point to discontinue the patient's use of the item at the time of termination of his stay as an inpatient. (For example, a brace temporarily attached to the patient's body while he is receiving treatment as an inpatient and which is needed to facilitate departure from the skilled nursing facility.)

(f) Medical services provided by an intern or resident-in-training. Medical services provided by an intern or resident-in-training are included as extended care services if provided by an intern or resident-in-training of a hospital with which the skilled nursing facility has in effect an agreement for the transfer of patients and exchange of medical records (see § 405.1133), and under a teaching program of such hospital approved in accordance with the provisions described in § 405.116(f).

(g) Other diagnostic or therapeutic services. Other diagnostic or therapeutic services are included as extended care services if provided by a hospital with which the skilled nursing facility has in effect an agreement for the transfer of patients and exchange of clinical records (see § 405.1133).

ex

(h) Services not generally provided. Except as specifically enumerated in this section, only those items and services generally provided by skilled nursing facilities are considered as tended care services. For example, though an individual is furnished the use of an operating room by a skilled nursing facility, such service is not included as "extended care service" since operating rooms are not generally maintained as part of skilled nursing facilities.

[31 FR 10119, July 27, 1966, as amended at 34 FR 11205, July 3, 1969. Redesignated at 42 FR 52826, Sept. 30, 1977]

§ 405.126 Posthospital extended care; level of care requirements.

One of the eligibility requirements for posthospital extended care benefits under title XVIII of the Act is that the beneficiary require the type and level of care which has been defined as posthospital extended care. A beneficiary who requires this level of care and meets all other eligibility requirements shall be entitled to have payment made under the health insurance program for all covered services

furnished him in a skilled nursing facility 'see § 405.125).

(a) Defined. For a beneficiary to meet the skilled nursing facility level of care, he must need, on a daily basis (see § 405.128), skilled nursing services or skilled rehabilitation services (see § 405.127), which as a practical matter (see § 405.128a) can be provided only in a skilled nursing facility on an inpatient basis, and which are for either (1) a condition for which he received inpatient hospital services (see § 405.120(c)), or (2) for a condition which arose while he was in a skilled nursing facility receiving care for a condition for which he received inpatient hospital services.

(b) Coverage criteria. In determining whether the services a patient requires in connection with a condition specified in paragraph (a)(1) or (a)(2) of this section constitute the level of care covered under the extended care benefit, three criteria must be met:

(1) Skilled nursing services or skilled rehabilitation services must be required;

(2) Such services must be required on a daily basis; and

(3) As a practical matter, the service can only be provided in a skilled nursing facility (or only in such a facility or a hospital) on an inpatient basis.

[40 FR 43896, Sept. 24, 1975. Redesignated at 42 FR 52826, Sept. 30, 1977]

§ 405.127 Posthospital extended care; skilled nursing and rehabilitation services.

(a) Defined. Skilled nursing and/or skilled rehabilitation services are those services furnished pursuant to physician orders which:

(1) Require the skills of technical or professional personnel, e.g., registered nurse, licensed practical (vocational) nurse, physical therapist, occupational therapist, speech pathologist, audiologist as defined in § 405.1101 (c), (k), (m), (q), and (t) and

(2) Are provided either directly by or under the supervision (§ 405.1101(u)) of such personnel.

(b) Determination of services as skilled. In determining whether a service is skilled, the following criteria shall apply:

(1) Where the inherent complexity of a service prescribed for a patient is such that it can be safely and/or effectively performed only by or under the supervision of technical or professional personnel, the service would constitute a skilled service.

(2) The restoration potential of a patient is not the deciding factor in determining whether a service is to be considered skilled or nonskilled. Even where full recovery or medical improvement is not possible, skilled care may be needed to prevent, to the extent possible, deterioration of the condition or to sustain current capacities. For example, even though no potential for rehabilitation exists, a terminal cancer patient may require skilled services as defined in the following paragraphs of this section.

