Involve the Interdisciplinary Team. A} 2?d`aYW!3,8h|J/K\J:s&Ve>1|9WiixusVo\sGP8saBT!+(z$lYnAZZp@6Y1m`[ jKeMQ5i.7HCGIC1iGIc' Whats in it for me? As under the previous RUG-IV model, the presence of an AIDS diagnosis continues to be identified through the SNFs entry of ICD-10-CM code B20 on the claim. It's easy to get to those 50, but the tricky part is understanding which ICD-10 codes match to the comorbidities. Verify coding, dont assume. For example, Mr. Steve is a long term care resident due to Parkinson's Disease. }|YAxz .diS\]0}3sfowMm@ Intermittent Catheterization? Title: Microsoft Word - FINAL PDPM Triple Check Checklist.docx Author: jleatherbarrow Created Date: 1/29/2020 4:19:17 PM Highlights: But if the resident is transferred back to the hospital and is admitted as an inpatient, let's say for pneumonia, then returns to the SNF after the 3-day interrupted stay window, a new 5-Day will be required and the surgery will not be able to be coded in J2100, because the surgery did not occur "during the inpatient hospital stay that immediately preceded the residents Part A admission". 0000001865 00000 n They are assisted by certified nursing assistants (CNAs) and licensed staff assist them during medication administration ordered by the patients attending physician in the facility. Non-Therapy Ancillary (NTA) classification in PDPM is determined by the presence of certain conditions or the use of certain extensive services that were found to be correlated with increases in NTA costs for SNF patients. Ill also compare urban versus rural facilities when it comes to NTA case-mix. The higher the total point value, the greater the payment (CMI). The visualization is interactive. MDS Item Field rows in tan represent MDS item groups identified in CMS PDPM documentation and do not have data entry fields. or privately paid by the patient if he/she does not qualify under the Medi-Cal program. And lastly, an update on therapy revenue codes and the claim CMS Transmittal 2270 from March 13, 2019 states that beginning October 1, 2019, the Medicare contractor will no longer require therapy services to be present on SNF or Swing Bed claims. The RUG-IV consists of two case-mix adjusted components: Therapy which is based on volume of services provided and nursing. As outlined in the SNF PDPM technical report, CMS was looking for the new reimbursement plan to account accurately and appropriately for the increased costs associated with caring for patients with AIDS. The decision to change the definition was because CMS believes that therapists, using their clinical judgment, will allow for more flexibility and that residents often benefit from the psychosocial aspects of group therapy. The FY 2022 SNF PPS Final Rule: Learn the Facts behind the headlines Part 2 ICD-10 Revisions and PDPM. [|Qc\0aXjK@ EdO4&_? Visit www.TrainingInMotion.org for more details of how we can help you achieve your PDPM goals. The functional scoring is based on residents performance in eating, oral hygiene, toileting hygiene, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, and toilet transfer assessed on the first three days of admission to the facility with the admission day counted as day 1. Below is the full listing of conditions and services used for NTA classification and the associated number of points for that comorbidity. Basic versions of many 2019 AHCA PDPM Academy copyrighted document resources and webinars are available to . 0000009611 00000 n The calculation of payments is based on the five case-mix adjusted components: Physical Therapy (PT), Occupational Therapy (OT), Speech Language Pathology (SLP), Nursing and Non-therapy ancillary (NTA). (At this point, I can feel the cold stares from our MDS Experts. As we continue to become more knowledgeable in coding accuracy to drive care and maximize reimbursement, here are 15 quick tips to keep in mind: Those were just a few quick tips that are derived from recent Q&A's with clients. IV medications provided as a resident and coded in Section O would also qualify for NTA points. SAMPLE Task List for the Nurse Assessment Coordinator (NAC) November 23, 2022. Remember that on the therapy plan of care the Treatment Diagnoses should be directly linked the Medical Diagnoses. Focuses on clinically relevant factors rather than volume-based services or RUG levels. var divElement = document.getElementById('viz1528375166404'); var vizElement = divElement.getElementsByTagName('object')[0]; vizElement.style.width='100%';vizElement.style.height=(divElement.offsetWidth*0.75)+'px'; var scriptElement = document.createElement('script'); scriptElement.src = 'https://public.tableau.com/javascripts/api/viz_v1.js'; vizElement.parentNode.insertBefore(scriptElement, vizElement); Use the rate filter to show only the highest or lowest NTA rates. 