Clarifying Skilled Nursing and Therapy

By Lori O’Hara, CCC-SLP, Skilled Reimbursement Resource
IDRS (Interdisciplinary Documentation and Reimbursement Systems)

From CMS:

  • Skilled nursing/therapy services are those services that are so complex they can only be safely and effectively provided by a nurse or under the supervision of a nurse/therapist.
  • Coverage does not turn on the presence or absence of an individual’s potential for improvement from nursing/therapy care, but rather on the beneficiary’s need for skilled care.
  • A condition that would not ordinarily require skilled nursing/therapy services may nevertheless require them under certain circumstances: the patient’s medical complications require the skills of a registered nurse/therapist 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 nurse/therapist are required to furnish the services.


  • To support a Part A episode, nursing services must be provided (and documented) 7x/week; to support a Part A episode, therapy must provide (and document) services at least 5x/week.
  • Please note: The importance of a particular service to an individual patient, or the frequency with which it must be performed, does not, by itself, make it a skilled service.

Defining Skilled Nursing Services
These nursing services automatically support a Part A episode when provided (and documented). They include but are not limited to:

  • Intravenous or intramuscular injections and intravenous feeding
  • Enteral feeding that comprises at least 26 percent of daily calorie requirements and provides at least 501 milliliters of fluid per day
  • Naso-pharyngeal and tracheotomy aspiration
  • Insertion, sterile irrigation, and replacement of suprapubic catheters
  • Treatment of decubitus ulcers, of a severity rated at Stage 3 or worse, or a widespread skin disorder until/unless the wound is deemed chronic
  • Heat treatments that have been specifically ordered by a physician as part of active treatment and that require observation by skilled nursing personnel to evaluate the patient’s progress adequately

Other interventions are considered skilled nursing in their initial phases but would be considered unskilled once the patient is stable and the regimen well-established:

  • Application of dressings involving prescription medications and aseptic techniques
  • Rehabilitation nursing procedures, including the related teaching and adaptive aspects of nursing, that are part of active treatment and require the presence of skilled nursing personnel, e.g., the institution and supervision of bowel and bladder training programs
  • Initial phases of a regimen involving administration of medical gasses such as bronchodilator therapy
  • Care of a colostomy during the early post-operative period in the presence of associated complications; the need for skilled nursing care during this period must be justified and documented in the patient’s medical record
  • Initial care-planning and comprehensive assessments

Many other things might be skilled, if the documentation supported that they were complex enough that they required the skills of a licensed nurse:

  • Assessment of medical presentation
  • Observation and monitoring of new or potentially unstable conditions
  • Some skin treatments
  • Some respiratory treatments
  • Implementation of physician’s orders

Other things to consider:

  • There are often state regulations that limit a patient’s ability to keep or self-administer medications. But even so, administration of routine medications is not considered a skilled service by CMS.
  • Wound-vac treatments are administered to heal very complex wounds, but because they are not a daily service. they will never, by themselves, be enough to support a Part A episode.
  • Trachs are intimidating apparatus that are generally present only in vulnerable patients. But the presence of a trach is not enough to sustain a Part A episode (although treatments or suction provided through the trach often are).
  • Likewise, just having a PEG tube is not enough to sustain a Part A episode — the patient must be meeting a minimum caloric/fluid amount as it’s the complexity of administering the feeds and assessing for residuals that requires the skills of a nurse.
  • A service that is ordinarily considered nonskilled could be considered a skilled service in cases in which, because of special medical complications, skilled nursing or skilled rehabilitation personnel are required to perform or supervise it or to observe the patient. The key in these situations is great documentation to capture and clarify the “special medical complications.”

It is expected that the documentation in the patient’s medical record will reflect the need for the skilled services provided. The patient’s medical record is also expected to provide important communication among all members of the care team regarding the development, course, and outcomes of the skilled observations, assessments, treatment, and training performed. Taken as a whole, then, the documentation in the patient’s medical record should illustrate the degree to which the patient is accomplishing the goals as outlined in the care plan. In this way, the documentation will serve to demonstrate why a skilled service is needed.

The patient’s medical record must have documentation as appropriate that captures:

  • The history and physical exam pertinent to the patient’s care, including the response or changes in behavior to previously administered skilled services
  • The skilled services provided
  • The patient’s response to the skilled services provided during the current visit
  • The plan for future care based on the rationale of prior results
  • A detailed rationale that explains the need for the skilled service in light of the patient’s overall medical condition and experiences
  • The complexity of the service to be performed
  • Any other pertinent characteristics of the beneficiary