(3) A service that is generally nonskilled would be considered to be a skilled service where, because of special medical complications, its performance or supervision or the observation of the patient necessitates the use of skilled nursing or skilled rehabilitation personnel. For example, the existence of a plaster cast on an extremity generally does not indicate a need for skilled care, but a patient with a preexisting acute skin problem or a need for special traction of the injured extremity might need to have technical or professional personnel properly adjust traction or observe him for complications. In such cases, the complications and special services involved must be documented by physicians' orders and nursing and/or therapy notes.

(c) Skilled nursing or rehabilitation services. Some examples of skilled nursing and other skilled rehabilitation services include, but are not limited to, the following:

(1) Services which could qualify as either skilled nursing or skilled rehabilitation services-(i) Overall management and evaluation of care plan. The development, management, and evaluation of a patient care plan, based on the physician's orders constitute skilled services when, in terms of the patient's physical or mental condition, such development, management, and evaluation necessitate the involvement of technical or professional per

sonnel to meet his needs, promote his recovery, and actuate his medical safety. This would include the management of a plan involving only a variety of personal care services where in light of the patient's condition the aggregate of such services necessitates the involvement of technical or professional personnel. For example, an aged patient with a history of diabetes mellitus and angina pectoris who is recovering from an open reduction of a fracture of the neck of the femur requires, among other services, careful skin care, appropriate oral medications, a diabetic diet, an exercise program to preserve muscle tone and body condition, and observation to detect signs of deterioration in his condition or complications resulting from his restricted, but increasing mobility. Although any of the required services could be performed by a properly instructed person, such a person would not have the ability to understand the relationship between the services and evaluate the ultimate effect of one service on the other. Since the nature of the patient's condition, his age, and his immobility create a high potential for serious complications, such an understanding is essential to assure the patient's recovery and safety. Under these circumstances, the management of such a plan of care would require the skills of a nurse even though the individual services are not skilled. Skilled planning and management activities are not always specifically identified in the patient's clinical record. In light of this, where the patient's overall condition would support a finding that his recovery and/or safety could be assured only if the total care he requires is planned, managed, and evaluated by technical or professional personnel, it would be appropriate to infer that skilled services are being provided.

(ii) Observation and assessment of the patient's changing condition. When the patient's condition is such that the skills of a nurse or other technical or professional person are required to identify and evaluate the patient's need for possible modification of treatment and the initiation of additional medical procedures until his condition is stabilized, such services

constitue skilled services. For example, a patient with congestive heart failure may require continuous close observátion to detect signs of decompensation, abnormal fluid balance, or adverse effects resulting from prescribed medication(s) which serve as indicators for adjusting therapeutic measures. Likewise, surgical patients transferred from a hospital to a skilled nursing facility while in the complicated, unstabilized postoperative period, e.g., after hip prosthesis or cataract surgery, may need continued close skilled monitoring for postoperative complications and adverse reaction. Patients who in addition to their physical problems, exhibit acute psychological symptoms such as depression, anxiety, or agitation, etc., may also require skilled observation and assessment by technical or professional personnel to assure their safety and/or the safety of others, i.e., to observe for indications of suicidal or hostile behavior. In such cases, special services required must be documented by physicians' orders and/or nursing or therapy notes.

(iii) Patient education services. In cases where the use of technical or professional personnel is necessary to teach a patient self-maintenance, such teaching services would constitute skilled services. For example, a patient who has had a recent leg amputation needs skilled rehabilitation services provided by technical or professional personnel to provide gait training and to teach prosthesis care. Likewise, a patient newly diagnosed with diabetes requires instruction from technical or professional personnel to learn the self-administration of insulin or footcare precautions, etc.

