Clinical UM Guideline


Subject:  Skilled Nursing and Skilled Rehabilitation Services (Outpatient)
Guideline #:  CG-REHAB-07Current Effective Date:  04/15/2014
Status:ReviewedLast Review Date:  02/13/2014

Description

This document defines skilled nursing and skilled rehabilitation services and addresses the medical necessity of these services when provided in the outpatient setting.

Skilled nursing and skilled rehabilitation services are those services, furnished pursuant to physician orders, that:

Note: Please see the following related documents for additional information:

Clinical Indications

Outpatient Skilled Nursing and Skilled Rehabilitation Services

Medically Necessary:

Outpatient skilled nursing services are considered medically necessary in the following circumstances:

  1. When the inherent complexity of a service required by an individual is such that it can be performed safely and effectively only by or under the general supervision of skilled nursing personnel; AND
  2. When the likelihood of change in an individual's condition requires skilled nursing personnel to observe and assess the individual in order to identify and evaluate the need for possible modification of treatment or initiation of additional medical procedures, until the treatment regimen is essentially stabilized; AND
  3. When they are not custodial in nature (see definition of custodial care under "Discussion/General Information" section below).

Outpatient skilled rehabilitation services are considered medically necessary when all of the following conditions are met:

  1. Individual has a new (acute) medical condition or acute exacerbation of a chronic medical condition that has resulted in a decrease in functional ability such that they cannot adequately recover without therapy; AND
  2. Individual's overall medical condition and medical needs can be addressed in the outpatient setting; AND
  3. Therapy must be reasonable and necessary for the individual's condition, including the amount, duration and frequency of services and must be directly and specifically related to an active written treatment plan developed by physician and therapist: AND
  4. Individual's mental and physical condition prior to the onset of the medical condition indicates there is a potential for improvement or the services must be necessary for the establishment of a safe and effective maintenance program: AND
  5. Individual must be medically stable enough to participate in the treatment plan; AND
  6. Individual is expected to show measurable functional improvement in a reasonable and generally predictable period of time; AND
  7. Individual requires the judgment, knowledge and skills of a qualified therapist; AND
  8. Therapy includes a discharge plan.

Examples of Skilled Services include, but are not limited to, the following:

Note:

Not Medically Necessary:

Outpatient skilled nursing services are considered not medically necessary when the criteria above are not met.

Outpatient skilled rehabilitation services are considered not medically necessary when the criteria above are not met.

Coding

Coding edits for medical necessity review are not implemented for this  guideline. Where a more specific policy or guideline exists, that document will take precedence and may include specific coding edits and/or instructions.  Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

Discussion/General Information

Skilled nursing and skilled rehabilitation services, furnished pursuant to physician orders, require the skills of qualified technical or professional health personnel such as registered nurses, physical therapists, occupational therapists and speech pathologists or audiologists. These services must be provided directly by or under the general supervision of these skilled nursing or skilled rehabilitation personnel to assure the safety of the individual and to achieve the medically desired result.

Definition of Custodial Care:

References

Peer Reviewed Publications:

  1. Cruise CM, Sasson N, Lee MH. Rehabilitation outcomes in the older adult. Clin Geriatr Med. 2006: 22(2):257-267.
  2. Ensberg M, Gerstenlauer C. Incremental geriatric assessment. Prim Care. 2005; 32(3):619-643.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. Centers for Medicare and Medicaid Services. Medicare Benefit Policy Manual. Chapter 8. Coverage of Extended Care (SNF) Services Under Hospital Insurance. Rev. 161, 10-26-12. Available at: http://www.cms.hhs.gov/manuals/Downloads/bp102c08.pdf. Accessed on December 27, 2013.
  2. Centers for Medicare and Medicaid Services. Medicare Benefit Policy Manual. Chapter 16. General Exclusions from Coverage. Rev.122, 04-09-10. Available at: http://www.cms.hhs.gov/manuals/Downloads/bp102c16.pdf. Accessed on December 27, 2013.
  3. Centers for Medicare and Medicaid Services. Benefit Policy Manual. Chapter 7: Home Health Services. Rev. 172, 10-18-13. Available at: http://www.cms.hhs.gov/manuals/Downloads/bp102c07.pdf. Accessed on December 27, 2013.
History

Status

Date

Action

Reviewed02/13/2014Medical Policy & Technology Assessment Committee (MPTAC) review. Reference section updated.
Reviewed02/14/2013MPTAC review. Reference section updated.
Reviewed02/16/2012MPTAC review. References updated.
Reviewed02/17/2011MPTAC review. Title of Clinical Indication section, Description, Discussion (including definition of custodial care), and Reference links updated. Clarifications made to examples of skilled services.
Reviewed02/25/2010MPTAC review. Reference links updated.
Reviewed02/26/2009MPTAC review. References and discussion updated. Case management section removed.
Revised02/21/2008MPTAC review. Added not medically necessary statements for outpatient skilled nursing services and outpatient skilled rehabilitation services. Minor clarification made to example of skilled services. Description, discussion and references updated. Coding updated to remove specific codes from this definition document.
Reviewed03/08/2007MPTAC review. References and coding updated.
Revised03/23/2006MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization. 
Pre-Merger Organizations

Last Review Date

Document Number

Title

Anthem, Inc.

 

 No Policy
Anthem MW

02/11/2005

MA-020Skilled Nursing Facility Setting, Skilled and Custodial Services Defined
WellPoint Health Networks, Inc.

09/22/2005

Clinical GuidelineSkilled Nursing and Skilled Rehabilitation Services