nursing facility (SNF) services are medically necessary when ALL
of the following criteria in Section A are met and one or more of the
criteria in Section B are met:
The individual requires skilled
nursing or skilled rehabilitation services that must be performed by, or
under the supervision of, professional or technical personnel; and
The individual requires these
skilled services on a daily basis; (note: if skilled
rehabilitation services are not available on a 7-day-a-week basis, an
individual whose inpatient stay is based solely on the need for skilled
rehabilitation services would meet the "daily basis" requirement when he/she
needs and receives those services at least 5 days a week); and
As a practical matter, the daily
skilled services can be provided only on an inpatient basis in a skilled
nursing facility (SNF) setting; and
SNF services must be furnished
pursuant to a physician`s orders and be reasonable and necessary for the
treatment of an individual`s illness or injury (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; and
Initial admission and subsequent
stay in a SNF for skilled nursing services or rehabilitation services must
include development, management and evaluation of a plan of care as follows:
The involvement of skilled nursing personnel is required to meet the
individual`s medical needs, promote recovery and ensure medical safety
(in terms of the individual`s physical or mental condition); and
There must be a significant probability that complications would arise
without skilled supervision of the treatment plan by a licensed nurse;
Care plans must include realistic nursing goals and objectives for the
individual, discharge plans and the planned interventions by the nursing
staff to meet those goals and objectives; and
Updated care plans must document the outcome of the planned
There must be daily documentation of the individual`s progress or
and monitoring of a complicated or unstable condition.
A complex or unstable condition of the individual must require the
skills of a licensed nurse or rehabilitation personnel in order to
identify and evaluate the individual`s need for possible modification of
the treatment plan or initiation of additional medical procedures.
There must be a high likelihood of a change in an individual`s condition
due to complications or further exacerbations.
Daily nursing or therapy notes must give evidence of the individual`s
condition and documentation must indicate the results of monitoring.
Complex teaching services
to the individual or caregiver requiring 24-hour SNF setting vs.
intermittent home health care setting.
The teaching itself is the skilled service. The activity being taught
may or may not be considered skilled.
Documentation should include the reasons why the teaching was not
completed in the hospital, as well as the individual`s or caregiver`s
capability of compliance
Complex medication regimen
The individual must have a complex range of new medications (including
oral medications) following a hospitalization where there is a high
probability of adverse reactions or a need for changes in the dosage or
type of medication.
Documentation required to authorize initial admission and extensions
must include the individual`s unstable condition, medication changes and
continuing probability of complications. Documentation also includes
the individual’s progression in meeting goals or improvement in
Initiation of tube
Nasogastric tube and percutaneous tubes (including gastrostomy and
Active weaning of
ventilator dependent individuals
These individuals are considered skilled due to their complex care.
Wound care (including
NOTE: Skilled nursing facility placement solely for the
purpose of wound care should be rare.
All of the following criteria must be met:
Wound care must be ordered by a physician; and
The individual must require extensive wound care (e.g., packing,
debridement or irrigation of multiple stage II, or one or more stage III
or IV pressure ulcers); and
Skilled observation and assessment of a wound must be documented daily
and should reflect any changes in wound status to support the medical
necessity for continued observation.
Suspected Deep Tissue Injury:
Purple or maroon localized area of discolored intact skin or blood-filled
blister due to damage of underlying soft tissue from pressure and/or shear. The
area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or
cooler as compared to adjacent tissue.
Deep tissue injury may be difficult to detect in individuals with dark skin
tones. Evolution may include a thin blister over a dark wound bed. The wound may
further evolve and become covered by thin eschar. Evolution may be rapid
exposing additional layers of tissue even with optimal treatment.
Intact skin with non-bleachable redness of a localized area usually over a bony
prominence. Darkly pigmented skin may not have visible blanching; its color may
differ from the surrounding area.
The area may be painful, firm, soft, warmer or cooler as compared to adjacent
tissue. Stage I may be difficult to detect in individuals with dark skin tones.
May indicate "at risk" persons (a heralding sign of risk)
Partial thickness loss of dermis presenting as a shallow open ulcer with a red
pink wound bed, without slough. May also present as an intact or open/ruptured
Presents as a shiny or dry shallow ulcer without slough or bruising.* this stage
should not be used to describe skin tears, tape burns, perineal dermatitis,
maceration or excoriation.
