Medical Review Criteria Skilled Nursing Facility & Care Subject: Skilled Nursing Facility and Care Background: Skilled nursing facilities () provide facility-based skilled nursing care and related services for patients recovering from illness or injury, and rehabilitation services (e.g., physical therapy, occupational therapy, speech therapy) for individuals with musculoskeletal, neurological, complex medical, amputee, stroke and/or pulmonary conditions. Patients who require short-term care do not need to stay in an acute care hospital, but are unable to safely care for themselves at home; the goal of care is to provide the appropriate therapeutic interventions to facilitate independence, and to discharge the patient to the least restrictive (most independent) living environment. care facilities provide facility-based skilled nursing and rehabilitation services to individuals with serious illness or injury who do not require hospital level of care (e.g., acute hospitalization, inpatient rehabilitation, longterm acute care) but require a more intense level of service than can safely be provided at level of care. and subacute care facilities must be fully equipped and capable of providing required care, and have appropriate state licensure and accreditation/certification from an appropriate accrediting organization (e.g., the Joint Commission for the Accreditation of Healthcare Organizations/JCAHO). and subacute care services must be ordered under a plan of care established and reviewed regularly by the attending physician, and provided directly by, or under the supervision of qualified skilled technical or professional health personnel (RNs, LPNs, and/or licensed physical, occupational or speech therapists). Services are considered skilled if the inherent complexity of the service is such that it only can be performed safely/effectively by, or under the supervision of, licensed nursing or rehabilitation personnel. (A service that might ordinarily be considered non-skilled may be considered skilled in situations where, due to the patient s condition or medical complications, skilled nursing or rehabilitation personnel are required to perform or supervise the care, or observe the member.) Authorization: Prior authorization is required for admissions to skilled nursing facilities () and subacute care facilities provided to members enrolled in commercial and Marketplace Exchange (HMO, POS, and PPO) products. Policy and Coverage Criteria: Harvard Pilgrim Health Care (HPHC) covers skilled services provided in Skilled Nursing Facilities () and subacute care facilities when: Benefits are available under the member s Harvard Pilgrim Health Care plan; The member requires (and can be expected to benefit from) facility-based skilled nursing or rehabilitation services that cannot be safely provided in a less restrictive clinical setting; and Criteria below are met. and Care Page 1 of 8
A preadmission evaluation of the patient s condition and need for or subacute care must document all the following: Baseline level of function, and summary of medical history that has led to the need for or subacute care; Medical treatment needs (e.g., skilled therapies, specialized nursing care), including expected frequency and duration of treatment, and other information relevant to the member s care needs; Prognosis including expected level of improvement, and anticipated length of stay required to achieve that level of improvement; Family/caregivers willingness and ability to actively participate in learning techniques and medical management that will be needed to assist the member at home after discharge (as appropriate). An inpatient plan of care including ALL the following must be developed, managed, and updated by facility staff: Nursing and/or skilled rehabilitation goals and objectives for the individual member (including realistic and measurable functional goals), planned nursing and rehabilitation interventions to meet goals/objectives and promote recovery, and outcome(s) of the planned interventions; Evidence of active involvement of skilled nursing that is medically necessary to meet the member s medical needs, promote recovery and ensure medical safety. (Documentation must confirm that, in the absence of skilled nursing supervision of the treatment plan, there is a significant probability that physical/medical complications will arise.) Discharge plans (as appropriate). Daily documentation of the member s progress and/or complications is required; medical necessity/clinical appropriateness of ongoing and subacute care is evaluated through concurrent review. Service Admission Facility Admission On-Going Care ( or LOC) Criteria Medical record documentation confirms ALL the following: 1. Member requires skilled services (i.e., services that must be performed by, or under the supervision of, licensed nurses and/or physical or