437 27 Educate yourself on the. The PT and OT payment would be based on: primary reason for SNF care and functional status at admission The sum of the lowest per diem rate under each PDPM component, plus the non-case-mix component is the: default code Which of the following is NOT a case-level adjustment for a MS-LTC-DRG long term stay outlier There is also the impact of the Variable Per Diem Adjustment Factor that is applied to the NTA Component. Character 3: Nursing Case Mix Group (NSG CMG) Character 4: NTA Case Mix Group (NTA CMG) Character 5: Assessment Indicator HIPPS Code PT/OT CMG SLP CMG NSG CMG NTA CMG HIPPS Code A TA SA ES3 NA A B TB SB ES2 NB B C TC SC ES1 NC . For example, if a resident admits and the dietitian notes the BMI is over 40, query the physician to confirm a morbid obesity diagnosis. This article was originally published in February 2019, and has been updated in October 2019 with several more tips. Specialties Hyperemesis Gravidarum: More Than Just Morning Sickness Pregnancy and nausea are terms used in unison with one another. After the PDPM rate for each component is determined, the sum of the PDPM component rates is added to the fixed non-case mix rate which will be the final reimbursement rate for the patient for the entire skilled nursing facility stay. Yes, Im aware that if you dont look at every. 0000189184 00000 n SNF FY 2022 Proposed Rule Learn the Facts Behind the Headlines Part 3: How is My Rate Calculated, Regulatory Reminder! Identification of NTA conditions and services should start even before the SNF admission. Base rates are either rural or urban as determined by geographic location. b!+XQ{ +LgOIYe/Q6RVpYY_N/.~iMu1fY*eR}W_E[,7vrR!XSF};qZW&e"S5!CW}3GU|muc?_X`dcg7(zRU8k? ;iHIBK = >N]Y}dZ}HvtZ04D8YV4r4Od^/NJ x/i"9WirMdy2d*{E^lEu}Jg t@C`[aNOGgg0?bd'r EVm@Av;*%f?Wp :1&[+cZhqhU;IKBU While mild nausea and vomiting is a common discomfort of pregnancy, patientswith severe cases become diagnosed with hyperemesis by NCC News and Content Team | Dec 6, 2022 | Specialties. Determinants of payment are based on the patients characteristics assigned to six components: Patients are assigned to classification groups known as RUG Classification Groups based on various characteristics of patients and the intensity of therapy services provided. The administration of IV fluids may qualify for the Parenteral/IV Feeding - High or Parenteral/IV Feeding - low NTA points. This gives you enough time to prepare for their implementation of any changes as MDS assessments are time sensitive. yid T[KaEev0D/wRDQhDB['QgDTBEB)2"xt"Xn2 QN[%=> FhzdBI^8/HD SLP: NSG: NTA: This audit format form contains the MDS 3.0 items that drive payment for the Part A Medicare PDPM SNF-PPS payment. Its interesting to note that the data CMS provided, that I am using here, came from some assessments that we no longer will be doing. If your facility has a low NTA rate, it may just mean you have work to do, documentation-wise. endstream endobj 452 0 obj <>stream The provider will report on the Minimum Data Set (MDS) each of the comorbidities that a person has. Either way, you must still also code the I0020B primary condition I0010 through I8000. The skilled services are provided by a Medicare-certified SNF. No software installation. CMS 100-2 Chapter 8 Series Part I: Access to Medicare Part A Benefits In a SNF. CMS 100-2 Chapter 8 Series Part I: Access to Medicare Part A Benefits In a SNF. <<50FFC127310FCF468ABFE4B7414A5B70>]/Prev 423154>> Based on that, we can calculate the rate. These conditions may warrant completion of an Interim Payment Assessment (IPA) thus increasing the NTA component score and potentially the total per diem. The non-therapy ancillary (NTA) part of the patient driven payment model (PDPM) is considered by most people Ive talked to as being better than what were currently doing. Just 1 NTA point can have an average worth of anywhere from $18 to $55 per day. Not having the correct codes can have a domino effect and result in missed reimbursement, or claim inaccuracies. For example, IV medications (5 points) coded in MDS item O0100H2 or isolation (1 point) coded in O0100M2. h4Pj0^z[ 8 >BRA$+Vfa Under