Sunflower Health Plan Skilled Nursing Facility Leveling (PDF) Form

Criteria for skilled nursing facility (SNF) levels of care, to be used in conjunction with general SNF placement criteria in InterQual®. Note: For post-acute care leveling (used for plans without InterQual criteria), see CP.MP.213 Post-Acute Care. Policy/Criteria I. It is the policy of health plans affiliated with Centene Corporation® that the following skilled nursing facility levels of care, for facilities contracted for levels 1 through 4, are medically necessary when the applicable criteria are met in A through C: A. Patient status meets all of the following: 1. Medically stable with medical or surgical comorbidities manageable and not requiring acute medical attention; 2. Requires care that is directly related and reasonable for the presenting condition and/or illness; 3. There is expected improvement from medical and/or rehab intervention (or end-stage disease) within a reasonable and predictable period of time; 4. Those who require rehabilitative services must exhibit a decline in physical function (compared to prior level of function) in order for rehab services to be considered medically appropriate. Prior level of function can include: independent, modified independent in the community, supervised in the community or minimum/moderate/maximum/total assistance in the community with caregiver support, or long-term resident. B. Program requirements meet all of the following: 1. Assessment and oversight by a medical practitioner such as a doctor, nurse practitioner (NP) or physician assistant (PA) required > 1 time per week; 2. Interdisciplinary and goal-oriented treatment by professional nursing, social worker, or case manager, and/or rehab therapists with specialized training, education and/or certification; 3. Treatment plan developed within 2 days of admission; 4. Daily documentation of treatment and response to interventions with progress toward meeting goals documented at least weekly or more frequently; 5. Medical specialty consultative service, pharmacy and diagnostic services available. C. Skilled nursing facility level of care meets one of the following: 1. Level of Care 1 (Rev Code 191) - Skilled Nursing Services Requirements: Skilled nursing up to 4 hours per day, 7 days per week, or skilled therapy 1 to 2 hours per day, at least 5 days per week; Page 1 of 11 CLINICAL POLICY Skilled Nursing Facility Leveling Examples of conditions and treatments appropriate to Level 1 include, but are not limited to: nebulizer treatments; stable tracheostomy maintenance and suctioning, tube feedings or percutaneous endoscopic gastrostomy (PEG) tubes; simple wound care for healing surgical wounds, cellulitis not requiring debridement, or more than two dressing changes or topical antibiotic treatments per day; intramuscular or subcutaneous injections and in and out catheterizations. 2. Level of Care 2 (Rev Code 192)- Comprehensive Care Services Requirements: Skilled nursing at least 4 hours per day, 7 days per week, or skilled therapy for at least 2 hours per day, at least 5 days per week. Examples of conditions and treatments appropriate to Level 2 include, but are not limited to: negative pressure wound therapy; open wounds and up to Stage III decubiti; new tracheotomy requiring suctioning and site care, but not ventilator dependent; IV therapy for hydration; oxygen use and treatments for multiple medical complexities. 3. Level of Care 3 Complex (Rev Code 193) - Medical/Surgical Sub-Acute Care Services Requirements: Skilled nursing for more than 4 hours per day, 7 days per week, and skilled therapy for at least 3 hours per day, at least 5 days per week; Examples of conditions and treatments appropriate to Level 3 include, but are not limited to: combination IV antibiotic therapy; initiation or adjustment of parenteral anticoagulant therapy; orthopedic cases; total parenteral nutrition (TPN) administration; spinal or pelvic fractures; completed transient ischemic attack (TIA)/cerebrovascular accident (CVA) care; congestive heart failure requiring IV medication; urosepsis, respiratory disease requiring high flow oxygen treatment, arterial blood gas oximetry, tracheostomy tube changes and postural drainage and percussion. 4. Level of Care 4 (Rev Code 194) – Intensive Care Services Requirements, both of the following: a. Skilled nursing for more than 4 hours per day, 7 days per week; b. Patient requires Level 4 – Intensive Care Services due to one of the following high acuity needs: i. Catastrophic multiple traumas; ii. Severe head injury or CVA; iii. Stabilized spinal cord injury; iv. Weanable and non-weanable ventilator dependent patients. II. It is the policy of health plans affiliated with Centene Corporation that the following skilled nursing facility levels of care, for facilities contracted for levels 1 through 5, are medically necessary when the criteria in A through C are met: A. Patient status meets all of the following: 1. Medically stable with medical or surgical comorbidities manageable and not requiring acute medical attention; Page 2 of 11 CLINICAL POLICY Skilled Nursing Facility Leveling 2. Requires care that is directly related and reasonable for the presenting condition and/or illness; 3. There is expected improvement from medical and/or rehab intervention (or end-stage disease) within a reasonable and predictable period of time; 4. Those who require rehabilitative services must exhibit a decline in physical function (compared to prior level of function) in order for rehab services to be considered medically appropriate. Prior level of function can