Clinical UM Guideline |
Subject: Skilled Nursing and Skilled Rehabilitation Services (Outpatient) | |
Guideline #: CG-REHAB-07 | Publish Date: 10/01/2024 |
Status: Reviewed | Last Review Date: 08/08/2024 |
Description |
This document addresses skilled nursing and skilled rehabilitation services provided in the outpatient setting.
Skilled nursing and skilled rehabilitation services are those services, furnished pursuant to physician orders, that:
Note: Please see the following related documents for additional information:
Clinical Indications |
Outpatient Skilled Nursing and Skilled Rehabilitation Services
Medically Necessary:
Outpatient skilled nursing services are considered medically necessary in the following circumstances:
Outpatient skilled rehabilitation services are considered medically necessary when all of the following conditions are met:
Examples of Skilled Services include, but are not limited to, the following:
Note:
Not Medically Necessary:
Outpatient skilled nursing services are considered not medically necessary when the criteria above are not met.
Outpatient skilled rehabilitation services are considered not medically necessary when the criteria above are not met.
Coding |
Coding edits for medical necessity review are not implemented for this guideline. Where a more specific policy or guideline exists, that document will take precedence and may include specific coding edits and/or instructions. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.
Discussion/General Information |
Skilled nursing and skilled rehabilitation services, furnished pursuant to physician orders, require the skills of qualified technical or professional health personnel such as registered nurses, physical therapists, occupational therapists and speech pathologists or audiologists. These services must be provided directly by or under the general supervision of these skilled nursing or skilled rehabilitation personnel to assure the safety of the individual and to achieve the medically desired result.
Definition of Custodial Care:
Note: Custodial care may occur in settings other than the home.
References |
Peer Reviewed Publications:
Government Agency, Medical Society, and Other Authoritative Publications:
History |
Status | Date | Action |
Reviewed | 08/08/2024 | Medical Policy & Technology Assessment Committee (MPTAC) review. References section updated. |
Reviewed | 08/10/2023 | MPTAC review. References section updated. |
Reviewed | 08/11/2022 | MPTAC review. References section updated. |
Reviewed | 08/12/2021 | MPTAC review. References section updated. |
Reviewed | 08/13/2020 | MPTAC review. References section updated. |
Reviewed | 08/22/2019 | MPTAC review. References section updated. |
Revised | 11/08/2018 | MPTAC review. Changed “qualified” to “licensed” in medically necessary statement on outpatient skilled rehabilitation services. Description and References sections updated. |
Reviewed | 02/27/2018 | MPTAC review. Updated header language from “Current Effective Date” to “Publish Date. References section updated. |
Reviewed | 02/02/2017 | MPTAC review. Formatting updated in clinical indication section. Discussion and References section updated. |
Revised | 05/05/2016 | MPTAC review. Clarified examples of skilled services in clinical indication section related to insulin injections and feedings. References section updated. |
Revised | 02/04/2016 | MPTAC review. Defined abbreviations in clinical indications section. Reference section updated. |
Reviewed | 02/05/2015 | MPTAC review. Description and References sections updated. |
Reviewed | 02/13/2014 | MPTAC review. References section updated. |
Reviewed | 02/14/2013 | MPTAC review. References section updated. |
Reviewed | 02/16/2012 | MPTAC review. References section updated. |
Reviewed | 02/17/2011 | MPTAC review. Title of Clinical Indication section, Description, Discussion (including definition of custodial care), and Reference links updated. Clarifications made to examples of skilled services. |
Reviewed | 02/25/2010 | MPTAC review. Reference links updated. |
Reviewed | 02/26/2009 | MPTAC review. References and discussion updated. Case management section removed. |
Revised | 02/21/2008 | MPTAC review. Added not medically necessary statements for outpatient skilled nursing services and outpatient skilled rehabilitation services. Minor clarification made to example of skilled services. Description, discussion and references updated. Coding updated to remove specific codes from this definition document. |
Reviewed | 03/08/2007 | MPTAC review. References and coding updated. |
Revised | 03/23/2006 | MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization. |
Pre-Merger Organizations | Last Review Date | Document Number | Title
|
Anthem, Inc. |
|
| No Policy |
Anthem MW | 02/11/2005 | MA-020 | Skilled Nursing Facility Setting, Skilled and Custodial Services Defined |
WellPoint Health Networks, Inc. | 09/22/2005 | Clinical Guideline | Skilled Nursing and Skilled Rehabilitation Services |
Federal and State law, as well as contract language, and Coverage Guidelines take precedence over Clinical UM Guidelines. We reserve the right to review and update Clinical UM Guidelines periodically. Clinical guidelines approved by the Medical Policy & Technology Assessment Committee are available for general adoption by plans or lines of business for consistent review of the medical necessity of services related to the clinical guideline when the plan performs utilization review for the subject. Due to variances in utilization patterns, each plan may choose whether to adopt a particular Clinical UM Guideline. To determine if review is required for this Clinical UM Guideline, please contact the customer service number on the member's card.
Alternatively, commercial or FEP plans or lines of business which determine there is not a need to adopt the guideline to review services generally across all providers delivering services to Plan’s or line of business’s members may instead use the clinical guideline for provider education and/or to review the medical necessity of services for any provider who has been notified that his/her/its claims will be reviewed for medical necessity due to billing practices or claims that are not consistent with other providers, in terms of frequency or in some other manner.
No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from the health plan.
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