What Isn’t Changing Under PDPM: Skilled Care Requirements

The technical requirements for Medicare Part A coverage have not changed.

Physician Certification and Recertifications

The physician must certify that the skilled care is needed on a continuing basis because of the resident’s need for skilled nursing or rehabilitative care. 

Certifications must be obtained at the time of admission or as soon thereafter as is practical. The first recertification must be on or before day 14 of the Medicare stay, and each recertification after that must be at intervals not exceeding 30 days from the last recertification. The timing of 30 days is based on the physician’s signature for the designated recertification beyond the 14th day.

If a resident is admitted (or readmitted) directly to the SNF from a qualifying hospital stay, the resident can be considered to meet the level of care requirements, up to and including the ARD for the five-day assessment, when correctly assigned to one of the designated case-mix groups. Although the case-mix groups have been updated for PDPM, this provision remains in place.

In conclusion, if questions remain as to whether your new admission or readmission qualifies for skilled care, please reference the Medicare Benefit Policy Manual, Chapter 8, section 30.2.

Technical Requirements

  • The prospective resident must have Medicare Part A coverage with days available in their benefit period.
  • The individual must have been an inpatient of a hospital for a medically necessary stay for at least three consecutive calendar days (midnights). Days in observation or the emergency room do not count.
  • The beneficiary must be admitted to a Medicare-certified bed within 30 days of the qualifying Part A stay. The transfer and admission to the SNF can be from the beneficiary’s home, assisted living facility, or a non-skilled stay in a nursing facility. The day of discharge from the hospital is not counted in the 30 days.
  • The beneficiary must require skilled care for a condition that was treated during the qualifying hospital stay, or for a condition that arose while in the SNF for treatment of a condition for which the beneficiary previously was treated in the hospital. Remember that the applicable hospital condition need not have been the principal diagnosis that precipitated the hospital admission, but any condition present during the qualifying hospital stay.

Additional factors needed to establish eligibility for skilled coverage remain in place. These include:

  • Services must be ordered by the physician;
  • The resident requires daily skilled services:
    • Five days or greater per week for rehabilitation services;
    • Seven days per week for nursing services; or
    • Six days per week for skilled restorative programming (with a word of caution that, when skilled services are based on a skilled restorative program, medical evidence documentation must justify the services, which generally are only a few weeks in duration);
  • The daily skilled services must be provided as an inpatient in a SNF; and
  • The services delivered must be reasonable and necessary for treatment of the resident’s illness or injury.

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