UM Guidelines

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	Skilled Nursing Facility (SNF) Admission UM Guidelines Skilled Nursing Facility/Inpatient Rehabilitation Fax Form Exceptions may be required to comply with EPSDT & TennCare regulations. All skilled nursing facility cases are to be reviewed by Case Management and/or Transition of Care Nurses. If review does not meet criteria or no progress is given the review will be sent to the RMD Physician. Skilled services are services requiring the skills of qualified technical or professional health personnel such as registered nurses, licensed practical nurses, physical therapists, occupational therapists, speech pathologists, and/or audiologists. Skilled services must be provided directly by, or under the general supervision of, technical or professional health care personnel. I. SNF Admission If a covered benefit, SNF admission may be approved for members with ALL of the following: A condition requiring skilled nursing services or skilled rehabilitation services on an inpatient basis at least daily A physician's order for skilled services Ability and willingness to participate in ordered therapy Medical necessity for the treatment of illness or injury (this includes the treatment being consistent with the nature & severity of the illness or injury, and consistent with accepted standards of medical practice) Expectation for significant reportable improvement within a predictable amount of time Attachment #A for Commercial Lines of Business - details the 3 levels of SNF care listed below. Attachment #B for BlueCare/TCS - details the 3 levels of SNF care listed below. II. Evaluation and Plan of Care Evaluation of the patient must be submitted including the following as appropriate: - Ordering MD & last visit - Gait analysis - Primary diagnosis - Circulation & sensation - Date of diagnosis onset - Cooperation & comprehension - Baseline status - Developmental delays (pediatric patients) - Current functional abilities - Other therapies or treatments - Functional potential - Patient's goals - Strength - Medical compliance - ROM - Support system Plan of care must be submitted including the following as appropriate: - Short- and long-term goals - Proposed admission date - Discharge goals - Frequency of treatment - Measurable objectives - Specific modalities, therapy, exercise - Functional objectives - Safety & preventive education - Home program - Community resources III. Therapy services appropriate for SNF include OT, PT, and ST not possible on an outpatient basis. Specific therapy services, which may be appropriate for SNF include (but are not limited to) the following: Complex wound care requiring hydrotherapy Gait evaluation & training to restore function in a patient whose ability to walk has been impaired by neurological, muscular, or skeletal abnormality IV. Nursing services appropriate for SNF include skilled nursing services not possible on an outpatient basis. Specific nursing services, which may be appropriate for SNF include (but are not limited to) the following: Intramuscular injections or intravenous injections or infusions Initiation of and training for care of newly placed: Tracheostomy In-dwelling catheter with sterile irrigation and replacement Colostomy Levin tube Gastrostomy tube and feedings Complex wound care involving medication application & sterile technique Treatment of Grade 3 or higher decubitus ulcers or widespread skin disorder V. Nursing and Therapy services not requiring SNF placement. SNF placement is not necessary for the services listed below. This list is not all-inclusive. Administration of routine oral, intradermal or transdermal medications, eye drops, & ointments Routine dressing changes (i.e., noninfected postoperative or chronic conditions) Custodial services (i.e., turning, positioning, bathing, assistive walking, ADL's) Activities or programs primarily social or diversional in nature General supervision of exercises that have been or can be taught to the patient &/or family Passive ROM exercises in paralyzed extremities, not related to a specific loss of function Routine care of colostomy or ileostomy Routine services to maintain functioning of indwelling catheters Routine care of incontinent patients Routine care in connection with braces & similar devices Prophylactic & palliative skin care (i.e., bathing, application of creams, or treatment of minor skin problems) Duplicative services - Physical therapy services that are duplicative of Occupational Therapy services being provided or vice versa. Invasive procedures (i.e., iontophoresis involving needle) General supervision of aquatic exercise or water-based ambulation Heat modalities (hot packs, diathermy or ultrasound) for pulmonary conditions or wound treatment, or as a palliative or comfort measure only (whirlpool & hydrocollator) Hot and cold packs applied in the absence of associated modalities do not require the skill of a Physical Therapist Diagnostic procedures performed by a Physical Therapist (i.e., nerve conduction studies) Electrical stimulation for strokes when there is no potential for restoration of functional improvement. Nerve supply to the muscle must be intact. VI. Extension of Services for up to 7 days requires the following documentation: Clinical progress in meeting goals FIMS Score if applicable Updated goals Compliance & participation with