During the COVID-19 pandemic, the federal government has implemented some key blanket 1135 waivers designed to assist skilled nursing facility to help manage this Public Health Emergency (PHE). This included adopting a waiver of the requirement to have a three-day stay in a hospital to get Medicare coverage of a skilled nursing stay.  This has led to some confusion among operators and those responsible for implementing those waivers during these difficult times.  Now that these claims will be getting reviewed, it’s important to prepared to prevent denials.

Here are the PDPMpro™ Top 5 key pitfalls to avoid with these waivers:


5.  60-day break in spell of illness is no longer in place under the waivers.
This has been confusing to many providers and patients since even CMS did not have a long description.  The fact is, that this situation only applies to those beneficiaries who have been delayed or prevented by the emergency itself from commencing or completing the process of ending their current benefit period and renewing their SNF benefits that would have occurred under normal circumstances.  We have found that this situation applies to very few patients.

4.  The 3-day Wavier was to skill COVID-19 patients.

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. That’s because 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.  Only observation may not be enough to support a skilled level of service.  It you plan on skilling for COVID positive test only, be sure the skills of your nursing staff is fully utilized including; vitals daily, o2 sat levels are monitored, daily temperature and comprehensive notes are entered into the Medicare record daily.

3.  Therapy Services are optional now under PDPM during the PHE.

Medicare has made it very clear that they would not place blanket waivers for essential procedures and treatments.  Therapy is an essential treatment, and the “standard of care” is expected to be maintained during this emergency.  Facilities do have the ability to pause services as part of an emergency response plan to maintain a safe environment.  If such a plan is initiated, CMS gives guidance to ensure that all members of the care team are documenting in the medical record their efforts to adhere to the clients plan of care, including all refused and alternate methods use to preform client visits. Furthermore, therapy follow-ups should be done with all patients that received a lower level of services than usually expected for their condition because of facility emergency procedures.

2.  Isolation patients can be cohorting with other COVID patients and still be consider in “isolation”.

This was a significant problem in the beginning of the pandemic.  Since then, CMS has clarified that NONE of the requirements or regulations regarding the MDS have changes.  Therefore, in order for any patient to be coded for “isolation” on the MDS they MUST be in a room alone and not paired, grouped, or cohorted with any other COVID patients.

1.  A suspected COVID case isolated and reimburse for nursing “Extensive Services” (even if the test comes back negative) can be skilled only if all of the following four factors (with exception of hospital stay) are met:

  • The patient requires skilled nursing services or skilled rehabilitation services (nursing or therapy)
  • The patient requires these skilled services on a daily basis and are documented.
  • The daily skilled services can be provided only on an inpatient basis.
  • The services delivered are reasonable and necessary for the treatment of a patient’s illness or injury.
Questions or concerns?  Feel free to send JMD Healthcare questions concerning therapy documentation or treatments to receive a FREE risk analysis with referenced Medicare Guidelines to help maintain compliance in your facility. 
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JMD Healthcare Solutions LLC is a skilled nursing facility management service.  The purpose of this email is to provide educational discussions of the skilled nursing facility industry and promote the value of our services. This is advertising material.

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