PDPM there are 161 Minimum Data Set (MDS) item fields. Item I0020 and I0020B: Item I0020 (primary medical condition category that best describes the primary reason for admission lists several options. These conditions, along with the number of points associated with the condition and how it is reported, can be found by downloading the CMS document titled "Fact Sheet: NTA Comorbidity Score. Yes, I get that is bad. If the Primary Diagnosis you listed in I0020B also happens to be a SLP Comorbidity qualifier from the SLP Comorbidity list, the grouper software will pick it up as a comorbidity from I8000. The NTA component is an important component to capture and reimburse the facility for costly medications, services, and supplies needed to care for residents. What do I need to know? The resulting sum is the NTA comorbidity score, which is used to classify each resident into an NTA case-mix group. Le^#N"TaAKTt This does not include conditions that are resolved. The correct coding for NTA will require a team effort and diligent review of coding and supporting documentation to ensure 100% accuracy. |Pa(E8BNJA!-tUiX%:h~GJ?J.H% kZ*qyXjBy@C(zHhzQhhlL2cO`.$p6_[3R^IrHrr6#eq7**2uWytb$HyZi[F2_ GBM*.`k@/9cO9R*^fo_MOK6_xg,eM'jv}5E|SWNH0$z|.WL7y9 ;4H*h;H8H"*RW l? 26 11.4 Will section I0020B override section I0020, 1-13 for the primary reason for SNF admission since you could miss something. requires an analytical mind and financial knowledge to determine the highest allowable reimbursement for the facility. color: white; Inappropriate Schizophrenia Diagnosis/Coding and Survey Citation Posting, Regulatory Reminders: Consolidated Billing Update 2023. h2430Q0P0430S0 CMS stated in the final rule for FY 2023 that they intend to take a more cautious approach to mitigate the potential negative impacts on the nursing home industry with this parity adjustment by spreading it across a two-year period. AVONA confirms that rural facilities do indeed have lower NTA case-mix. (Nursing, Social Services, Dietary and Activity Staff). Custodial care does not require the assistance of a licensed staff. In this post Im going to take a deeper look at it and calculate the average NTA payment by state and facility. His claim's principal diagnosis is Parkinson's Disease. (Ui7A7dR;5|jDM\sEamJFK3O.C[=vBD:]'N+T_ rhc_ex>mHR&o6Bfr*W0zG3KWmxK6P46n=Jt0Pn'OGC~&S};& Dt];vwj+E0R"^T Continuous training is the key and implementation of what was learned in coordination with the facility team members will ensure success in providing skilled care for the patients and maximizing facility reimbursement. (Click either image to enlarge.). Hover over a facility to see the name, NTA Rate, NTA case-mix index and whether the facility is urban or rural. SNF FY 2022 Proposed Rule Learn the Facts Behind the Headlines Part 3: How is My Rate Calculated, Regulatory Reminder! The Patient-Driven Payment Model (PDPM), is fast approaching with implementation set for October 2019. PDPM consists of five case-mix adjusted components: Physical therapy (PT) Occupational therapy (OT) Speech-language pathology (SLP) Nursing Non-therapy ancillary (NTA) PDPM also includes a variable per diem (VPD) adjustment that adjusts the per diem rate to reflect varying costs throughout a patient's stay. @ Homework - Chapter 31: HlTT x + . We earn 1 NTA point for second or third degree burn coded in M1040F. All Rights Reserved. With several big changes ahead, the margin for error slim for most providers. Given that CMS has released the distribution of case-mix groups for NTA for all skilled nursing facilities, we can calculate an average case-mix index for everyone. Often overlooked, Non-Therapy Ancillaries or NTAs will be more important than ever in PDPM. Center for Medicare and Medicaid Services. Facilities that work to establish these best practices associated with the NTA component will increase revenue and see other benefits such as improved Quality Measures, reduced readmission rates, and improve skilled documentation. 