Payment Policy: Skilled Nursing Facility Leveling Form
Payment Policy: Skilled Nursing Facility Leveling
Reference Number: CC.PP.206
Product Types: All
Last Review Date: 4/2024
[Coding Implications](Coding Implications)
[Revision Log](Revision Log)
See [Important Reminder](Important Reminder) at the end of this policy for important regulatory and legal information.
Policy Overview
The purpose of this policy is to ensure that the level of skilled nursing facility care reported by the provider reflects the services performed.
| High-Cost Drug List* | ||
|---|---|---|
| Adempas | Avastin | Cinryze |
| Advate | Benefix | Cubicin |
| Afinitor | Bexarotene | Cuprimine |
| Aldurazyme | Bosulif | Daklinza |
| Apokyn | Advate | Daraprim |
| Aralast NP | Cimzia Starter Kit | Dificid |
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CLINICAL POLICY
Skilled Nursing Facility Leveling
| Dispserz | Lenvima (24 mg Daily Dose) | Sprycel |
|---|---|---|
| Elaprase | Letairis | Stelara |
| Elocotate | Linezolid | Stivarga |
| Erivedge | Leukine | Subsys |
| Esbriet | Lynparza | Supprelin LA |
| Exjade | Mekinist | Sutent |
| Farydak | Myalept | Syprine |
| Ferriprox | Naglazyme | Tafinlar |
| Firazyr | Neulasta | Tarceva |
| Gamagard Liquid | Neupogen | Tasigna |
| Gamunex-C | Nexavar | Tetrabenazine |
| Gattex | Ofatumumab | Thalomid |
| Glassia | Ofev | Thiola |
| Geevec | Olysio | Tobi Podhaler |
| Hrvoni | Opdivo | Tyvaso Refill |
| Herceptin | Orenitram | Valchlor |
| Hetlioz | Orkambi | Velcade |
| HP Acthar | Opsumit | Viekira Pak |
| Humira Pen (Crohn’s Disease) | Pomalyst | Votrient |
| Ibrance | Privigen | Vpriv |
| Iclusig | Prolastin-C | Xalkori |
| Ilaris | Promacta | Xenazine |
| Imbruvica | Ravicti | Xtandi |
| Increlex | Revlimid | Xyrem |
| Inlyta | Rituxan | Zelboraf |
| Jadenut | Sabril | Zemaira |
| Jakafi | Samsca | Zolinza |
| Juxtapid | Serostim | Zydelig |
| Kalydeco | Simponi | Zykadia |
| Kuvan | Soliris | Zytiga |
| Lazanda | Sovaldi | Zyvox |
Background
The following information is a synopsis from the Medicare Benefit Policy Manual¹:
Skilled nursing and/or skilled rehabilitation services are services, furnished in accordance with physician orders, that:
- 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
- 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.
In order for a nursing service to be considered a “skilled service” it must be a service that can only be safely and effectively performed by, or under the supervision of, a registered nurse or, when provided by regulation, a licensed practical nurse.
A condition that would not ordinarily require skilled nursing services may still require skilled nursing under certain circumstances. In such instances, skilled nursing care is necessary only when:
- The particular patient’s special medical complications require the skills of a registered nurse or, when provided by regulation, a licensed practical nurse to perform a type of service that would otherwise be considered non-skilled; OR,
- The needed services are of such complexity that the skills of a registered nurse or, when provided by regulation, a licensed practical nurse are required to furnish the services.
A service is not considered a skilled nursing service merely because it is performed by or under the direct supervision of a nurse.
Coding and Modifier Information
This payment policy references Current Procedural Terminology (CPT®). CPT® is a registered trademark of the American Medical Association. All CPT® codes and descriptions are copyrighted 2023, American Medical Association. All rights reserved. CPT codes and CPT descriptions from current manuals and those included herein are not intended to be all-inclusive and are included for informational purposes only. Codes referenced in this payment policy are for informational purposes only. Inclusion or exclusion of any codes does not guarantee coverage. Providers should reference the most up-to-date sources of professional coding guidance prior to the submission of claims for reimbursement of covered services.