occupational therapists) at least 5 days per week; 2. Services can only be safely provided in an inpatient, and cannot be safely provided in a less restrictive clinical setting (e.g., at home with skilled home health services, or in outpatient setting); 3. Service Specific Level of Care (LOC) Criteria below are met. Medical record documentation confirms ALL the following: 1. Member requires more skilled services than are typically available at level of care (i.e., skilled nursing, and >2 hours of rehabilitation services per day, at least 6 days per week); 2. Medically necessary services can only be safely provided in an inpatient subacute care facility, and cannot be safely provided in a less restrictive clinical setting (e.g., LOC, at home with skilled home health services, or outpatient setting); 3. Member requires frequent on-site evaluation by a physician, nurse practitioner, or physician assistant; and 4. Service Specific LOC Criteria below are met. Medical record documentation confirms ALL the following: 1. Continued need for the inpatient or (as appropriate) setting, and significant medical and/or functional progress toward established goals; and Care Page 2 of 8
Service Criteria 2. Required services cannot be safely provided in a less restrictive setting; 3. Service Specific LOC Criteria below are met. On-going inpatient care may also be authorized (within applicable benefit limits) in situations where medical record documentation confirms the member has required frequent medical intervention that interfered with his/her participation in rehabilitative therapies or progress towards meeting therapy goals. Service Specific Level of Care Criteria(LOC) Service Skilled Intervention LOC Comments Catheters 1. Nursing management of indwelling bladder catheter, nephrostomy tube, or suprapubic tube during the early postinsertion period, or in the presence of catheter complications; OR Routine maintenance of an indwelling bladder catheter or suprapubic catheter does not constitute LOC. 2. Insertion, sterile irrigation, and/or replacement of suprapubic catheters. Central Lines Diabetic Care Administration of total or peripheral parenteral nutrition (TPN, PPN), medications, or fluids via a central line (e.g., Hickman Catheter, Porta- Cath). Daily monitoring of unstable blood sugars, and administration of varied doses of insulin (sliding scale). Existing central lines that are not in active use do not constitute or subacute LOC. Subcutaneous (SC) insulin injections at a stable dose in a stable diabetic do not constitute LOC, regardless of whether or not the member is able to self-inject. Enteral Tube Feedings via: Nasogastric (NG) tube Jejeunostomy tube (J-tube) Gastrostomy (G-tube) Management of enteral feeding regimen for a member with a newly inserted enteral tube when member is functionally incapable of sufficient oral intake to sustain life. Titration of enteral feedings to meet functional goals in a member with a newly inserted NG-tube, J-tube, or G- tube. A physician s order for sliding scale insulin does not constitute LOC if sliding scale insulin is not being administered daily. Maintenance of a stable enteral feeding regimen, or stable NGtube, J-tube, or G-tube alone does not constitute LOC. and Care Page 3 of 8
Service Skilled Intervention LOC Comments Medication Administration and Monitoring Monitoring of medication effects including a complicated p.o. medical regime. SC injections alone do not constitute LOC. Ostomy Care Pain Management Parenteral Fluids and/or Medications Management and/or teaching re: management of a new colostomy or ileostomy during the early postoperative period. Monitoring and adjustment of a complex pain management treatment plan including frequent dose adjustment, changes in the route of medication administration, or skilled intervention for uncontrolled pain and/or an unstable medical condition. Administration of at least one intravenous (IV) or intramuscular (IM) injection per day. Routine ostomy care does not constitute LOC. Subcutaneous (SC) injections alone do not constitute LOC. Parenteral Fluids and/or Medications Rehabilitative Care Administration of 2 or more different IM or IV medications on a daily basis (may include dosage adjustments and/or monitoring of lab results.) At least 1-2 hours of direct physical, occupational, or speech therapy per day, at least 5 days/week. SC insulin injections (stable dose) in a stable diabetic do not constitute LOC, regardless of whether or not the member is able to selfinject. Direct therapy time does not include time for documentation, family or team meetings, etc. Rehabilitative Care At least 2 hours of direct therapy (physical, occupational, or speech therapy) per day, at least 6 days/week (i.e., at least 12 hours of direct therapy per week). Dysphagia treatment by a Speech/Language Pathologist may qualify as skilled care, but Speech/Language therapy for language therapy alone does not constitute LOC. Direct therapy time does not include time for documentation, family or team meetings, etc. Member must be physically and cognitively willing and able to and Care Page 4 of 8
