Functional assessment and the coordination it drives qualify as skilled nursing under the Medicare coverage categories below. The note must connect skilled need to the diagnosis and the specific risk; management and evaluation of the plan of care is frequently the operative category.
Observation and assessment
The patient's functional status has a reasonable potential for change requiring skilled observation to identify the need to modify the plan. Grading the level of assistance, evaluating transfer safety, and recognizing a decline from baseline require nursing judgment.
Teaching and training
Safe transfer and mobility techniques, correct equipment use, and caregiver training in safe assistance require skilled instruction with reinforcement to mastery.
Management and evaluation of the plan of care
When the patient's overall condition and the complexity of the unskilled services — personal care, therapies, and caregiver assistance — require a registered nurse to coordinate them and ensure they achieve their purpose and promote safe function, management and evaluation of the plan of care is itself a skilled service.
Skilled procedures
For example, assessment for and training in a new assistive device or transfer technique where performed.