(2) Services which would qualify as skilled nursing services. (i) Intravenous, intramuscular, or subcutaneous injections and hypodermoclysis or intravenous feeding;

(ii) Levin tube and gastrostomy feedings;

(iii) Nasopharyngeal and tracheotomy aspiration;

(iv) Insertion and sterile irrigation and replacement of catheters;

(v) Application of dressings involving prescription medications and aseptic techniques;

(vi) Treatment of extensive decubitus ulcers or other widespread skin disorder;

(vii) Heat treatments which have been specifically ordered by a physician as part of active treatment and which require observation by nurses to adequately evaluate the patient's progress;

(viii) Initial phases of a regimen involving administration of medical gases;

(ix) Rehabilitation nursing procedures, including the related teaching and adaptive aspects of nursing, that are part of active treatment, e.g., the institution and supervision of bowel and bladder training programs.

(3) Services which would qualify as skilled rehabilitation services. (i) Ongoing assessment of rehabilitation needs and potential: Services concurrent with the management of a patient care plan, including tests and measurements of range of motion, strength, balance, coordination, endurance, functional ability, activities of daily living, perceptual deficits, speech and language or hearing disorders;

(ii) Therapeutic exercises or activities: Therapeutic exercises or activities which, because of the type of exercises employed or the condition of the patient, must be performed by or under the supervision of a qualified physical therapist or occupational therapist to ensure the safety of the patient and the effectiveness of the treatment;

(iii) Gait evaluation and training: Gait evaluation and training furnished to restore function in a patient whose ability to walk has been impaired by neurological, muscular, or skeletal abnormality;

(iv) Range of motion exercises: Range of motion exercises which are part of the active treatment of a specific disease state which has resulted in a loss of, or restriction of, mobility (as evidenced by a therapist's notes showing the degree of motion lost and the degree to be restored);

(v) Maintenance therapy: Maintenance therapy, when the specialized knowledge and judgment of a qualified therapist is required to design and establish a maintenance program based on an initial evaluation and periodic reassessment of the patient's needs,

and consistent with the patient's capacity and tolerance. For example, a patient with Parkinson's disease who has not been under a rehabilitation regimen may require the services of a qualified therapist to determine what type of exercises will contribute the most to the maintenance of his present level of functioning;

(vi) Ultrasound, short-wave, and microwave therapy treatments by a qualified physical therapist;

(vii) Hot pack, hydrocollator, infrared treatments, paraffin baths, and whirlpool: Hot pack, hydrocollator, infrared treatments, paraffin baths, and whirlpool, in particular cases where the patient's condition is complicated by circulatory deficiency, areas of desensitization, open wounds, fractures, or other complications, and the skills, knowledge, and judgment of a qualified physical therapist are required; and

(viii) Services of a speech pathologist or audiologist when necessary for the restoration of function in speech or hearing.

(d) Personal care services. Personal care services which do not require the skills of qualified technical or professional personnel are not skilled services except under the circumstances specified in paragraph (b)(3) of this section. Personal care services include, but are not limited to, the following:

(1) Administration of routine oral medications, eye drops, and ointments; (2) General maintenance care of colostomy and ileostomy;

(3) Routine services to maintain satisfactory functioning of indwelling bladder catheters;

(4) Changes of dressings for noninfected postoperative or chronic conditions;

(5) Prophylactic and palliative skin care, including bathing and application of creams, or treatment of minor skin problems;

(6) Routine care of the incontinent patient, including use of diapers and protective sheets;

(7) General maintenance care in connection with a plaster cast;

(8) Routine care in connection with braces and similar devices;

(9) Use of heat as a palliative and comfort measure, such as whirlpool and hydrocollator;

(10) Routine administration of medical gases after a regimen of therapy has been established;

(11) Assistance in dressing, eating, and going to the toilet;

(12) Periodic turning and positioning in bed; and

(13) General supervision of exercises which have been taught to the patient; including the actual carrying out of maintenance programs, i.e., the performance of the repetitive exercises required to maintain function do not require the skills of a therapist and would not constitute skilled rehabilitation services (see paragraph (c)(3) of this section). Similarly, repetitious exercises to improve gait, maintain strength, or endurance; passive exercises to maintain range of motion in paralyzed extremities, which are not related to a specific loss of function; and assistive walking do not constitute skilled rehabilitation services.