Service Skilled Intervention LOC Comments participate in, and benefit from, the rehabilitation program. Respiratory Care Administration of a system of care including skilled nursing observation and assessment to evaluate the member s need for modifications of treatment: Chest PT and/or aerosol delivery of medication (to mobilize secretions) at least 3x/day; or New respiratory treatments including initial phases of a regimen involving administration of medical gases (e.g., oxygen, bronchodilator therapy); or Naso-pharyngeal or tracheostomy suctioning provided on a frequent basis, with a documented need for member observation for respiratory distress; or Respiratory treatments provided (at least daily) on an as needed (PRN) basis in response to changes in the member s clinical condition. A physician s order for any of these systems of care does not constitute LOC if PRN services are routinely utilized on a less than daily basis. Respiratory Care Routine respiratory care of the stable, chronic vent-dependent member including chest physical therapy (PT), suctioning, tracheostomy care, and occasional need for changes in vent settings. Administration of chest PT and/or aerosol delivery of medication at least 3x/day including: >30% oxygen therapy; or Monitoring of oxygen saturation levels (and subsequent changes in O2 orders); or New nebulizer treatments; or Skilled respiratory assessment, suctioning, and/or care of an unstable tracheostomy. Slow weaning from oxygen, or routine tracheostomy care does constitute Sub-acute LOC. Respiratory care for a newly admitted vent-dependent member who requires chest PT, suctioning, and Care Page 5 of 8
Service Skilled Intervention LOC Comments tracheostomy care, and close clinical monitoring, to assure stability in the transition period. Wound Care Skilled care of decubitus ulcers, wounds, and/or widespread skin disorders involving ALL the following: Aseptic technique; Prescription medication; Skilled nursing observation/evaluation of the wound or ulcer. Wound Care Complex treatment of decubitus ulcers that, as a practical matter, can only be provided in a skilled nursing facility. Complex wound care requiring aseptic technique, packing, debridement, irrigation, and/or frequent assessment for complications such as infection or vascular compromise. May include surgical wounds, burns, or Stage 3-4 decubiti. Use of wound vacuum device requiring multiple setting changes. Coding: Codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive. Deleted codes and codes which are not effective at the time the service is rendered may not be eligible. CPT Code Description 92507 ST Treatment 92521 Evaluation of speech fluency (e.g., stuttering, cluttering) 92522 Evaluation of speech sound production (e.g., articulation, phonological process, apraxia, dysarthria) 92523 Evaluation of speech sound production (e.g., articulation, phonological process, apraxia, dysarthria) with evaluation of language comprehension and expression (e.g., receptive and expressive language) 92524 Behavioral and qualitative analysis of voice and resonance 92610 Evaluation of oral and pharyngeal swallowing function 97161 Physical therapy evaluation: low complexity, requiring these components: a history with no personal factors and/or comorbidities that impact the plan of care; an examination of body system(s) using standardized tests and measures addressing 1-2 elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; a clinical presentation with stable and/or uncomplicated characteristics; and clinical decision making of low complexity using standardized patient assessment instrument and Care Page 6 of 8
CPT Code Description and/or measurable assessment of functional outcome. Typically, 20 minutes are spent faceto-face with the patient and/or family. 97162 Physical therapy evaluation: moderate complexity, requiring these components: a history of present problem with 1-2 personal factors and/or comorbidities that impact the plan of care; an examination of body systems using standardized tests and measures in addressing a total of 3 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; an evolving clinical presentation with changing characteristics; and clinical decision making of moderate complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 30 minutes are spent face-to-face with the patient and/or family. 