Medicare Coverage for Skilled Nursing Care
                     
Medicare Coverage for Skilled Nursing Care
To be covered as skilled nursing services, the services must require the skills of a registered nurse, or a licensed 
practical (vocational) nurse under the supervision of a registered nurse, must be reasonable and necessary to 
the treatment of the patient's illness or injury. Coverage of skilled nursing care does not turn on the presence or 
absence of a patient’s potential for improvement from the nursing care, but rather on the patient’s need for 
skilled care. Let’s understand Medicare coverage for skilled nursing care in detail.
Skilled Nursing Services Coverage
If all other eligibility and coverage requirements under the home health 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 (‘skilled care’) are necessary. Skilled nursing services are 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. 
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Medicare Coverage for Skilled Nursing Care
However, the individualized assessment does not demonstrate such a necessity for skilled care, including when 
the services needed do not require skilled nursing care because they could safely and effectively be performed 
by the patient or unskilled caregivers, such services will not be covered under the home health benefit. Skilled 
nursing care is necessary only when 
• 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 
• 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. 
To be considered a skilled service, the service must be so inherently complex that it can be safely and effectively 
performed only by, or under the supervision of, professional or technical personnel as provided by regulation.
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Medicare Coverage for Skilled Nursing Care
Reasonable and Necessary Services
The skilled nursing service must be reasonable and necessary to the diagnosis and treatment of the patient's 
illness or injury within the context of the patient's unique medical condition. To be considered reasonable and 
necessary for the diagnosis or treatment of the patient's illness or injury, the services must be consistent with 
the nature and severity of the illness or injury, the patient's particular medical needs, and accepted standards of 
medical and nursing practice.
The determination of whether the services are reasonable and necessary should be made in consideration that 
a physician or allowed practitioner has determined that the services ordered are reasonable and necessary. The 
services must, therefore, be viewed from the perspective of the condition of the patient when the services were 
ordered and what was, at that time, reasonably expected to be appropriate treatment for the illness or injury 
throughout the certification period.
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Medicare Coverage for Skilled Nursing Care
A patient's overall medical condition, without regard to whether the illness or injury is acute, chronic, terminal, 
or expected to extend over a long period of time, should be considered in deciding whether skilled services are 
needed. A patient's diagnosis should never be the sole factor in deciding that a service the patient needs is 
either skilled or not skilled. Skilled care may, depending on the unique condition of the patient, continue to be 
necessary for patients whose condition is stable.
We shared excerpt from Medicare Benefit Policy Manual Chapter 7 (Home Health Services) for reference 
purpose only, you can refer reference link for detailed information. MedicalBillersandCoders (MBC) is a leading 
revenue cycle company providing complete medical billing services. We can assist you in receiving accurate 
Medicare reimbursement. To know more about our services, contact us at [email protected] 
/888-357-3226
Reference: Medicare Benefit Policy Manual Chapter 7 (Home Health Services)
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