"Your assumptions are your windows on the world. Scrub them off occasionally, or the light won't come in."
- Isaac Asimov.
This blog is to help clarify the rules of Medicare and the benefits for Medicare Part A residents in a Skilled Nursing Facility.
- Observation and Assessment – COVID-19 Exposed
A blog subscriber sent a question regarding skilling patients who are exposed to COVID-19.
“Kris Mastrangelo's recent blog states exposure to Covid is a skilled need. I believe CMS and AAPACN have clarified this multiple times to be not accurate information.
I am a moderator of a national Facebook group of tens of thousands of MDS nurses.
Would love to discuss with Kris.”
Observation and Assessment is a skilled qualifier when:
- Observation and assessment are needed to identify and evaluate the patient’s need for treatment,
or
- Observation and assessment are needed to identify and evaluate the patient’s need for modification of treatment,
or
- Observation and assessment are needed to identify and evaluate the patient’s need for need additional medical procedures.
or
- There is a reasonable probability for complications or potential,
or
- There is a reasonable probability for further acute episodes.
A resident exposed to COVID-19 requires a nurse to observe and assess for signs and symptoms of COVID-19 in order to ensure medical safety and promote recovery. In April of 2020, CDC data depicted that 67% of deaths were individuals 65 years or older.
Examples of non-COVID-19 Observation and Assessment from the Medicare Guidelines below. If a patient does NOT acquire COVID-19, that does not negate the rationale or acceptability for skilled coverage. In fact, one could argue that skilled services may have prevented the spread.
Seeing there is a reasonable probability of COVID-19 transmission, the observation and assessment criterion meets the requirement.
Example #1:
“A patient with congestive heart failure may require continuous close observation to detect signs of decompensation, abnormal fluid balance, or adverse effects resulting from prescribed medication(s) that serve as indicators for adjusting therapeutic measures.” (Final Rule 7/31/99)
Example #2:
“Similarly, surgical patients transferred from a hospital to an SNF while in the complicated, un-stabilized postoperative period, for example, after hip prosthesis or cataract surgery, may need continued close skilled monitoring for postoperative complications and adverse reaction.” (Final Rule 7/31/99)
Example #3:
“Patients who, in addition to their physical problems, exhibit acute psychological symptoms such as depression, anxiety, or agitation, may also require skilled observation and assessment by technical or professional personnel to ensure their safety or the safety of others, that is, to observe for indications of suicidal or hostile behavior. The need for services of this type must be documented by physicians’ orders or nursing or therapy notes.” (Final Rule 7/31/99)
According to the CDC,
“Isolation is for people who are ill, while quarantine applies to people who have been in the presence of a disease but have not necessarily become sick themselves.”
“Isolation separates sick people with a contagious disease from people who are not sick.”
- Isolation is for patients with symptoms and or positive tests.
- Quarantine is for patients exposed but exhibits no symptoms.
HHI proclaims that exposed residents require the skills of a nurse to observe and assess for signs and symptoms of COVID-19.
Daily Skilled Nursing COVID-19 Quarantined and Isolated (An excerpt from the HHI Core Components)
Secondary to the patient’s positive COVID-19 diagnosis, changing medical condition, and the reasonable probability for complications, this patient inherently requires skilled nursing to identify and evaluate the need for modification of treatment and to assess for additional medical procedures until the patient’s medical condition is stabilized.
The patient’s condition required observation and assessment by a licensed nurse.
According to the CDC, symptoms can range from mild to severe and may appear up to two weeks after exposure to the virus.
Skilled nursing observation and assessment as follows:
- Skilled nursing for observation and assessment of signs and symptoms of exacerbation of dehydration.
- Skilled nursing for observation and assessment of signs and symptoms of exacerbation of septicemia.
- Skilled nursing for observation and assessment of signs and symptoms of exacerbation of pneumonia.
- Skilled nursing for observation and assessment of signs and symptoms of exacerbation of nutritional risk.
- Skilled nursing for observation and assessment of signs and symptoms of exacerbation of weight loss.
- Skilled nursing for observation and assessment of signs and symptoms of exacerbation of blood sugar control.
- Skilled nursing for observation and assessment of signs and symptoms of exacerbation of impaired cognition.
- Skilled nursing for observation and assessment of signs and symptoms of exacerbation of mood and behavior conditions.
- Skilled nursing for observation and assessment of signs and symptoms of exacerbation of cardio complications.
- Skilled nursing for observation and assessment of signs and symptoms of exacerbation of pulmonary complications.
- Skilled nursing for observation and assessment of signs and symptoms of fever.
- Skilled nursing for observation and assessment of signs and symptoms of rash.