0000000836 00000 n 463 0 obj <>stream It is highly advisable for MDS nurses to review each assessment to ensure that all skilled services are captured during the assessment period to maximize reimbursement rate for the facility based on the patients diagnosis and acuity. It is highly recommended for the MDS nurse to make calculations which can determine the highest acceptable reimbursement rate for the facility. Click the comorbidity and see the ICD-10 codes that are most likely to occur. We must also understand all the aspects of PDPM coding from every single angle, the relationship between each facet of the components, and the impact on care and revenue. border: 1px solid black; NTA Componenet NTA Component NTA Comorbidity Score NTA Case Mix Group CMI 12+ NA 3.25 9-11 NB 2.53 6-8 NC 1.85 3-5 ND 1.34 1-2 NE 0.96 0 NF 0.72 Presumption of Coverage Comorbidities Included in NTA Comorbidity Score and Assigned Points Condition/Extensive Service MDS Item Points HIV/AIDS SNF Claim ICD-10 B20 8 Parenteral IV Feeding: Level High Everyone I've talked to agrees the NTA payment is a good idea. Wound Care? 0000003793 00000 n As mentioned earlier, these NTA comorbidities are reported (coded) throughout the MDS. PDPM payments will be based on six groupsone non-case mix group (CMG) and five specific CMGs: PT, OT, SLP, NTA and nursing. 0000009034 00000 n Skilled nursing services are covered under the Federal Governments. This is to offset the high cost of medications and supplies that would be required to support the patient characteristics with these NTA conditions upon admission. Remember that after the 3 day interrupted stay he is considered a new admission for purposes of Part A PDPM. For example, if the MDS Coordinator counts only two of the three comorbidities that a patient has, the CMI for NTA would be 0.96 instead of 1.34. As a result, patients with AIDS are assigned the highest point value (8 points) of any condition or service for purposes of classification under the PDPMs NTA component, and they also receive a special 18% add-on to the nursing component of the payment. Always be on the lookout for new updates which usually happen every year and usually effective by October 1 of each updated year. Also, there is a 25% combined limit on concurrent and/or group therapy. 5!!!!!May!be!used!by!permission!only!Proactive!Medical!Review,!LLC!!!!!www.proactivemedicalreview.com!!!! PDPM ICD10 Consulting Confidential 2019 A Native American-Owned business Page . 0000008175 00000 n SNF PDPM Provider-Specific Impact File. As a result, client facilities realize improved wound healing results, improved survey scores and NTA reimbursement under PDPM. Daily Medicare charting should focus on all possible nursing clinical categories, special care high, special care low, clinically complex, behavioral symptoms and cognitive performance, and reduced physical function. Primary Diagnosis - List I0020B Surgical Procedures - List J2100/J2300-J5000 Aphasia I4300 Cerebrovascular Accident . In it, youll find the 1,612 codes that map to the different comorbidities. This simply shows you a starting point. Any delay in getting this information is going to be problematic. ANOVA Rural versus Urban NTA case-mix (click to enlarge). This has been a key consideration in designing the various elements of the new model. Other ancillary services include room and board, activity planning, housekeeping, laundry, and maintenance of fixtures/equipment. Seek advice from experts, trainers and other MDS nurses when needed to clarify any areas in the MDS assessment or PDPM calculation. Refer to RAI pages J37-J38 for more on coding J2100. The functional scoring is based on residents performance in. Non-Therapy Ancillary (NTA) Services - At a Glance The Patient-Driven Payment Model (PDPM) takes effect on October 1, 2019 and represents a significantly different approach to reimbursement for care in Skilled Nursing Facilities (SNFs). These components for classification and payment include: Physical Therapy (PT), Occupational Therapy (OT), Speech Therapy (ST), Non-therapy Ancillary (NTA) as well as Nursing. The general method for calculation of any NTA category is as follows: The Fiscal Year (FY) 2021 PDPM ICD-10-CM Mappings file includes the NTA Comorbidity to ICD-10-CM Mapping, which maps comorbidities in the NTA component captured in item I8000 to allowable ICD-10 codes. %PDF-1.6 % We earn 1 NTA point when Other Skin Problems (foot ulcers/lesions) is coded in MDS item M1040A (infection of the foot such as cellulitis or purulent drainage), M1040B (diabetic foot ulcer), or M1040C (other open lesion of foot). The NTA component score is based on the presence of certain comorbidities and/or the use of extensive services. Each component has its case mix index to determine the component rate. You can read more about this in the Official ICD10 Guidelines for Coding and Reporting FY2020, Section II, Subsection K. For example: The definition of Group Therapy has changed. Section