include: independent, modified independent in the community, supervised in the community, or minimum/moderate/maximum/total assistance in the community with caregiver support, or long-term resident. B. Program requirements meet all of the following: 1. Assessment and oversight by a medical practitioner such as a doctor, nurse practitioner (NP) or physician assistant (PA) required > 1 time per week; 2. Interdisciplinary and goal-oriented treatment by professional nursing, social worker, or case manager, and/or rehab therapists with specialized training, education and/or certification; 3. Treatment plan developed within 2 days of admission; 4. Daily documentation of treatment and response to interventions with progress toward meeting goals documented at least weekly or more frequently; 5. Medical specialty consultative service, pharmacy and diagnostic services available. C. Skilled nursing facility level of care meets one of the following: 1. Level of Care 1 (Rev Code 191) – Skilled Nursing Services Requirements: Skilled nursing up to 4 hours per day, 7 days per week, or skilled therapy 1 to 2 hours per day, at least 5 days per week. Examples of conditions and treatments appropriate to Level 1 include, but are not limited to: nebulizer treatments; stable tracheostomy maintenance and suctioning, tube feedings or PEG tubes; simple wound care for healing surgical wounds, or cellulitis not requiring debridement, or more than two dressing changes or topical antibiotic treatments per day; intramuscular or subcutaneous injections and in and out catheterizations. 2. Level of Care 2 (Rev Code 192) – Comprehensive Care Services Requirements: Skilled nursing at least 4 hours per day, 7 days per week, or skilled therapy for at least 2 hours per day, at least 5 days per week. Examples of conditions and treatments appropriate to Level 2 include, but are not limited to: negative pressure wound therapy; open wounds and up to Stage III decubiti; new tracheotomy requiring suctioning and site care, but not ventilator dependent; IV therapy for hydration; oxygen use and treatments for multiple medical complexities. Page 3 of 11 CLINICAL POLICY Skilled Nursing Facility Leveling 3. Level of Care 3 (Rev Code 193) – Medical/Surgical Services Requirements: Skilled nursing for more than 4 hours per day, 7 days per week, and skilled therapy for at least 3 hours per day, at least 5 days per week; Examples of conditions and treatments appropriate to Level 3 include, but are not limited to: combination IV antibiotic therapy; initiation or adjustment of parenteral anticoagulant therapy; orthopedic cases; TPN administration; spinal or pelvic fractures; completed TIA/CVA care; congestive heart failure requiring IV medication; urosepsis, respiratory disease requiring high flow oxygen treatment, arterial blood gas oximetry, tracheostomy tube changes and postural drainage and percussion. 4. Level of Care 4 (Rev Code 194) – Medically Complex Services Requirements: Skilled nursing more than 4 hours per day, 7 days per week, and skilled therapy at least 3 hours per day, at least 5 days per week; Examples of conditions and treatments appropriate to Level 4 include, but are not limited to: bedside dialysis, severe cerebrovascular accident, severe head injury, stabilized spinal cord injuries, etc. 5. Level of Care 5 (Rev Code 199) – Intensive Care Services Requirements: Skilled nursing required for more than 4 hours per day, 7 days per week. Examples of conditions and treatments appropriate to Level 5 include, but are not limited to: more medically complex conditions, including but not limited to: high cost drugs, Guillain Barre syndrome, ventilator dependent patients, catastrophic multiple trauma, severe head injury, etc. Background Skilled Nursing Facility (SNF)6 A skilled nursing facility (SNF) is 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. The following information is a synopsis from the Medicare Benefit Policy Manual: Skilled nursing and/or skilled rehabilitation services are services, furnished in accordance physician orders, that: 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. Page 4 of 11 CLINICAL POLICY Skilled Nursing Facility Leveling 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: A. 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, B. 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 Implications This clinical policy references Current Procedural Terminology (CPT®). CPT® is a registered trademark of the American Medical Association. All CPT codes and descriptions are copyrighted 2020, American Medical Association. All rights reserved. CPT codes and CPT descriptions are from the current manuals and those included herein are not intended to be all-inclusive and are included for informational purposes only. Codes referenced in this clinical 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. CPT®* Codes 99304 99305 99306 99307 99308 Initial nursing facility care, per day, for the evaluation and management of a patient, which requires these 3 key components: A detailed or comprehensive history; A detailed or comprehensive examination; and Medical decision making that is straightforward or of low complexity. Initial nursing facility care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Initial nursing facility care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Subsequent nursing facility care, per day for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A problem focused interval history; A problem focused examination; Straightforward medical decision making. Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of low complexity. Page 5 of 11 CLINICAL POLICY Skilled Nursing Facility Leveling CPT®* Codes 99309 99310 99315 99316 99318 92507 92508 92521 92522 92523 92524 92526 92597 92609 97161 97162 97163 97164 91765 97166 97167 97168 97532 97533 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; Medical decision making of moderate complexity. Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A comprehensive interval history; A comprehensive examination; Medical decision making of high complexity. Nursing facility discharge day management; 30 minutes or less Nursing facility discharge day management; more than 30 minutes Evaluation and management of 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. Individual Treatment of speech, language, voice, communication, and/or auditory processing disorder Group, 2 or more - Treatment of speech, language, voice, communication, and/or auditory processing disorder Evaluation of speech fluency (eg, stuttering, cluttering) Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria); Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (eg, receptive and expressive language) Behavioral and qualitative analysis of voice and resonance Treatment of swallowing dysfunction and/or oral function for feeding Evaluation for use and or fitting of voice prosthetic device to supplement oral speech Therapeutic services for the use of speech-generating device including programming and modification Physical therapy evaluation: low complexity Physical therapy evaluation: moderate complexity Physical therapy evaluation: high complexity Re-evaluation of physical therapy established plan of care Occupational therapy evaluation, low complexity Occupational therapy evaluation, moderate complexity Occupational therapy evaluation, high complexity Re-evaluation of occupational therapy established plan of care Development of cognitive skills to improve attention, memory, problem solving (includes compensatory training), direct (one-on-one) patient contact, each 15 minutes Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one to one) patient contact by the provider, each 15 minutes Page 6 of 11 CLINICAL POLICY Skilled Nursing Facility Leveling CPT®* Codes 97535 97537 97542 97760 97761 97762 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 by provider, each 15 minutes Community/work integration training (eg, shopping, transportation, money management, avocational activities and/or work environment/modification analysis, work task analysis, use of assistive technology device/adaptive equipment), direct one-on-one contact by provider, each 15 minutes Wheelchair management (eg, assessment, fitting, training), each 15 minutes Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(s), lower extremity(s) and/or trunk, each 15 minutes Prosthetic training, upper and/or lower extremity(s), each 15 minutes Checkout for orthotic/prosthetic use, established patient, each 15 minutes Reviews, Revisions, and Approvals Original approval date Approved by MPC. Added Covered Services Summary and section on High Cost Drugs Approved by MPC. Clarified coverage language Approved by MPC. Inclusion of note in Coding section re: non-coverage of codes for Nebraska. Approved by MPC. Clarified NE verbiage and coding Approved by MPC. Removed “Rehabilitation” from title; updated CMS language, leveling included for every SNF review. Approved by MPC. Included information on RUG scoring. Approved by MPC. Kentucky Medicare included in the policy as it was previously omitted. Approved by MPC. No changes. Approved by MPC. Removed ADL scoring; leveling medical necessity criteria; and codes (HIPPS, RUG-IV, Nebraska). Approved by CPC. No changes. Transitioned to Centene policy template from HS-311. Recategorized into 4 levels of care. Minor rewording without clinical significance. Removed list of high cost drugs. Removed CMS billing requirements and exclusions from background. Added negative pressure wound therapy to I.B., “Examples of treatments appropriate to Level 2”. Added note to refer to CP.MP.213 Post-Acute Care if IQ criteria not available. Specified that criteria I applies to facilities contracted for levels 1-4 and added criteria II, which applies to facilities contracted for levels 1-5. Condensed criteria that was the same between levels. Revision Date 11/15 01/16 Approval Date 11/15 01/16 04/16 01/17 09/17 11/17 12/17 02/18 02/19 09/19 08/20 12/20 04/16 01/17 09/17 11/17 12/17 02/18 02/19 09/19 08/20 12/20 02/21 04/21 04/21 Page 7 of 11 CLINICAL POLICY Skilled Nursing Facility Leveling Reviews, Revisions, and Approvals Changed hourly requirements for nursing and therapy for each LOC. Updated background. Updated therapy requirement verbiage for SNF Level 1 from “skilled therapy for up to 2 hours per day” to “skilled therapy 1-2 hours per day.” For SNF Levels 1 and 2, changed requirement from skilled nursing hours and therapy hours to skilled nursing hours or therapy hours. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.” Annual review. In I.B.1 and II.B.I, corrected list of appropriate oversight to include doctors. References reviewed and updated. Reviewed by specialist. Added corresponding revenue codes to each level’s “care requirements” section in I.C and II.C. Annual review completed. Added “in the community” and “moderate/maximum/total” to Section I.A.4. and II.A.4. Updated II.C.4. from 3 hours of skilled therapy per day to “at least” 3 hours of skilled therapy per day. Additional minor rewording with no clinical significance. References reviewed and updated. Specialist reviewed. Revision Date Approval Date 06/21 06/21 08/21 08/21 01/22 08/22 08/22