- Skilled nursing for observation and assessment of signs and symptoms of cognitive changes.
- Skilled nursing for observation and assessment of proper infection control procedures and compliance.
- Skilled nursing for observation and assessment of proper isolation and quarantine
- Skilled nursing for observation and assessment of pulse oximetry.
- Skilled nursing for observation and assessment of signs and symptoms of cough.
- Skilled nursing for observation and assessment of signs and symptoms of shortness of breath.
- Skilled nursing for observation and assessment of signs and symptoms of difficulty breathing.
- Skilled nursing for observation and assessment of signs and symptoms of chills.
- Skilled nursing for observation and assessment of signs and symptoms of shaking with chills.
- Skilled nursing for observation and assessment of signs and symptoms of muscle pain.
- Skilled nursing for observation and assessment of signs and symptoms of headache.
- Skilled nursing for observation and assessment of signs and symptoms of sore throat.
- Skilled nursing for observation and assessment of loss of taste or smell.
- Skilled nursing for observation and assessment of signs and symptoms related to exacerbation of COVID.
- Skilled nursing for observation and assessment of treatments and conditions that arose secondary to isolation and quarantine.
- Skilled nursing for observation and assessment of signs and symptoms related to exacerbation of current or prior diagnoses.
- Overall management of care plan to ensure medical safety and promote recovery.
- Skilled teaching and training activities for pulmonary hygiene.
- Skilled teaching and training activities for avoidance of infection and irritants.
- Skilled teaching and training activities for importance of rest.
- Skilled teaching and training activities for importance of prompt reporting of signs of recurrence of pneumonia.
- Skilled teaching and training activities for medication regimen.
- Essentially Stabilized
The caller also included the below excerpt which further supports HHI position that the daily skills of a nurse are required to observe and assess the patient when the likelihood of change exists.
30.2.3.2 – 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.”
The caller bolded “essentially stabilized”, of which HHI agrees and feels compelled to expound on these quoted words.
The daily observation and assessment skills of a nurse are skilled until the resident’s treatment regimen is essentially stabilized, and the resident does not have the need for additional procedures, modifications, or treatment changes.
- Treatment or Conditions
Per the Medicare SNF Guidelines, the skilled rationale includes:
“Treated for a condition which was treated during a qualified stay…
or…
which arose
while in a SNF for a treatment of condition
for which the beneficiary previously was treated in a hospital”
“treatments or conditions that arose secondary
to
isolation or quarantine”
For Example:
Fractured hip develops pneumonia secondary to immobility. Skilled nursing for the Pneumonia.
For Example:
Fractured hip develops swallowing issues secondary to immobility. Skilled Speech Therapy services rendered for swallowing.
For Example:
An isolated patient’s anxiety is exacerbated due to isolation. The skilled coverage criterion transcends to overall management of care plan to ensure medical safety and promote recovery in relation to the resident’s anxiety.
Perhaps, these skilled opportunities are more obvious the me as a therapist because this has been the foundation for skilled therapy since the beginning of Medicare Coverage criterion.
- COVID-19 Positive Skilled or Not Skilled
The caller stated that she had, in writing, that CMS disallows skilling the COVID-19 positive patient. I asked for this in writing and she sent below: (Please note, caller emailed CMS while we were on the phone.)
On Tue, Jan 24, 2023, at 6:03 PM
WAIVER FOR A POSITIVE TEST. Please see CMS COVID-19 FAQs, section X: "6.
Question:
Can a positive COVID-19 test qualify a beneficiary (including a beneficiary who is currently receiving non-skilled services in a nursing home?) for a covered Medicare Part A skilled nursing facility (SNF) stay?
Answer:
A COVID-19 diagnosis would not in and of itself automatically serve to qualify a beneficiary for coverage under the Medicare Part A SNF benefit.
That’s because SNF coverage isn’t based on particular diagnoses or medical conditions, but rather on whether the beneficiary meets the statutorily prescribed SNF level of care definition of needing and receiving skilled services on a daily basis which, as a practical matter, can only be provided in a SNF on an inpatient basis."
HHI feels that the above CMS answer does not disallow skilling COVID-19 patients as the caller stated. The answer does assume the inquirer understands the Practical Matter Criterion.
With that said, we need to unpack the Practical Matter Criterion:
5.) Practical Matter Criterion
The practical matter criterion is a principle used in decision-making to determine whether an action or decision is practical and able to be carried out in the real world. It is used to assess the feasibility and likelihood of success of a proposed plan or idea, and to ensure that resources and constraints are considered. The intent of the practical matter criterion is to help ensure that decisions are realistic and achievable, rather than being based on idealistic or unrealistic assumptions.