97163 Physical therapy evaluation: high complexity, requiring these components: a history of present problem with 3 or more personal factors and/or comorbidities that impact the plan of care; an examination of body systems using standardized tests and measures addressing a total of 4 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; a clinical presentation with unstable and unpredictable characteristics; and clinical decision making of high complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 45 minutes are spent face-to-face with the patient and/or family. 97165 Occupational therapy evaluation, low complexity, requiring these components: an occupational profile and medical and therapy history, which includes a brief history including review of medical and/or therapy records relating to the presenting problem; an assessment(s) that identifies 1-3 performance deficits (i.e., relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and clinical decision making of low complexity, which includes an analysis of the occupational profile, analysis of data from problem-focused assessment(s), and consideration of a limited number of treatment options. Patient presents with no comorbidities that affect occupational performance. Modification of tasks or assistance (e.g., physical or verbal) with assessment(s) is not necessary to enable completion of evaluation component. Typically, 30 minutes are spent face-to-face with the patient and/or family. 97166 Occupational therapy evaluation, moderate complexity, requiring these components: an occupational profile and medical and therapy history, which includes an expanded review of medical and/or therapy records and additional review of physical, cognitive, or psychosocial history related to current functional performance; an assessment(s) that identifies 3-5 performance deficits (i.e., relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and clinical decision making of moderate analytic complexity, which includes an analysis of the occupational profile, analysis of data from detailed assessment(s), and consideration of several treatment options. Patient may present with comorbidities that affect occupational performance. Minimal to moderate modification of tasks or assistance (e.g., physical or verbal) with assessment(s) is necessary to enable patient to complete evaluation component. Typically, 45 minutes are spent faceto-face with the patient and/or family. 97167 Occupational therapy evaluation, high complexity, requiring these components: an occupational profile and medical and therapy history, which includes review of medical and/or therapy records and extensive additional review of physical, cognitive, or psychosocial history related to current functional performance; an assessment(s) that identifies 5 or more performance deficits (i.e., relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and clinical decision making of high analytic complexity, which includes an analysis of the patient profile, and Care Page 7 of 8
CPT Code G0151 G0152 G0153 Description analysis of data from comprehensive assessment(s), and consideration of multiple treatment options. Patient presents with comorbidities that affect occupational performance. Significant modification of tasks or assistance (e.g., physical or verbal) with assessment(s) is necessary to enable patient to complete evaluation component. Typically, 60 minutes are spent face-to-face with the patient and/or family. PT Treatment, 15 minutes OT Treatment, 15 minutes Services performed by a qualified speech-language pathologist in the home health or hospice setting, each 15 minutes Billing Guidelines: Member s medical records must document that services are medically necessary for the care provided. Harvard Pilgrim Health Care maintains the right to audit the services provided to our members, regardless of the participation status of the provider. All documentation must be available to HPHC upon request. Failure to produce the requested information may result in denial or retraction of payment. Exclusions: Harvard Pilgrim Health Care (HPHC) does not cover or subacute facility care when criteria listed within this policy are not met. Per member s benefit contract exclusion, HPHC does not cover custodial care services (i.e., services furnished primarily for maintenance therapy or to assist an individual with Activities of Daily Living). References: 1. Compilation of the Social Security Laws; Requirements for, and Assuring Quality of Care in Skilled Nursing Facilities: https://www.ssa.gov/op_home/ssact/title18/1819.htm (Accessed 11/29/16) 2. Medicare: State Operations Manual Chapter 7 - Survey and Enforcement Process for Skilled Nursing Facilities and Nursing Facilities (Rev. 63, 09-10-10) at http://www.cms.gov/regulations-and- Guidance/Guidance/Manuals/downloads/som107c07.pdf (Accessed 11/29/16) Summary of Changes: Date Changes 10/17 Policy coverage criteria reviewed 12/14/16 Formatting updated. Coding added. Approved by Medical Review Committee: 11/28/17 Reviewed/Revised: 4/03, 5/04, 4/05, 4/06, 4/07, 5/08, 5/09, 5/10, 5/12, 5/13, 6/14, 9/14, 10/15, 12/16; 10/17 Initiated: 5/02 and Care Page 8 of 8