the sole factor in deciding that a service is skilled


The Medical Record must support the patients’ unique complexities:

  • History and physical exam pertinent to care being delivered should include the response or changes in behavior to previously administered skilled services

  • Include:

a. Patient response to skilled service provision

b. Plan for future care based on rationale

c. Explain the need for skilled service considering the patient’s overall medical condition and experiences

d. Complexity of service to be performed

e. Any pertinent characteristics of the patient

  • DO NOT Include unskilled and vague documentation

a. Patient tolerated treatment well

b. Continue with POC

c. Patient remains stable


Let's Get to the Point:

Get to know each of our patients’ unique medical complexities, conditions, characteristics and co-morbidities. Discuss them as an IDT. Document them, obtain physician documentation, engagement and support and all should be well! Sounds a lot like where PDPM is driving us.

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