CMS Pub. 100-02, ch. 8, § 30.3

A3-3132.2, SNF-214.2

Nursing services are considered skilled when they are so inherently complex that they

can be safely and effectively performed only by, or under the supervision of, a registered

nurse or, when provided by regulation, a licensed practical (vocational) nurse. (See

42CFR §409.32) If all other requirements for coverage under the SNF benefit are met,

skilled nursing services are covered when an individualized assessment of the patient’s

clinical condition demonstrates that the specialized judgment, knowledge, and skills of a

registered nurse or, when provided by regulation, a licensed practical (vocational) nurse

are necessary. Skilled nursing services would be covered where such skilled nursing

services are necessary to maintain the patient’s current condition or prevent or slow

further deterioration so long as the beneficiary requires skilled care for the services to be

safely and effectively provided, and all other requirements for coverage under the SNF

benefit are met. Coverage does not turn on the presence or absence of an individual’s

potential for improvement from nursing care, but rather on the beneficiary’s need for

skilled care.

A condition that would not ordinarily require skilled nursing services may nevertheless

require them under certain circumstances. In such instances, skilled nursing care is

necessary only when (a) the particular patient’s special medical complications require the

skills of a registered nurse or, when provided by regulation, a licensed practical nurse 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 registered nurse or, when

provided by regulation, a licensed practical nurse are required to furnish the services.

A service is not considered a skilled nursing service merely because it is performed by or

under the direct supervision of a nurse. If a service can be safely and effectively

performed (or self-administered) by an unskilled person, the service cannot be regarded

as a skilled nursing service although a nurse actually provides the service. Similarly, the

unavailability of a competent person to provide a nonskilled service, regardless of the

importance of the service to the patient, does not make it a skilled service when a nurse

provides the service.

Some examples of direct skilled nursing services are:

• 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;

• Application of dressings involving prescription medications and aseptic

techniques (see §30.5 for exception);

• Treatment of decubitus ulcers, of a severity rated at Stage 3 or worse, or a

widespread skin disorder (see §30.5 for exception);

• Heat treatments which have been specifically ordered by a physician as part of

active treatment and which require observation by skilled nursing personnel to

evaluate the patient’s progress adequately (see §30.5 for exception);

• 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 gases such as

bronchodilator therapy; and

• 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.