MDS Alert

Experts shed some light on this controversial coverage debate.

If a Medicare beneficiary doesn't RUG into one of the upper 26 case-mix categories but requires restorative nursing care, you'd count him out of the running for a skilled stay, right?

Not so fast, experts caution.

The SNF can potentially skill the beneficiary for restorative nursing as a "stand alone" service, according to Rena Shephard, RN, MHA, FACDONA, president of RRS Healthcare Consulting in San Diego. "There's actually a regulatory basis for the coverage in the Code of Federal Regulations, which describes direct skilled nursing services, including IVs, IM injections, IV feedings, suprapubic catheters - and rehabilitation nursing procedures (with specific mention of bowel and bladder training programs)," Shephard says.

"To qualify as a skilled service, the restorative program has to be active - and the resident has to make progress," Shephard adds.

"The Centers for Medicare & Medicaid Services was kind enough to slip that information into [chapter 8] of the online Medicare Benefit Policy Manual," adds Shephard. But she's not sure all of the fiscal intermediaries are aware of the information. Thus, SNFs should check with their FI for advice on providing restorative as a daily skilled nursing service, Shephard says.

Example: A patient admitted from the hospital doesn't meet the requirements for gait training because he lacks a musculoskeletal or orthopedic reason to require the skills of a trained therapist, Shephard postulates. But he needs someone to walk with him to increase his endurance and recover functioning. "Providing that service would count as a skilled restorative service if it met other requirements for coding Section P3," says Shephard.

Restorative can be a stand-alone skilled nursing service in limited situations, agrees Roberta Reed, RN, MSN, NHA, but the facility has to be able to define why the restorative is skilled rather than maintenance. "And the resident has to show improvement within about two weeks," says Reed, a consultant with Howard, Wershbale & Co. in Cleveland.

Other Skillable Routes to Restorative

A restorative program can help the person maintain and improve on the progress he has secured in therapy, notes Cheryl Field, MSN, RN, a consultant with LTCQ Inc. in Lexington, MA. In such a case, "you can skill the person under observation and assessment where there's a likelihood of change in his status and treatment plan - or under teaching and training (with mentoring and coaching)," Field advises.
"Mobility (walking, transfer skills, self-care) is vitally important to prevent many health problems, including pressure ulcers, cardiovascular decline, hypostatic pneumonia, constipation, etc.," Field points out.

In some cases, the goal of restorative may be to keep a medical condition at bay. "Or the goal may be to assess the resident's response to exercise or increasing mobility/self-care," Field adds.

In that case, "the nurse would do a cardiopulmonary assessment after or while the resident walks or exercises (pulse rate, lung sounds, assessment of skin color, breathing, blood pressure, pulse oximetry, pain levels, etc.)," Field continues.

What about skilling someone for restorative nursing under evaluation and management of a patient care plan? It's doable, some experts say.

But Shephard believes the policy manuals have been "pretty clear in their examples that care plan management refers to medically complex patients with a lot of medical needs."

An example would be a diabetic who has decreased mobility and circulation and appetite problems for whom nursing assistants provide the care but the licensed nurse has to develop the care plan and ensure the CNAs know what to do, adds Shephard. She thus doesn't believe that category of skilled nursing coverage fits most restorative care.

How long might someone stay on skilled restorative care as a Part A Medicare-covered service? Coverage probably won't extend for more than a couple of weeks, says Reed.

Editor's Note: See related story on restorative nursing, later is this issue.