- Medical Review
- Medical Review Focus Areas
- Service Specific Post-Payment Audits of Home Health PDGM Bills
- Service Specific Post-Payment Audits for Hospice Length of Stay > 730 Days
- Service Specific Post Payment Review of Psychotherapy, 60 Minutes with Patient – CPT 90837
- Service Specific Post Payment Review of Ambulance Transport and Mileage When Billed With Modifiers RJ, JR, RG, GR, NJ, JN, NG, GN
- Service Specific Post-Payment Audits of Home Health Value Code 17 Bills
- Announcing Service Specific Post-Payment Audits of Hyperbaric Oxygen (HBO) Services for J6 A Regions: IL, WI, and MN
- Service Specific Post-Payment Medical Review Notice Home Health PDGM (Edit 5AAGP)
- Service Specific Post Payment Review of Botulinum Injection, onabotulinumtoxina, 1 Unit – CPT J0585
- Service Specific Post Payment Review of Floweramnioflo, 0.1 CC – CPT Q4177
- Service Specific Post Payment Review of Grafix Prime (CPT Q4133)
- Service Specific Post Payment Review of Nonemergency Ambulance Transport and Mileage
- Service Specific Post Payment Review - Hospice GIP Services Over 7 Days (5ANLP) for JK A Regions: NY/CT, MA, ME, NH/VT and RI
- Service Specific Post Payment Review of Home Health Homebound Criteria (Edit 5AAHP)
- Service Specific Post Payment Review of Fluoroscopic Guidance for Needle Placement - CPT 77002
- Service Specific Post Payment Review of Computed Tomography, Abdomen and Pelvis with Contrast Material(s) - CPT 74177
- Service Specific Post Payment Review of Darbepoetin Alfa Injection, 1 microgram (Non-ESRD Use)
- Service Specific Post Payment Review of Therapeutic Procedure, 1 or More Areas, Each 15 Minutes; Aquatic Therapy With Therapeutic Exercise – CPT 97113
- Service Specific Post Payment Medical Review Summary Results of Hospice Services with Length of Stay > 730 Days
- Service Specific Post Payment Medical Review Summary Results of Home Health Value Code 17 Bills
- Review Results For Service Specific Postpayment Review of Psychotherapy, 60 Minutes With Patient
- Service Specific Post-Payment Medical Review Notice Hospice with Length of Stay over 730 Days (Edit 5ANKP)
- Service Specific Post-Payment Audits of Hospice GIP Care, DOS 3/1/2020 and After
- Service Specific Post-Payment Audits of Home Health LUPA Claims
- Service Specific Post Payment Review of Debridement, Subcutaneous Tissue (Includes Epidermis and Dermis, If Performed); First 20 Square Centimeters or Less– CPT 11042
- Service Specific Post-Payment Review of Tangential Biopsy of Skin-Single Lesion CPT 11102 with Destruction-Premalignant Lesion-First Lesion CPT 17000
- Service Specific Post Payment Review Summary Results – Home Health PDGM Bills (Edit 5AAGP)
- Review Results for Service Specific Post-Payment Review of Artacent Wound, per Square Centimeter - CPT Q4169
- Review Results for Service Specific Post-Payment Review of Q4133 - Grafix Prime
- Announcing Service Specific Post-Payment Audits of Group Psychotherapy Services for J6 A Regions: IL, WI and MN
- Service Specific Post Payment Medical Review Summary Results of Hospice Services with GIP > 7 Days
- Service-Specific Postpayment Medical Review Summary Results of Home Health PDGM Bills
- Review Results for Service Specific Post-Payment Review of Hyaluronan or Derivative - CPT J7326
- Review Results for Service Specific Post Payment Review of Hyaluronan or Derivative – CPT J7327
- Review Results for Service Specific Post-Payment Review of Fluoroscopic Guidance for Needle Placement
- J6_B_Review Results for Service Specific Post-Payment Review of J0585 – Botulinum Injection, Onabotulinumtoxina
- Review Results for Service Specific Post-Payment Review of Computed Tomography, Abdomen And Pelvis; With Contrast Material(s)
- Review Results for Service Specific Post-Payment Review of Therapeutic Procedure, 1 or More Areas, Each 15 Minutes; Aquatic Therapy with Therapeutic Exercise - CPT 97113
- Review Results for Service Specific Post Payment Review of Floweramnioflo
- Review Results for Service Specific Postpayment Review of Tangential Biopsy of Skin; Single Lesion CPT 11102 with Destruction, Premalignant Lesion; First Lesion CPT 17000