[40 FR 43897, Sept. 24, 1975. Redesignated at 42 FR 52826, Sept. 30, 1977]

§ 405.128 Posthospital extended care; frequency of services; "daily basis."

Skilled nursing services or skilled rehabilitation services must be required and provided on a "daily basis"-i.e., on essentially a 7-day-a-week basis. However, if skilled rehabilitation services are not available on a 7-day-aweek basis, a patient whose inpatient stay is based solely on the need for skilled rehabilitation services would meet the "daily basis" requirement where he needs and receives such services on at least 5 days a week. Accordingly where a facility provides physical therapy on only 5 days a week and the patient in such a facility requires and receives physical therapy on each of the days on which such is available, the requirement that skilled rehabilitation services be provided on a daily basis would be met. The requirements that skilled rehabilitation services be required on a daily basis should not be applied so strictly that it would not be met merely because there is a break of a day or two during which no skilled rehabilitation services are furnished and discharge from the facility would

not be practical. For example, a patient who normally requires skilled rehabilitation services on a daily basis exhibits extreme fatigue which results in his physician's suspending therapy sessions for a day or two. Payment would be made for these days since discharge in such a case would not be practical.

[40 FR 43898, Sept. 24, 1975; 40 FR 46309, Oct. 7, 1975. Redesignated at 42 FR 52826, Sept. 30, 1977]

§ 405.128a Posthospital

need for institutionalization; “practical matter."

(a) In determining whether the care needed by a beneficiary can, as a practical matter, only be provided in a skilled nursing facility on an inpatient basis, consideration must be given to the patient's condition and to the availability and feasibility of using more economical alternative facilities and services.

(b) If the needed service is not available in the area in which the individual resides and transporting him to the closest facility furnishing such services would be an excessive physical hardship, it would be appropriate to conclude that the needed care can, as a practical matter, only be provided in a skilled nursing facility. This would also be true even though the patient's condition might not be adversely affected, if it would be more economical or more efficient to provide the covered services in the institutional setting. For example, if the patient's condition was such that daily transportation by ambulance was necessary, it might be more economical to provide the needed care in an institutional setting.

(c) In determining the availability of alternative facilities and services, availability of funds to pay for the services furnished by such alternative facilities is not a factor to be considered. For instance, an individual in need of daily physical therapy might be able to receive the needed services from an independent physical therapy practitioner. The fact that reimbursement could not be made under the health insurance program for the services in a year after $100 in expenses had been incurred, would not be a

basis for determining that the needed care could be provided only in a skilled nursing facility.

[40 FR 43898, Sept. 24, 1975. Redesignated at 42 FR 52826, Sept. 30, 1977]

§ 405.130 Posthospital home health services; general.

Home health service benefits are provided under the hospital insurance benefits plan described in this Subpart A and also under the medical insurance benefits plan described in Subpart B of this part. The conditions for payment for the services vary, however. The basic difference is that under the hospital insurance benefits plan, the home health services must be furnished as an extension of inpatient hospital services or posthospital extended care services furnished the individual. Under the medical insurance plan described in Subpart B, it is not necessary that the individual have first been an inpatient of a hospital or skilled nursing facility in order to have payment made for the home health services provided under that plan. The fact that payment may be made under this Subpart A for posthospital home health services for up to 100 visits does not preclude the payment, under Subpart B of this part, for an additional 100 home health service visits furnished to him in the same calendar year if the conditions and requirements for payment are met. The following sections set forth the posthospital home health service benefits and the conditions for entitlement to such benefits.

[31 FR 10119, July 27, 1966. Redesignated at 42 FR 52826, Sept. 30, 1977]

§ 405.131 Posthospital home health services; benefits provided.

An individual who meets the requirements set forth in § 405.102 is eligible to have payment made on his behalf to a home health agency for home health services (as defined in § 405.236) furnished for up to 100 visits (charged in accordance with § 405.238) if the services are furnished:

(a) To an individual who is under the care of a physician (other than a doctor of podiatry or surgical chiropody);