Questions and answers from the American Association of Nurse Assessment Coordinators - AANAC - AANAC's PPS Review

Nursing Homes, June, 2003

To skill or not to skill, that is the question:

Q: We have a resident who was admitted to the hospital because of weakness from chronic congestive heart failure. He was stabilized at the hospital but had no medication changes, and the doctor ordered therapy in the nursing home in preparation for returning home. Our social worker says that this is not a "skillable" stay. Is that true?

A: To be covered for rehab under Part A, a resident must require services that are complex enough to require the skills of a licensed therapist. If a resident has decreased endurance related to a medical condition, it is considered that the resident will bounce back spontaneously, or perhaps with the assistance of nonlicensed personnel. Here is what the Medicare SNF Manual says about gait training, for example:

Gait evaluation and training furnished to 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 reasonably 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. (Section 230.3)

Here's what the manual says about OT:

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) (1). (Section 230.3)

If the resident had IVs or other services in the hospital that can be captured in the look-back period in order to classify into a skilled RUG level, the resident can be covered under the presumption of coverage until the ARD of the 5-day MDS. If there were no such services, you may be able to justify observation for a few days, if there is a reasonable chance that the resident's condition will deteriorate. In the absence of a skilled service that would classify the resident into one of the upper 26 RUG levels, however, observation would be at a nonskilled RUG level.

Q: The revised RAI User's Manual, in Section P, says not to code services that were provided solely in conjunction with a surgical procedure and the immediate postoperative recovery period. What does that mean?

A: The instructions for K5a, parenteral/IV, state: "Do not include IV fluids that were administered as a routine part of an operative procedure or recovery room stay" (p. 3-153). The Section P clarification says: "Do not code services that were provided solely in conjunction with a surgical procedure, such as IV medications or ventilators. Surgical procedures include routine pre- and postoperative procedures" (p. 3-184).

Surgical patients routinely have an IV started to provide hydration and medications during the surgery. They also often have ventilator support because of the effects of the anesthesia. In many cases, the IV and the ventilator are discontinued in the recovery room (or the IV fluids are continued after the patient leaves the recovery room only until the existing bag is empty). These are "routine" and are not to be coded on the MDS. It is no longer "routine" if the resident is unable to be taken off the ventilator within the usual amount of time, or if the hydration or IV meds are continued beyond the patient's exiting the recovery room, because of the resident's medical needs.

Q: I understand that radiation therapy and MRI are not included in the SNF PPS per diem payment when furnished in a Medicare-participating hospital or critical access hospital, and therefore the nursing home does not have to pay for them. Does this mean that if the radiation therapy or MRI is furnished in a freestanding center, it is included in the SNF PPS per diem payment and not separately billable to Medicare?

A: The radiation must be administered at a Medicare-participating hospital or critical-access hospital to qualify as an exclusion. If it is provided at a freestanding facility, it is included in the SNF's PPS per diem, and therefore it is not separately billable by the provider of the radiation. Additional information on consolidated billing and which services are excluded from the SNF PPS per diem payment can be found in Transmittal A-02-118, which includes the annual update of HCPCS codes that are excluded from consolidated billing, at http://cms.hhs.gov/manuals/pm_trans/A02118.pdf.>