Skilled Services

Table of Contents

• Skilled Services
  • Skilled Nursing
  • Examples of skilled nursing
  • Skilled Therapy
  • Skilled Respiratory
  • Nonskilled Service Examples
    • Examples of personal care services
• General Skilled Services Resources

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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.

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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.

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Examples of skilled nursing

1. Intravenous or intramuscular injections and intravenous feeding.
2. Enteral feeding that comprises at least 26 percent of daily calorie requirements and provides at least 501 milliliters of fluid per day.
3. Nasopharyngeal and tracheostomy aspiration.
4. Insertion and sterile irrigation and replacement of suprapubic catheters.
5. Application of dressings involving prescription medications and aseptic techniques.
6. Treatment of extensive decubitus ulcers or other widespread skin disorder.
7. 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.
8. Initial phases of a regimen involving administration of medical gases.
9. 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.

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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.

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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.

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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).

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Examples of personal care services include, but are not limited to, the following:

1. Administration of routine oral medications, eye drops, and ointments.
2. General maintenance care of colostomy and ileostomy.
3. Routine services to maintain satisfactory functioning of indwelling bladder catheter.
4. Changes of dressings for noninfected postoperative or chronic conditions.
5. Prophylactic and palliative skin care, including bathing and application of creams, or treatment of minor skin problems.
6. Routine care of the incontinent patient, including use of diapers and protective sheets.
7. General maintenance care in connection with a plaster cast.
8. Routine care in connection with braces and similar devices.
9. Use of heat as a palliative and comfort measure, such as whirlpool and hydrocollator.
10. Routine administration of medical gases after a regimen of therapy has been established.
11. Assistance in dressing, eating, and going to the toilet.
12. Periodic turning and positioning in bed.
13. 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.

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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 6/26/2024