Director of Nursing Manual
For Health Care Facilities
Checklist for Determining Medicare Coverage
Overall Management and Evaluation of Care Plan
Note: This constitutes skilled services when the Development, Management, and
Evaluation of the care plan based on Physician’s orders require the involvement of
technical or professional personnel in order to meet needs, promote recovery, and
ensure medical safety. Activities may be personal care, but in light of the
beneficiary’s total condition, these activities in aggregate require a technical or
professional staff daily to manage plan.
Observation and Assessment of Changing Condition
Note: Observation and Assessment constitutes skilled services when the skills of a
technical or professional person are required to identify and evaluate the patient’s
need for modification of treatment or for additional medical procedures until condition
is stabilized.
 Neurological Services
a. Level of consciousness-responds to
verbal/painful stimuli
b. Pupil size, reaction
c. Movement/weakness
d. Seizure activity
 Cardiac
a.
b.
c.
d.
e.
Pulse, rate, rhythm
Peripheral edema
Chest pain
Lung sounds
Medication-adverse reactions and/or
adjustments
f. Rapid weight gain
g. Cyanosis
 Circulatory
a.
b.
c.
d.
e.
Pedal pulse
Color, warmth of extremity
Capillary refill
Edema
Pain/numbness/tingling
 Genitourinary
a. Urinary tract infection-burning,
frequency, hematuria, pain and fever
 Respiratory
a. Shortness of breath
b. Dyspnea, cyanosis
c. Lung sounds, rales, rhonchi,
wheezing
d. Productive cough, thick, copious
sputum
e. Respiration, depth, and rate
 Gastrointestinal
a.
b.
c.
d.
e.
f.
g.
Nausea, vomiting
Diarrhea
Bowel sounds
Distention
Sudden weight loss
Gastric pain
Hemocult (stools)
 Surgical
a. Incision site signs and symptoms of
infection, approximation
 Medications
a. Adverse side effects and dosage
adjustment
b. Electrolyte imbalance due to
medication therapy
c. Coumadin -presence or absence of
symptoms
d. Antibiotic therapy
e. Steroid therapy (new or with
adjustments)
f. Chemotherapy-monitor nausea,
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Director of Nursing Manual 2008
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Director of Nursing Manual
For Health Care Facilities
vomiting, fever, ulceration
g. Pain management- frequency, side
effects, effectiveness
h. Psychotropic medications,
adjustments monitor therapeutic
i. Effects
 Dehydration/Malnutrition
 Laboratory
 Isolation (Precautions)
Skilled Nursing Services:
 IV/IM Injections/Continuous Sub-Q
Pump
a. Heparin
b. Antibiotics
c. Pain medications
d. Other (Excludes subcutaneous
injections)
 Tube Feedings (N/G, GT, or Jejunostomy)  Stage III or IV Pressure Sores
a. Meet calorie and fluid requirements
 Wound Care/Dressing
a. With prescription and aseptic technique
 Urological
 Respiratory Treatments
a. Suctioning (Nasopharyngeal and
trach)
b. Initial phases of a regimen involving
administration of medical gases
c. Oxygen therapy
 Intravenous Therapy or Feeding
a. Supra-pubic catheter insertion or
irrigation
 Heat Treatment
a. Physician orders, nurse needed to
monitor progress
Rehabilitation Services:
Need both #1 and #2 to qualify
 Requires skills of a licensed therapist 5 days a week. Can be a combination of therapy (i.e.
Physical, occupational, or speech). Note: Goal is to improve patient’s functional ability.
 Requires skills of licensed therapist
 Requires whirlpool for stage III or IV Pressure Sore or burns (for purpose of cleaning/draining
wound or debridement)
Patient Education Services:
If YES is noted on any item below, the beneficiary is skilled for Patient Education
 Self-administration of an injectable medications or a complex range of medications
 Self-Administration of insulin injections, to prepare and follow a diabetic diet, and observe foot
care
 Self-Administration of Medical Gases
 Gait training and Prosthesis care
 Care for a recent Colostomy and Ileostomy
 Self-Catherization and self Administration of Gastronomy Feedings
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Director of Nursing Manual 2008
2
Director of Nursing Manual
For Health Care Facilities
 Care and maintenance of central venous lines, such as Hickman Catheters
 Use and care of Braces, Splints, and Orthotics and any associated skin care
 Care of any specialized dressings or skin treatments
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Director of Nursing Manual 2008
3