The Practical Matter Criterion is used to ensure that the patient is not receiving services that can be provided in a less intensive setting, such as at home or in a community-based facility.
“As a practical matter, considering economy and efficiency,
the daily skilled services can only be provided in a skilled nursing facility?”
It is appropriate to skill a patient when:
- Outpatient services are not available in the area where the individual lives.
- Outpatient services are available in the area where the individual lives, but transportation to the closest facility could cause an excessive physical hardship, be less economical, or less effective than placement in the skilled nursing facility.
- The availability at home of a capable and willing caregiver should be considered, but the care can be furnished only in the skilled nursing facility if home care would be ineffective because there would be insufficient assistance at home for the patient/resident to reside there safely.
- If the use of alternative services would adversely affect the patient/resident’s medical condition, then as a practical matter the daily skilled service(s) can only be provided on an inpatient basis.
- COVID-19 Diagnosis and Presumption of Coverage Criterion
Per the CMS response above, “A COVID-19 diagnosis alone does not in itself automatically qualify” is not that simple. And it is recommended that providers utilize experts in the field of Medicare Skilled Coverage Criterion when they are unsure or encounter interfacility disagreement on a coverage decision. HHI agrees and applies the principle that every case needs to be reviewed individually and that multiple factors (diagnosis, functional level, medical conditions, co-morbidities, presumption of coverage, practical matter criterion, etc.) all impact the decision for skilled coverage.
HHI highlights the importance of understanding, considering and referencing the Presumption of Coverage Criterion. An isolated COVID-19 positive patient codes into an ES1 Nursing Case Mix Group (CMG) which is in fact supported by the Presumption of Coverage Criterion.
As a review, the PDPM CMG (Case Mix Group) is a classification system used in Skilled Nursing Facilities (SNFs) to determine the level of care and reimbursement rate for Medicare patients. The Nursing CMG level is determined by the patient's clinical condition, care needs, diagnosis, and approximately 103 plus elements from the MDS. The PDPM CMG (Case Mix Group) level is used in conjunction with the Presumption of Coverage Criterion, also known as the Skilled Coverage Criterion, to determine the patient's coverage under Medicare's SNF benefit.
The Presumption of Coverage Criterion
“Automatically classified as meeting the SNF level of care requirement i.e., skilled up to and including the assessment reference date (ARD).”
The SNF PPS Final Rule directs providers that a:
- Medicare Beneficiary is essentially skilled if the 5-Day PPS MDS Assessment is accurately coded and classifies the patient into one of the upper 17 Nursing CMGs.
The Upper 17 Nursing CMG’s Presumed Skilled:
- ES1 (COVID-19 Positive and Isolation),
- ES2,
- ES3,
- HDE2,
- HBC2,
- HDE1,
- HBC1,
- LDE2,
- LBC2,
- LDE1,
- LBC1,
- CDE2,
- CBC2,
- CA2,
- CDE1,
- CBC1
- Medicare Beneficiary is not automatically skilled if the 5-Day PPS MDS Assessment is accurately coded and classifies the patient into one of the lower 8 Nursing CMGs. However, a lower 8 CMG does not mean the patient does not qualify for skilled coverage.
The Lower 8 Nursing CMG’s NOT automatically Presumed Skilled (and more likely to be audited by MAC), but can be skilled:
- PDE2,
- PBC2,
- PA2,
- PDE1,
- PBC1,
- PA1,
- BAB2.
- Per the FY 2019 SNF PPS Final Rule, the purpose of the presumption is:
“to afford a streamlined and simplified administrative procedure for readily identifying those Beneficiaries with the greatest likelihood of meeting the level of care criteria ...”
The administrative presumption whereby a Medicare Party A Beneficiary who is correctly assigned to one of the designated, more intensive Case Mix classifiers on the initial 5-Day Medicare PPS Assessment is automatically presumed skilled.
- MA DPH Letter
The MA DPH letter was included to demonstrate the logic and wisdom of the department mandating that exposed residents are observed every shift. HHI agrees that if a patient is not observed, then symptoms cannot be identified, treatments cannot be rendered, nor can quality care be expected.
- Be Kind and Courteous
Please stay positive! It is much easier to be negative and to not pause to dissect the rules. The long-term industry needs advocates and thinkers to keep this industry afloat. Please be mindful and intentional about being part of the solution.
"An open mind is not an end in itself but a means to the end of finding truth."
- Peter Kreeft.
- HHI is Here to Help
This blog demonstrates the complexity of the Medicare reimbursement system. The intent is for providers to make proper decisions with all the facts of Medicare Entitlement, Eligibility and Coverage Criterion. If you do not know or need to ask a question, HHI is here to help.
HHI provides definitive coverage decisions only when a medical record review is completed.
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