- Review Results for Service Specific Post-Payment Review of Darbepoetin Alfa Injection (Non-ESRD Use)
- Service Specific Post-Payment Review Summary Results – Home Health Homebound Criteria (Edit 5AAHP)
- Service Specific Post-Payment Review Summary Results – Hospice GIP Services Greater than 7 Days (Edit 5ANLP)
- Service Specific Post Payment Medical Review Summary Results of Hospice Services with General Inpatient Care, Date of Service 3/1/2020 and After
- Service Specific Post Payment Medical Review Summary Results of Home Health Low Utilization Payment Adjustment Claims
- Announcing Service Specific Post-Payment Audits of Individual Psychotherapy Services for J6 A Regions: IL, WI and MN
- Review Results for Service Specific Post Payment Review of Debridement, Subcutaneous Tissue (Includes Epidermis and Dermis, if Performed); First 20 Square Centimeters or Less – CPT 11042
- Service Specific Post Payment Review of Artacent Wound, Per Square Centimeter - CPT Q4169
- Service Specific Post-Payment Audits of Hospice GIP Care
- Service Specific Post Payment Review of Hyaluronan or Derivative - HCPCS J7326, J7327
- Skilled Nursing Facility Education Center
Skilled Services
Table of Contents
Skilled Services
Education, evaluation, treatment, observation and skilled case management are components of skilled services.
Skilled nursing and skilled rehabilitation services must be provided "daily," seven days a week. A patient whose inpatient stay is based solely on a need for skilled rehabilitation services would meet the "daily basis" requirement when they need and receive those services at least five days a week.
To be considered a skilled service, the service must:
- be of sufficient complexity that can only be safely and effectively performed by or under the supervision of professional or technical personnel.
- 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.
- be provided directly by or under the general supervision of these skilled nursing or skilled rehabilitation personnel to assure the patient's safety and achieve the medically desired results.
Skilled Nursing
The deciding factors are always whether the services are considered reasonable, effective treatments for the patient’s condition and require the skills of a therapist or whether they can be safely and effectively carried out by nonskilled personnel or caregivers.
Examples of skilled nursing
- Intravenous or intramuscular injections and intravenous feeding.
- Enteral feeding that comprises at least 26 percent of daily calorie requirements and provides at least 501 milliliters of fluid per day.
- Nasopharyngeal and tracheostomy aspiration.
- Insertion and sterile irrigation and replacement of suprapubic catheters.
- Application of dressings involving prescription medications and aseptic techniques.
- Treatment of extensive decubitus ulcers or other widespread skin disorder.
- Heat treatments which have been specifically ordered by a physician as part of active treatment and which require observation by nurses to adequately evaluate the patient's progress.
- Initial phases of a regimen involving administration of medical gases.
- Rehabilitation nursing procedures, including the related teaching and adaptive aspects of nursing, that are part of active treatment, e.g., the institution and supervision of bowel and bladder training programs.
Skilled Therapy
Skilled therapy is indicated when the patient has some injury or physical deficit related to the recent hospital-qualifying stay. It now requires a structured rehabilitation program to reach a previous or highest level of function after an illness. The therapist must establish a plan which includes measurable goals to track progress, and the skilled therapy provided should be therapy only a skilled therapist can provide. Physical therapy notes must show the degree of motion lost, the degree to be restored, and the impact on mobility and/or function. Jimmo vs. Sebelius can be used with maintenance therapy designed to maintain or prevent deterioration.