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Skilled Nursing Facility Leveling
| CPT/HCPCS Code | Descriptor |
|---|---|
| 99304 | Initial nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 25 minutes must be met or exceeded. |
| 99305 | Initial nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 35 minutes must be met or exceeded. |
| 99306 | Initial nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 50 minutes must be met or exceeded. |
| 99307 | Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 10 minutes must be met or exceeded. |
| 99308 | Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded. |
| 99309 | Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded. |
| 99310 | Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded. |
| 99315 | Nursing facility discharge management; 30 minutes or less total time on the date of the encounter |
| 99316 | Nursing facility discharge management; more than 30 minutes total time on the date of the encounter |
| 99318 | Evaluation and management of a patient involving an annual nursing facility assessment, which requires these 3 key components: A detailed interval history; A comprehensive examination; and Medical decision making that is of low to moderate complexity. |
| 92507 | Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual |
| 92508 | Treatment of speech, language, voice, communication, and/or auditory processing disorder; group, 2 or more individuals |
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Skilled Nursing Facility Leveling
| 92521 | Evaluation of speech fluency (eg, stuttering, cluttering) |
|---|---|
| 92522 | Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria); |
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Skilled Nursing Facility Leveling
| 92523 | Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (eg, receptive and expressive language) |
|---|---|
| 92524 | Behavioral and qualitative analysis of voice and resonance |
| 92526 | Treatment of swallowing dysfunction and/or oral function for feeding |
| 92597 | Evaluation for use and/or fitting of voice prosthetic device to supplement oral speech |
| 92609 | Therapeutic services for the use of speech-generating device including programming and modification |
| 97161 | Physical therapy evaluation: low complexity |
| 97162 | Physical therapy evaluation: moderate complexity |
| 97163 | Physical therapy evaluation: high complexity |
| 97164 | Re-evaluation of physical therapy established plan of care |
| 97165 | Occupational therapy evaluation, low complexity |
| 97166 | Occupational therapy evaluation, moderate complexity |
| 97167 | Occupational therapy evaluation, high complexity |
| 97168 | Re-evaluation of occupational therapy established plan of care |
| 97532 | Development of cognitive skills to improve attention, memory, problem solving (includes compensatory training), direct (one-on-one) patient contact, each 15 minutes |
| 97533 | Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact, each 15 minutes |
| 97535 | Self-care/home management training (eg, activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact, each 15 minutes |
| 97537 | Community/work integration training (eg, shopping, transportation, money management, vocational activities and/or work environment/modification analysis, work task analysis, use of assistive technology device/adaptive equipment), direct one-on-one contact, each 15 minutes |
| 97542 | Wheelchair management (eg, assessment, fitting, training), each 15 minutes |
| 97760 | Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(ies), lower extremity(ies) and/or trunk, each 15 minutes |
| 97761 | Prosthetic(s) training, upper and/or lower extremity(ies), initial prosthetic(s) encounter, each 15 minutes |
| 97762 | Checkout for orthotic/prosthetic use, established patient, each 15 minutes |
| Modifier | Descriptor |
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CLINICAL POLICY
Skilled Nursing Facility Leveling
| ICD-10 Codes | Descriptor |
|---|---|
| NA | NA |
Definitions:
Skilled nursing facility (SNF)- An institution (or part of an institution) licensed under state laws and whose primary focus is to provide skilled nursing care and related services for residents requiring medical or nursing care. A SNF may also be a place of rehabilitation services for injured, disabled, or sick members/enrollees.
Related Documents or Resources
NA
| Revision History | |
|---|---|
| 09/08/2023 | Payment rules only transitioned from the retired CP.MP.206 SNF Facility Leveling. Changed LD.2. to note that the clinical circumstances noted are examples of intensive care. |
| 04/2024 | Annual review. Minor rewording in Background with no impact on criteria. References reviewed and updated. |
Important Reminder
For the purposes of this payment policy, “Health Plan” means a health plan that has adopted this payment policy and that is operated or administered, in whole or in part, by Centene Management Company, LLC, or any other of such health plan’s affiliates, as applicable.
The purpose of this payment policy is to provide a guide to payment, which is a component of the guidelines used to assist in making coverage and payment determinations and administering benefits. It does not constitute a contract or guarantee regarding payment or results. Coverage and payment determinations and the administration of benefits are subject to all terms, conditions, exclusions and limitations of the coverage documents (e.g., evidence of coverage, certificate of coverage, policy, contract of insurance, etc.), as well as to state and federal requirements and applicable plan-level administrative policies and procedures.
This payment policy is effective as of the date determined by Health Plan. The date of posting may not be the effective date of this payment policy. This payment policy may be subject to applicable legal and regulatory requirements relating to provider notification. If there is a discrepancy between the effective date of this payment policy and any applicable legal or regulatory requirement, the requirements of law and regulation shall govern. Health Plan retains the right to change, amend or withdraw this payment policy, and additional payment policies may be developed and adopted as needed, at any time.
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Skilled Nursing Facility Leveling
This payment policy does not constitute medical advice, medical treatment or medical care. It is not intended to dictate to providers to practice medicine. Providers are expected to exercise professional medical judgment in providing the most appropriate care, and are solely responsible for the medical advice and treatment of members. This payment policy is not intended to recommend treatment for members. Members should consult with their treating physician in connection with diagnosis and treatment decisions.
Providers referred to in this policy are independent contractors who exercise independent judgment and over whom Health Plan has no control or right of control. Providers are not agents or employees of Health Plan.
This payment policy is the property of Centene Corporation. Unauthorized copying, use, and distribution of this payment policy or any information contained herein are strictly prohibited. Providers, members and their representatives are bound to the terms and conditions expressed herein through the terms of their contracts. Where no such contract exists, providers, members and their representatives agree to be bound by such terms and conditions by providing services to members and/or submitting claims for payment for such services.
Note: For Medicaid members, when state Medicaid coverage provisions conflict with the coverage provisions in this payment policy, state Medicaid coverage provisions take precedence. Please refer to the state Medicaid manual for any coverage provisions pertaining to this payment policy.
Note: For Medicare members, to ensure consistency with the Medicare National Coverage Determinations (NCD) and Local Coverage Determinations (LCD), all applicable NCDs and LCDs should be reviewed prior to applying the criteria set forth in this payment policy. Refer to the CMS website at http://www.cms.gov for additional information.
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