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Appendix VIII — Description of Skilled Nursing Services

Units = 15 Minutes

Level of Care/Bill Codes
Skilled Nursing
A. Level 1
Skilled Nursing Care
Bill Code: 191
1–4 hours skilled nursing per day
Up to 1.5 hrs. multidiscipline therapies per day; min. 5 days per week
B. Level 2
Rehabilitation Therapy
Bill Code: 192
Over 4 and up to 6 hours skilled nursing per day
Between 1.5–3 hrs. multidiscipline therapies per day; min. 5 days per week
C. Level 3
Subacute Skilled Care
Nonweanable Ventilator Management
Bill Code: 193
More than 6 hours of skilled nursing per day
Between 3-6 hrs. multidiscipline therapies per day; min 5 days per week
D. Level  4
Weanable Ventilator Management
Bill Code: 194
3–6 hours skilled nursing per day
More than 6 hrs. multidiscipline therapies per day; min. 5 days per week
·     Semi-private room
·     Administration of drugs and biologicals
·     Routine medications, including intramuscular (IM) medications and supplies (see exclusions)
·     Nutrition services, including enteral and parental supplies
·     Registered nurse onsite availability 24 hours a day
·     Nursing and personal care, including assistance in activities of daily living
·     Rehabilitation services: physical, speech, and occupational therapy
·     Attending physician services
·     Routine admission diagnostic radiology
·     Lab services based on medical necessity or diagnosis/physician plan care
·     Basis equipment, medical supplies, and appliances
·     Supervision of the use of durable medical equipment, assistive devices and, prescribed therapies
·     Recreational therapies
·     Social work and psychological services
·     Routine dental services
·     Maintenance of patient room cleanliness
·     Other services or furnishings related to the basic room, board, and care of the patient
·     Discharge planning
·    Specialty consults (except when consult is included in specific level of care)
·    Hemo and peritoneal dialysis
·    Blood and blood products
·    Enteral and TPN solutions
·    Transportation
·    Specialty equipment, supplies, wheelchairs, appliances, and beds
·    Nonroutine radiology (including MRI, CT scan,  PET scan) 
·    All of the foregoing excluded services must be precertified by a case manager or designated representative.  In the event that there is a question concerning the need for treatment, the matter shall be referred to the  Managed Care Organization 
·    Drugs exceeding $50 per day on average are excluded from the per diem and must be purchased through the MCO’s designated pharmacy network or contracted provider(s) of infusion therapy services