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Utilizing the 3-Day Waiver Among COVID-19 Influenza Increases

Many SNF providers are noting an increase in reporting of the number of positive residents with COVID-19 and Influenza A. With the recent uptick, now is an excellent time to review the current COVID-19 Public Health Emergency PHE waivers that are still in place, including the 3-day stay waiver for Medicare A residents, so that you don’t miss out on opportunities for increased revenue.

During the PHE, SNFs have the option to apply the 3-day Prior Hospitalization waiver in order to furnish Medicare A services without a qualifying hospital stay. Residents who are Medicare A eligible and have a positive influenza or COVID-19 diagnosis, should be reviewed to determine if they are now meeting the definition of needing and receiving a skilled level of care. This would require receiving services on a daily basis, which as a practical matter, can only be provided in a SNF or an inpatient basis. Patients in this situation should be reviewed with an interdisciplinary process to see if the services being provided, meet a skilled level of care. If the IDT determines the resident is meeting a skilled level of care, it should be documented in the medical record that the 3-day waiver is being utilized.

The Medicare Benefit Policy Manual, Chapter 8, Section 30 (found here) outlines examples of Medicare A skilling criteria providing specific examples skilled nursing services including: Management and Evaluation of a Patient Care Plan, Observation and Assessment of Patient’s Condition, Teaching and Training Activities, and Direct Skilled Nursing Services to Patients. It is important to identify that a diagnosis alone does not qualify a resident to be skilled, rather it’s based on whether the resident meets the prescribed SNF level of care definition of needing and receiving skilled services on a daily basis. Below we highlight and give greater detail on two specific examples of skilled nursing services:

Observation and Assessment of Patient’s Condition

“Observation and assessment are skilled services when the likelihood of 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 condition is essentially stabilized.”

Direct Skilled Nursing Services to Patients

“Nursing services are considered skilled when they are so inherently complex that they can be safely and effectively performed only by, or under the supervision of, a registered nurse, or when provided by regulation, a licensed practical (vocational) nurse.” Examples include but are not limited to: IV or IM injections and intravenous feeding, initial phases of a regimen involving administration of medical gases such as bronchodilator therapy.

These are two common skilled nursing services that are provided on a daily basis to residents with active diagnoses of COVID-19 and influenza A. The key in providing and maintaining a skilled level of care with these residents is having supportive documentation in the medical record to justify the decision to utilize the resident’s Medicare A benefit and that the skilled services were provided daily.

If you have specific questions about utilizing the PHE 3-Day Waiver or skilling influenza A and COVID-19 positive residents, please feel free to reach out to our Engage Consulting Director of Clinical Consulting, Jennifer Napier at

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