Cognitive ability is also a factor when considering skilled care. Please see links provided for more information on the specific requirements of Skilled Therapy and Jimmo vs. Sebelius.
Skilled Respiratory
Services that are provided by qualified professionals (respiratory therapists, respiratory nurse). Respiratory therapy services are for the assessment, treatment, and monitoring of patients with deficiencies or abnormalities of pulmonary function. Only minutes that the respiratory therapist or respiratory nurse spends with the resident shall be recorded on the MDS. This time includes resident evaluation/assessment, treatment administration and monitoring, and setup and removal of treatment equipment. Time that a resident self-administers a nebulizer treatment without supervision of the respiratory therapist or respiratory nurse is not included in the minutes recorded on the MDS.
Nonskilled Service Examples
Personal care services which do not require the skills of qualified technical or professional personnel are not skilled services except under the circumstances specified in Section 409.32(b).
Examples of personal care services include, but are not limited to, the following:
- Administration of routine oral medications, eye drops, and ointments.
- General maintenance care of colostomy and ileostomy.
- Routine services to maintain satisfactory functioning of indwelling bladder catheter.
- Changes of dressings for noninfected postoperative or chronic conditions.
- Prophylactic and palliative skin care, including bathing and application of creams, or treatment of minor skin problems.
- Routine care of the incontinent patient, including use of diapers and protective sheets.
- General maintenance care in connection with a plaster cast.
- Routine care in connection with braces and similar devices.
- Use of heat as a palliative and comfort measure, such as whirlpool and hydrocollator.
- Routine administration of medical gases after a regimen of therapy has been established.
- Assistance in dressing, eating, and going to the toilet.
- Periodic turning and positioning in bed.
- General supervision of exercises which have been taught to the patient; including the actual carrying out of maintenance programs, i.e., the performance of the repetitive exercises required to maintain function do not require the skills of a therapist and would not constitute skilled rehabilitation services. Similarly, repetitious exercises to improve gait, maintain strength, or endurance; passive exercises to maintain range of motion in paralyzed extremities, which are not related to a specific loss of function; and assistive walking do not constitute skilled rehabilitation services.
Although every reasonable effort has been made to assure the accuracy of the information, within these pages, at the time of publication, the Medicare Program is constantly changing, and each provider must remain abreast of the Medicare Program requirements. Please go directly to the source to view regulations and get guidance.
General Skilled Services Resources
Learn more about Skilled Services by accessing valuable resources via the links below.
- Local Coverage Determination Outpatient Physical and Occupational Therapy Services L33631
- Local Coverage Determination Speech-Language Pathology L33580
- Local Coverage Billing and Coding Article Speech-Language Pathology A52866
- Code of Federal Regulations section 409.33
- Code of Federal Regulations section 409.44
- CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15
- Local Coverage Billing and Coding Article Outpatient Physical and Occupational therapy Services A56566
Revised 8/8/2023
Targeted Probe and Educate Manual
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Targeted Probe and Educate Manual
The preferred method to submit Medical Records is NGSConnex:
Visit our Contact Us page for other methods of submission.
Targeted Probe and Educate Manual
The preferred method to submit Medical Records is NGSConnex:
Visit our Contact Us page for other methods of submission.
Targeted Probe and Educate Manual
The preferred method to submit Medical Records is NGSConnex:
Visit our Contact Us page for other methods of submission.
Targeted Probe and Educate Manual
The preferred method to submit Medical Records is NGSConnex:
Visit our Contact Us page for other methods of submission.
Targeted Probe and Educate Manual
The preferred method to submit Medical Records is NGSConnex:
Visit our Contact Us page for other methods of submission.
Targeted Probe and Educate Manual
The preferred method to submit Medical Records is NGSConnex:
Visit our Contact Us page for other methods of submission.
Targeted Probe and Educate Manual
The preferred method to submit Medical Records is NGSConnex:
Visit our Contact Us page for other methods of submission.