Fidelis SecureCare of North Carolina Provider Manual

Criteria for Authorizing Part A Skilled Interventions-Attachment A
Observation and Assessment are skilled services when the likelihood of a change in a
patient’s condition requires skilled nursing or skilled rehabilitation personnel to identify
and evaluate the patient’s need for possible modification of treatment or initiation of
additional medical procedures, until the patient’s treatment regimen is essentially
stabilized. (Excerpt from the Medicare Benefit Policy Manual, Chapter 8 - Coverage of
Extended Care (SNF) Services Under Hospital Insurance, 30.2.3.2 - Observation and
Assessment of Patient’s Condition).
To meet criteria for Observation and Assessment, one or more of the following tasks
must be needed and performed by licensed nursing personnel, (as appropriate to the
illness and as discussed with the care team).
1. Patient Assessments and/or Monitoring (completed a minimum of one time per shift)
Vital Signs q shift
¾ Blood Pressure
¾ Respiratory Rate
¾ Pulse
¾ Temperature
Cognitive Status
Neurological Checks
Behavior Changes
Lung Sounds
¾ Check for decreased breath sounds
¾ Rales, rhonchi
Cardiovascular Assessment
¾ Check heart sounds for murmurs, palpitations, etc.
¾ Check for edema (lower legs, ankles)
Bowel Sounds
¾ Check for active vs. non-active
Intensive management of intake and output (I.e., I&O q 8 hours, forcing fluids, straight
catheterization)
Skin Assessment
¾ Check for skin breakdown, tears, red areas
Pain Status
2. Monitoring response and/or titrating dose of medication over 24-48 hour period.
3. Diagnostic testing ordered and reported to the PCT, which will determine
appropriate interventions. Adjustments to the plan of care anticipated.