Medicare requires the initial visit at a Skilled Nursing Facility to be performed by a physician, not a midlevel. N121 means it is not covered for midlevels for the initial inpatient visit...."Medicare Part B does
not pay for items or services provided by
this type of practitioner for beneficiaries in a Medicare Part A covered Skilled Nursing Facility (SNF) stay."
The NP's Role in Nursing Facilities
Medicare requires that the initial visit (history and physical), for the purpose of certifying that the patient requires skilled care, must be performed by a physician. An NP may, however, make a "medically necessary" visit without an initial physician visit; this could occur when a newly admitted Medicare patient in a skilled nursing facility develops a problem that requires medical evaluation and intervention, before being seen by the physician. Girvin-Reisser advised cautious use of this practice because it could be viewed as an unnecessary visit (ie, if the physician were available to see the patient at the time of admission, only one visit would have been needed).
All subsequent visits may be performed by an NP (or other nonphysician), alternating with the physician.
NPs may perform the initial history and physical for new long-term care (nonskilled) admissions. NPs may also make additional visits, which must be substantiated based on the patient's need (ie, acute illness). Medicare provisions permit 1.5 visits per month; more than this frequency may invite increased scrutiny in the form of an audit. Medical necessity must be documented!
Assuming state law permits, Medicare allows NPs to help with monitoring and managing patient conditions, counseling patients and families, performing certain procedures, annual physical examinations, communication with hospital and community physicians, and discharge visits.
http://www.medscape.org/viewarticle/464725