I8000 alone has 27 of these conditions, while sections K, M, N, and O also have items that can contribute to the NTA score. With the transition from Resource Utilization Group Version IV (RUG-IV) to the Patient-Driven Payment Model (PDPM) on October 1, 2019, the MDS nurse requires an analytical mind and financial knowledge to determine the highest allowable reimbursement for the facility. The higher the score, the higher the NTA rate. THURSDAY JUNE 23, 2022 2 PM EASTERN - 90 MINUTES, OHIO HEALTH CARE ASSOCIATION- Virtual Webinar, COST $35 FOR OHCA MEMBERS, $90 FOR NON-MEMBERS, https://webinars.ohca.org/?pg=semwebCatalog&panel=showLive&seminarid=16339, 6/23/22 Capturing Non-Therapy Ancillary (NTA) in PDPM. 0 The PDPM classification system is based on support of the patients characteristics. Yes, I am aware that ICD-10 codes do change occasionally. To ease some of this burden, AAPACN developed the Sample Task List for the Nurse Assessment Coordinator tool . For more information on preparing for the transition to PDPM, register for our 9-Part PDPM Webinar Series. Five are case-mix adjusted to allow for variances in diagnoses, severity of illness and other variables associated with the probability of improvement with treatment: Physical therapy (PT) - includes a variable per diem factor Occupational therapy (OT) - includes a variable per diem factor Facilities must ensure efficient processes are in place when selecting the primary diagnosis. by NCC News and Content Team | Mar 1, 2023 | Hospitals, Specialties. Good talk. Q: Our EMR system will calculate the BMI. The patients NTA comorbidity score is the sum of the points associated with each relevant comorbidity. 3HFDRkse$:stHqPJoHK-qL_sh|Kg?unioWAsfH8[^9{'~-? Condition/Extensive Service Source Points Aseptic Necrosis of Bone MDS Item I8000 1 Asthma COPD Chronic Lung Disease MDS Item I6200 2 by Proactive LTC Consulting | Jan 6, 2020 | Audits, Compliance, Education, MDS, Medical Review, PDPM. 0000004542 00000 n Admitted in the Skilled nursing facility (SNF) within a short time (generally 30 days) of leaving the hospital and require skilled services related to hospital stay. You should understand those things too, reader.). Resolved conditions should not be listed since therapy would not be treated for a resolved condition. endstream endobj 1696 0 obj <>stream Payment is based on services provided by five disciplines: physical therapy, occupational therapy, speech language pathology, nursing, and non-therapy ancillary (NTA). The PDPM Clinical Categories are discussed below. Try Now! You can see in the histogram that not only are there a lot fewer rural facilities, but they also appear to have lower average case-mix. Observation services are not covered as part of the inpatient stay. A SANE nurse is an RN who has been trained to examine and assess clients who have a reported a sexual assault. Inappropriate Schizophrenia Diagnosis/Coding and Survey Citation Posting, Regulatory Reminders: Consolidated Billing Update 2023, Osteomyelitis of vertebra, site unspecified, Other acute osteomyelitis, unspecified ankle and foot, Staphylococcal arthritis, unspecified knee, Other acute osteomyelitis, unspecified site, Pneumococcal arthritis, unspecified joint, Other chronic osteomyelitis, unspecified ankle and foot, Other acute osteomyelitis, unspecified tibia and fibula, Other chronic osteomyelitis, unspecified site, Direct infection of unspecified joint in infectious and parasitic diseases classified elsewhere, Staphylococcal arthritis, unspecified hip, Direct infection of unspecified knee in infectious and parasitic diseases classified elsewhere, Staphylococcal arthritis, unspecified shoulder, Other chronic osteomyelitis, unspecified tibia and fibula, Other acute osteomyelitis, unspecified femur, Direct infection of vertebrae in infectious and parasitic diseases classified elsewhere, Other chronic osteomyelitis, unspecified thigh, Direct infection of multiple joints in infectious and parasitic diseases classified elsewhere, Other acute osteomyelitis, multiple sites, Staphylococcal arthritis, unspecified ankle and foot, Chronic myeloid leukemia, BCR/ABL-positive, not having achieved remission, Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, Infection and inflammatory reaction due to unspecified internal joint prosthesis, initial encounter, Embolism due to internal orthopedic prosthetic devices, implants and grafts, initial encounter, Embolism due to vascular prosthetic