*Bruising indicates suspected deep tissue injury
Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or
muscle are not exposed. Slough may be present but does not obscure the depth of
tissue loss. May include undermining and tunneling.
The depth of a stage III pressure ulcer varies by anatomical location. The
bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue
and stage III ulcers can be shallow. In contrast, areas of significant adiposity
can develop extremely deep stage III pressure ulcers. Bone/tendon is not visible
or directly palpable.
Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar
may be present on some parts of the wound bed. Often include undermining and
The depth of a stage IV pressure ulcer varies by anatomical location. The bridge
of the nose, ear, occiput and malleolus do not have subcutaneous tissue and
these ulcers can be shallow. Stage IV ulcers can extend into muscle and/or
supporting structures (e.g., fascia, tendon or joint capsule) making
osteomyelitis possible. Exposed bone/tendon is visible or directly palpable.
Full thickness tissue loss in which the base of the ulcer is covered by slough
(yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the
Until enough slough and/or eschar is removed to expose the base of the
wound, the true depth, and therefore stage, cannot be determined. Stable (dry,
adherent, intact without erythema or fluctuance) eschar on the heels serves as
"the body`s natural (biological) cover" and should not be removed.
(National Pressure Ulcer Advisory
pressure ulcer is localized injury to the skin and/or underlying tissue usually
over a bony prominence, as a result of pressure, or pressure in combination with
shear and/or friction. A number of contributing or confounding factors are also
associated with pressure ulcers; the significance of these factors is yet to be
The need for respiratory therapy, either by a nurse or by a respiratory
therapist, does not alone qualify an individual for skilled nursing facility (SNF)
skilled nursing facility (SNF) setting is considered not medically necessary
when ANY ONE of the following is present:
Services do not meet the
medically necessary criteria above; or
The individual`s condition has
changed such that skilled medical or rehabilitative care is no longer
Physical medicine therapy or
rehabilitation services in which there is not a practical improvement in the
level of functioning within a reasonable period of time; or
Services that are solely
performed to preserve the present level of function or prevent regression of
functions for an illness, injury or condition that is resolved or stable; or
The individual refuses to
participate in the recommended treatment plan; or
Care is initially or has become
The services are provided by a
family member or another non-medical person. When a service can be safely
and effectively self-administered or performed by the average non-medical
person without the direct supervision of a nurse, the service cannot be
regarded as a skilled service; or
Required services can be safely
provided in the home health setting.
following services are examples of services that do not require the skills of a
licensed nurse or rehabilitation personnel and are therefore considered to be
not medically necessary in the skilled nursing facility setting
unless there is documentation of comorbidities and
complications that require individual consideration.
Routine services directed toward
the prevention of injury or illness
Routine or maintenance medication
administration. SNF admissions solely for the administration of routine or
maintenance medications, including intravenous (IV), intramuscular (IM) and
subcutaneous (SQ) medications are not considered skilled. Parenteral
medication administration in medically stable members is most often managed
in the home setting by a home health or home infusion therapy provider.
Care solely for the
administration of oxygen, IPPB (intermittent positive pressure breathing)
treatments and nebulizer treatments
Routine enteral feedings
Routine colostomy care
Custodial care by a licensed
practical nurse (LPN) or registered nurse (RN)
Emotional support or counseling
Suctioning of the nasopharynx or
nasotrachea. Suctioning daily or as needed (PRN) with occurrences less
frequently than every four hours is not considered skilled.
Administration of suppositories
Routine foot and nail care
Medically stable ventilator care
that can be safely provided in an alternative setting
Urinary catheters. The presence
of a stable indwelling or suprapubic catheter, the need for routine
intermittent straight catheterization or ongoing intermittent straight
catheterization for chronic condition, catheter replacement or routine
catheter irrigation does not qualify an individual for SNF placement unless
other skilled needs exist.
Heat treatment – wet or dry
Whirlpool baths, paraffin baths or heat lamp treatments do not qualify
an individual for care in a SNF.
There may be a rare instance when a severely compromised individual with
desensitizing neuropathies or severe burns requires skilled observation
during the above treatments. These cases are to be reviewed on an
individual basis. Documentation must support the medical necessity for