any ordered therapy Discharge plans & target date ATTACHMENT A SKILLED NURSING FACILITY LEVELS OF CARE DESCRIPTIONS For Commercial Lines of Business Level I (Skilled Care) Patients receiving the following types of care will meet the clinical criteria to qualify as Level I. Examples of the types of care include, but are not limited to: Semi-Private Room Meals (Including specialized dietary and administration of feeding) 24-Hour Skilled Nursing Care 24-Hour Physician Coverage* Colostomy Care Wound Care (Stage 1 & 2) Tube Feeding & Medication Administration Routine Respiratory Care (Oxygen, Aerosol Treatments, Oxygen Saturations) Routine DME & Routine Medical Supplies Routine Oral & Inhaled Medications and Pharmacy Supplies SQ Insulin Case Management Services Social Services Laboratory Services Routine Diabetic Supplies (Lancets, Test Strips) Routine X-Rays Continuous IV Fluid Therapy (Peripheral Lines) 1.5 hrs or less of Rehabilitation Therapy per day Speech Therapy (at any level) must be provided in conjunction with another skilled service Level II (Comprehensive Care) Patients receiving Level I types of care - plus the following types of care - will meet the clinical criteria to qualify as Level II. Examples of the types of care include, but are not limited to: Wound Care (Stage 3) IV Site Care (Central Lines) Tracheotomy Care Respiratory Care (Frequent Suctioning) Routine Medications (Examples: IV, IM & SQ: 1st, 2nd & 3rd Generation Cephalosporins, Natural & Amino Penicillins, Extended Spectrum Penicillins, Tetracyclines, Sulfonamides, Fluoroquinolones, Aminoglycosides, Heparin, Coumadin) 1.75 - 3 hrs of Rehabilitation Therapy per day Level III (Complex Care) Patients receiving Level I & II types of care - plus the following types of care - will meet the clinical criteria to qualify as Level III. Examples of the types of care include, but are not limited to: Respiratory Care (Ventilator) Specialty Beds (Hill-Rom, KCI) High Cost IV, IM & SQ Medications: (Examples: 4th Generation Cephalosporins, Penicillinase-Resistant Penicillins, Desferal, Desmopressin, Epoetin Alfa, IVIG, Panretin, Remicade, Thrombolytic Enzymes, Chemo-Therapy Agents). Requests from providers for Level III based on cost of drugs other than above, should be verified with BCBST Pharmacy Benefit Management representative as needed, prior to approving this level of care. IV TPN, Lipids Authorization is given for a specific level and period of care. The provider must call BCBST if a change in the level of care occurs, or to obtain approval for additional days - prior to the expiration of the authorization. Physicians must bill for their services separately* Specialty / custom wheelchairs are excluded—billed by a DME provider (see Exhibit B for definition). Transportation Request (Commercial ONLY), examples: home, facility to facility. Please review benefits/contract and refer to Case Management. ATTACHMENT B SKILLED NURSING LEVELS OF CARE REIMBURSEMENT For BlueCare/TCS ***Name of Skilled Nursing Facility*** BCBST Provider No.:_________ Level I - Skilled Nursing Care Including 1 Therapy Per Diem Examples: 1.5 hours or less of Rehabilitation Therapy per day, Simple wound care, or Continuous IV Therapy Semi-Private Room Meals (Including Specialized Dietary and Administration of Feeding) 24-hour Skilled Nursing Care Traction and Positioning Colostomy Care Wound Care (Stage 1 and 2) Tube Feeding and Medication Administration Routine Respiratory Care (Oxygen, Inhaler Treatments, Oxygen Saturations) Routine Durable Medical Equipment and Routine Medical Supplies Routine Medications and Pharmacy Supplies Case Management Services Social Services Laboratory Services (Examples: CBC, Bloodglucose, Urine Analysis, etc.) Routine X-Rays Routine Diabetic Supplies Hospice Rehabilitation Therapies (Physical, Occupational, Speech) 1.5 hours or less per day Speech therapy must be provided in conjunction with another skilled service. Excludes: Specialized/Customized DME (Examples: Beds, Wheelchairs, etc.) TPN, IV Medications (Pain, Antibiotics) Physician Services Level II - Subacute Per Diem Examples: 1.75 hours to 3 hours of Rehabilitation Therapies per day, Complex wound care, or IV medications (2 or more per day) Services included in addition to Level I care: 24-hour Skilled Nursing Care Wound Care (Stage 3) IV Care (Peripheral, Subclavian) Tracheostomy Care Respiratory Care (Frequent Suctioning) Medications and Pharmacy Supplies (IV Fluids, IV Medications [Excluding Third Generation Antibiotics]) Rehabilitation Therapies (Physical, Occupational, Speech) 1.75 hours to 3 hours per day Excludes: Specialized/Customized DME (Examples: Beds, Wheelchairs, etc.) Specialized Radiology (CT Scan, MRI) TPN, Lipids, Third Generation Antibiotics Physician Services Level III - Specialty Skilled Care Per Diem Examples: Ventilator dependent, Spinal Cord injury, or Brain injury Services included in addition to Level II care: Respiratory Care (Ventilator) Multiple Wound Care (Greater than three stage three or four wounds with wound vac or requires dressing changes BID to two or more stage three or four wounds) Bariatric Care Patient (> 400 lbs) Excludes: Specialized/Customized DME (Beds, Wheelchairs, etc.) Specialized Radiology (CT Scan, MRI) TPN, Lipids, Third Generation Antibiotics Physician Services Sources BlueCross BlueShield of Tennessee network physicians. April - June 2008.