devices, implants and grafts, initial encounter, Other mechanical complication of unspecified internal joint prosthesis, initial encounter, Dislocation of unspecified internal joint prosthesis, initial encounter, Infection and inflammatory reaction due to other internal prosthetic devices, implants and grafts, initial encounter, Infection and inflammatory reaction due to internal fixation device of unspecified site, initial encounter, Infection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts, initial encounter, Other mechanical complication of aortic (bifurcation) graft (replacement), initial encounter, Other mechanical complication of other internal orthopedic devices, implants and grafts, initial encounter, Breakdown (mechanical) of internal fixation device of unspecified bone of limb, initial encounter, Infection and inflammatory reaction due to cardiac valve prosthesis, initial encounter, Mechanical loosening of unspecified internal prosthetic joint, initial encounter, Broken internal joint prosthesis, unspecified site, initial encounter, Embolism due to genitourinary prosthetic devices, implants and grafts, initial encounter, Secondary esophageal varices without bleeding, Secondary esophageal varices with bleeding, Alcoholic cirrhosis of liver without ascites, Antineoplastic chemotherapy induced pancytopenia, Agranulocytosis secondary to cancer chemotherapy, Acute respiratory failure, unspecified whether with hypoxia or hypercapnia, Acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia, Chronic respiratory failure, unspecified whether with hypoxia or hypercapnia, Acute and chronic postprocedural respiratory failure, Acute pulmonary insufficiency following thoracic surgery, Acute and subacute infective endocarditis, Acute and subacute endocarditis, unspecified, Endocarditis and heart valve disorders in diseases classified elsewhere, Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, with status epilepticus, Epilepsy, unspecified, intractable, with status epilepticus, Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, with status epilepticus, Generalized idiopathic epilepsy and epileptic syndromes, intractable, with status epilepticus, Respiratory bronchiolitis interstitial lung disease, Respiratory disorders in diseases classified elsewhere, Other alveolar and parieto-alveolar conditions, Idiopathic interstitial pneumonia, not otherwise specified, Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema, Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema, Type 1 diabetes mellitus with unspecified diabetic retinopathy with macular edema, Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy with macular edema, Morbid (severe) obesity due to excess calories, Morbid (severe) obesity with alveolar hypoventilation, Body mass index (BMI) 70 or greater, adult, Ulcerative colitis, unspecified, without complications, Crohns disease, unspecified, without complications, Other ulcerative colitis without complications, Ulcerative (chronic) pancolitis without complications, Ulcerative (chronic) proctitis without complications, Crohns disease of small intestine without complications, Crohns disease of large intestine without complications, Idiopathic aseptic necrosis of unspecified femur, Idiopathic aseptic necrosis of unspecified bone, Idiopathic aseptic necrosis of bone, other site, Systemic lupus erythematosus, organ or system involvement unspecified, Ankylosing spondylitis of unspecified sites in spine, Wegeners granulomatosis without renal involvement, Polymyositis, organ involvement unspecified, Dermatopolymyositis, unspecified, organ involvement unspecified, Systemic involvement of connective tissue, unspecified, Unspecified inflammatory spondylopathy, site unspecified, Refractory anemia without ring sideroblasts, so stated, Other specified disorders involving the immune mechanism, not elsewhere classified, Disorder involving the immune mechanism, unspecified. On day 4 it goes back to the rate shown. To assist stakeholders in understanding the potential impacts of the proposed PDPM, we are providing a provider-specific impact analysis file, which details the estimated . At the direction of the attending physician, a patient needs skilled care from and/or under the supervision of a skilled nursing or therapy staff daily. We know now that every diagnosis and condition counts. The presence of these conditions and extensive services is reported by providers .

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