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Understanding How to Skill Residents Under Medicare A in a Post-PDPM World

Topics: Clinical Consulting, pdpm, clinical consulting services

20RHC023-Skillable-Services-Download-3D (ID 150159)


Here at Richter, our Clinical Consulting team has fielded an array of questions lately from skilled nursing facility (SNF) clients regarding what to skill residents for under Medicare A, and what the criteria is.

Based on our decades of experience in the industry, we’ve found that such questions aren’t out of the ordinary in “normal circumstances.” Indeed, under previous PPS payer rules, when a Medicare resident was discharged from an acute-care hospital, the general assumption was that they were eligible for skilled services through their need of therapy services. Accordingly, during this time, much of the documentation burden also lay with the therapist.

However, On October 1, 2019, “normal circumstances” became a thing of the past when PDPM went into effect. Now, therapy will no longer bear this burden; rather, it will be shared with nursing. Nursing is now responsible for finalizing the primary and admitting diagnosis, and those diagnoses should be carried through to all discipline documentation during the skilled stay. The diagnosis should be on the therapy evaluation and treatment records, in the physician’s H and P and notes and in nursing skilled documentation, just to name a few.

According to the Centers for Medicare and Medicaid Services (CMS):

“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-language 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.”

So, once you have the primary diagnosis, how do you determine what a resident will be skilled for? The answer is that at least one of five main areas applies. While each resident must fall into at least one of the skilled areas, up to five areas may apply as well. Below is a summary of each of the five areas as articulated by CMS in Chapter 8 of its Medicare Benefit Policy Manual. We have also developed a useful chart that explains the five areas in detail for your reference. You can download it here.

    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 and supporting documentation, 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.”

    Criteria for determining patient applicability:

    • The resident has likely potential for serious complications without skilled management.
    • The documentation in the medical record as a whole is essential for this determination and must illustrate the complexity of the unskilled services that are a necessary part of the medical treatment and which require the involvement of skilled nursing personnel to promote the patient's recovery and medical safety in view of the patient's overall condition.


    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 condition is essentially stabilized.”

    Criteria for determining patient applicability:

    • Where these signs and symptoms are such that there is a reasonable potential that skilled observation and assessment by a licensed nurse will result in changes to the treatment of the patient.
    • Such signs and symptoms as abnormal/fluctuating vital signs, weight changes, edema, symptoms of drug toxicity, abnormal/fluctuating lab values and respiratory changes on auscultation may justify skilled observation and assessment.
    • 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.


    1. Teaching and Training Activities

    “Teaching and training activities, which require skilled nursing or skilled rehabilitation personnel to teach a patient how to manage their treatment regimen, would constitute skilled services.”

    Criteria for determining patient applicability:

    • Self-administration of injectable medications.
    • New diabetic to administer insulin injections.
    • New diabetic to prepare and follow a diabetic diet.
    • New diabetic to observe foot-care precautions.
    • Self-administration of medical gases to a patient.
    • Gait training and teaching of prosthesis care for a recent leg amputation.
    • Teaching patients how to care for a recent colostomy or ileostomy.
    • How to perform self-catheterization and how to self-administer gastrostomy feedings.
    • How to care for and maintain central venous lines.
    • The use and care of braces, splints and orthotics, and any associated skin care.
    • Proper care of any specialized dressings or skin treatments.


    1. Direct Skilled Nursing Services to Patients

    “Nursing services are considered skilled when they are so inherently complex that they can be safely and effectively performed only by, or under the supervision of, a registered nurse or, when provided by regulation, a licensed practical (vocational) nurse.”

    Criteria for determining patient applicability:

    • Nursing services must be provided seven days a week.
    • Intravenous or intramuscular injections and intravenous feeding (TPN).
    • Enteral feeding that comprises at least 26 percent of daily calorie requirements and provides at least 501 milliliters of fluid per day.
    • Naso-pharyngeal and tracheotomy suctioning.
    • Insertion, sterile irrigation and replacement of suprapubic catheters.
    • Application of dressings with prescription medications and aseptic techniques.
    • Treatment of decubitus ulcers Stage 3 or worse, or widespread skin disorder.
    • Heat treatments which have been specifically ordered by a physician as part of active treatment and which require observation by skilled nursing personnel to evaluate the patient’s progress adequately.
    • 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.
    • Care of a colostomy during the early post-operative period in the presence of associated complications.


    1. Direct Skilled Therapy Services to Patients

    “Therapy services are considered skilled when they are so inherently complex that they can be safely and effectively performed only by, or under the supervision of, a qualified therapist. (See 42CFR §409.32) These skilled services may be necessary to improve the patient’s current condition, to maintain the patient’s current condition, or to prevent or slow further deterioration of the patient’s condition.”

    Criteria for determining patient applicability:

    • Skilled rehabilitation/therapy services require treatment at least five days a week.
    • Physical therapy.
    • Occupational therapy.
    • Speech and language pathology.

Skilled documentation remains one of the most difficult roadblocks for many facilities. Oftentimes, nurses do not chart, chart too little, or chart incorrectly. Consequently, the medical record does not reflect the care being provided. As with most things, education is the key to success. We need to provide more guidance on the specific items expected in the skilled note and what that looks like. Providing a skilled documentation cheat sheet can also be helpful steer the charting in the right direction. Below are some helpful tips when competing skilled documentation:

In Summary: Embrace Eight Keys to Great Medicare Charting

In each of the eight keys, documentation must:

  1. Be specific and support the primary diagnosis.
  2. Be complete a minimum of every 24 hours.
  3. Reflect the need for the continuation of skilled care (from the five areas above) – documentation must include all areas that are being skilled.
  4. Include vital signs and current condition.
  5. Describe any clinical deliverables—e.g., IV medications or dressings.
  6. Include the resident’s response to the care.
  7. Include how the resident is preforming the tasks being addressed by therapy—e.g., transfers – how is the resident transferring for the nursing staff?
  8. Avoid terminology in notes that is vague or non-descript. Examples include:
    • Patient tolerated treatment well
    • Continue with POC
    • Patient remains stable

Click Here to Download Printable Skillable Services Reference Guide


Contact Richter

Do you have questions about how to skill residents under Medicare A in a post-PDPM world or LTPAC clinical challenges? Call Richter’s clinical education consultants at 866-806-0799 to schedule a free consultation.

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Jennifer Leatherbarrow RN, BSN, RAC-CT, IPCO, QCP, CIC, is Manager of Clinical Consulting for Richter.

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