The Centers for Medicare & Medicaid Services (CMS) states in an FAQ for COVID-19 Medicare Fee-For-Service (FFS) that:
“A COVID-19 diagnosis would not in and of itself automatically serve to qualify a beneficiary for coverage under the Medicare Part A SNF benefit.”
covid and skilled
Yet Skilled Nursing Facilities remained confused on this issue. Providers argue that a resident with an active or suspected diagnosis of COVID-19 requiring isolation and around-the-clock monitoring must surely meet a skilled level of care.
Unfortunately it is not quite that simple.  The CMS FAQ’s further clarify the issue:

“…. Skilled Nursing Facility (SNF) coverage isn’t based on particular diagnoses or medical conditions, but rather on whether the beneficiary meets the statutorily-prescribed SNF level of care definition of needing and receiving skilled services on a daily basis which, as a practical matter, can only be provided in a SNF on an inpatient basis.”

Said another way - the diagnosis of COVID-19 alone is not enough to justify a skilled level of care. Instead, we must look to the guidelines in the Medicare Benefit Policy Manual (MBPM) chapter 8 to determine if a resident meets the skilled level of care criteria.

The MBPM states that a resident must meet the following to be covered under Medicare Part A skilled services:

Medicare Benefit Policy Manual (BPM) Chapter 8, Section 30 – SNF Skilled Level of Care

  • The patient requires skilled nursing services or skilled rehabilitation services (§30.2-30.4)
  • The patient requires these skilled services on a daily basis (nursing 7 days/week and/or therapy at least 5 days/week) (§30.6)
  • As a practical matter, the daily skilled services can be provided only on an inpatient basis in a SNF (§30.7)
  • The services delivered are reasonable and necessary for the treatment of a patient’s illness or injury

Providers should consider the following questions when deciding if a resident meets skilled criteria. If the facility can answer “yes” to these questions, then the resident is skilled.

  1. Does this resident have a daily skilled need?
  2. Would we ‘skill’ this resident if they didn’t have COVID-19, but still required the same level of care?
  3. Does this resident meet the skilled requirement as defined by the MBPM?

If a resident has a positive test and is stable, asymptomatic, and does not require any treatment, that resident does not meet the skilled criteria.

The resident may be in isolation for the safety and well-being of other residents but is not receiving any services that would require the knowledge, skills, and judgment of a professional nurse or therapist.  Keep in mind that a diagnosis or lack thereof should never be the sole deciding factor of whether or not to cover a resident under skilled Medicare.

If the resident’s illness requires daily skilled nursing care that is medically necessary, this will justify the skilled coverage under Medicare A regardless of a COVID-19 diagnosis.

For more information :

The COVID-19 FAQs on Medicare Fee-For-Service (FFS) Billing: https://mds-consultants.com/helpful-cms-info/

The Medicare Benefit Policy Manual Chapter 8: https://mds-consultants.com/helpful-cms-info/