PDPM: Qualifying for a Skilled Stay

As promised, each month Reliant will highlight a technical aspect or clinical component of the new Patient Driven Payment Model (PDPM). We believe these discussions will aide in understanding and minimize concerns regarding beneficiaries’ access to care. This month we will start at the beginning, qualifying for a skilled stay.

The criteria for a resident to qualify for a skilled stay has not changed under PDPM . Per the Medicare Benefit Policy Manual, care at the skilled nursing facility level is covered if the following four factors are met:

1. The patient requires skilled nursing services or skilled rehabilitation services, i.e., services that must be performed by or under the supervision of professional or technical personnel; are ordered by a physician and the services are rendered for a condition for which the patient received inpatient hospital services or for a condition that arose while receiving care in a SNF for a condition for which he received inpatient hospital services. Skilled nursing and/or skilled rehabilitation must

a. 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

b. 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.

2. The patient requires these skilled services on a daily basis. Daily basis is defined to be a. “on essentially a 7-days-a-week basis” but clarifies that a beneficiary’s inpatient stay based solely on the need for skilled rehabilitation services would meet the “daily basis” requirement when they need and receive those services on at least 5 days a week.

3. As a practical matter, considering economy and efficiency, the daily skilled services can be provided only on an inpatient basis in a SNF. (See §30.7.)

4. The services delivered are reasonable and necessary for the treatment of a patient’s illness or injury, i.e., are consistent with the nature and severity of the individual’s illness or injury, the individual’s particular medical needs, and accepted standards of medical practice. The services must also be reasonable in terms of duration and quantity.

Under PDPM, as long as these four conditions are met, the beneficiary will qualify for a stay in your SNF. A review of skilled services defined (section 30.2) is always beneficial and highlights the continued need for therapy involvement in the beneficiary’s care.

As Reliant partners to prepare for PDPM, steps to evaluate current trends should be taken. Reliant recommends conducting a facility assessment of the current skilled needs within your facility. Evaluating important factors such as what percentage of residents are skilled for nursing only, therapy only, or a combination of the two? Within each category, what is the breakdown of services provided? Analysis of the facility assessment will guide in predicting resource needs and planning under PDPM, as well as lead to a seamless transition with successful outcomes.

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