CurrentFidelis CarePolicy FC.PP.206

Skilled Nursing Facility Leveling

Defines reimbursement requirements and service-level criteria for skilled nursing facility (SNF) levels of care for Fidelis Care product lines (all lines except Medicare). Affects contracted SNF providers and claims processing.

Policy Summary

PayerFidelis Care

PolicySkilled Nursing Facility Leveling

Policy CodePolicy FC.PP.206

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionProviders must bill the appropriate SNF level revenue code (e.g., Rev Code 191–193) and ensure services meet level-specific therapy and nursing-hour requirements.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Levels 1–4SNF care levels described

Rev Code 191,192,193,120,101...Revenue/Coverage codes referenced

99304–99318E/M & assessment CPTs

97161–97168, 97532–97537Therapy CPTs

Skilled Nursing Facility Reimbursement Criteria

SNF reimbursement criteria

Reimbursement requires that providers meet level-specific service and billing requirements for contracted facilities (Levels 1–4).

Facility must be contracted for the SNF level billed and meet the policy requirements for that level.

Level of Care 1 (Rev Code 191)

Maintenance therapy when appropriate: up to 3 combined therapy treatments per day OR up to 2 additional skilled nursing hours per day beyond custodial services; bill using Rev Code 191.

Level of Care 2 (Rev Code 192)

Restorative therapy when appropriate: physical therapy and/or occupational therapy with a minimum of 0.5 hour each, plus 2.5 to 4.5 additional skilled nursing hours per day beyond custodial services; bill using Rev Code 192.

Level of Care 3 (Rev Code 193)

Policy Summary

PayerFidelis Care

PolicySkilled Nursing Facility Leveling

Policy CodePolicy FC.PP.206

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionProviders must bill the appropriate SNF level revenue code (e.g., Rev Code 191–193) and ensure services meet level-specific therapy and nursing-hour requirements.

SourceLink

On This Page

Included facility services

Routine facility services are included in level determinations, such as 24/7 nursing availability (including up to 3 hours of intensive skilled nursing care daily), private or semi‑private room, meals per physician diet, routine labs and radiology, medications, infection control, respiratory therapy and oxygen services, tracheostomy and enteral tube feeding care, discharge planning, DME as prescribed, therapeutic recreation, podiatry as routine, patient/family education, social work, hydration and IV therapy equipment, and routine medical supplies.

Codes, Revenue Codes, and Nursing Thresholds

Covered CPT Codes - Nursing Facility E/MCPTCovered

99304	Initial nursing facility care — detailed/comprehensive history and exam; straightforward or low complexity MDM
99305	Initial nursing facility care — comprehensive history and exam; moderate complexity MDM
99306	Initial nursing facility care — comprehensive history and exam; high complexity MDM
99307	Subsequent nursing facility care — problem focused interval history/exam; straightforward MDM
99308	Subsequent nursing facility care — expanded problem focused history/exam; low complexity MDM
99309	Subsequent nursing facility care — detailed history/exam; moderate complexity MDM
99310	Subsequent nursing facility care — comprehensive history/exam; high complexity MDM
99315	Nursing facility discharge day management; 30 minutes or less
99316	Nursing facility discharge day management; more than 30 minutes
99318	Annual nursing facility assessment — detailed history, comprehensive exam; low to moderate complexity MDM

Covered CPT Codes - Therapy Evaluations & Re-evaluationsCPTCovered

97161	Physical therapy evaluation: low complexity
97162	Physical therapy evaluation: moderate complexity
97163	Physical therapy evaluation: high complexity
97164	Re-evaluation of physical therapy established plan of care
97165	Occupational therapy evaluation: low complexity
97166	Occupational therapy evaluation: moderate complexity
97167	Occupational therapy evaluation: high complexity
97168	Re-evaluation of occupational therapy established plan of care

Covered CPT Codes - Therapy ProceduresCPTCovered

97532	Development of cognitive skills to improve attention, memory, problem solving; one-on-one; each 15 minutes
97533	Sensory integrative techniques; direct one-on-one; each 15 minutes
97535	Self-care/home management training (ADL, compensatory training); each 15 minutes
97536	(Not listed in source)
97537	Community/work integration training; direct one-on-one; each 15 minutes
97760	Orthotic(s) management and training; assessment/fitting when not otherwise reported; each 15 minutes
97761	Prosthetic training; each 15 minutes
97762	(Prosthetic/orthotic-related procedure code — incomplete in source)

Codes, Revenue Codes, and Nursing Thresholds

Level of Care Skilled Nursing HoursLevel 1: maintenance therapy — up to 3 combined therapy treatments per day or up to 2 additional skilled nursing hours/day beyond custodial services; Level 2: restorative therapy — PT/OT minimum ~1/2 hour each plus 2.5 to 4.5 additional skilled nursing hours/day beyond custodial; Level 3: sub-acute medical/surgical — >4.5 skilled nursing hours/day beyond custodial; Level 4: intensive/ventilator care — includes weanable and non-weanable, intensive nursing and respiratory therapy

Billing, Documentation, and Provider Responsibilities

Billing Rule

Bill correct SNF level revenue code and document level-specific therapy and nursing-hour requirements

Bill the member’s SNF claim with the appropriate level-specific revenue code (e.g., Rev Code 191 for Level 1, Rev Code 192 for Level 2, Rev Code 193 for Level 3, or the applicable Vent/AIDS/behavioral/pediatric revenue codes listed) and ensure the billed level is supported by documentation that services meet the level’s therapy and skilled nursing-hour requirements. Level 1 reimbursement requires maintenance therapy up to 3 combined therapy treatments or up to 2 additional skilled nursing hours/day beyond custodial services; Level 2 requires restorative therapy with PT and/or OT at a minimum of ½ hour each plus 2.5–4.5 additional skilled nursing hours/day beyond custodial services; Level 3 requires >4.5 skilled nursing hours/day above custodial services; Level 4 (ventilator) requires assessment of weanability and documentation of intensive nursing/respiratory/pulmonologist services as applicable.

Use Rev Code 191 for Level of Care 1, Rev Code 192 for Level of Care 2, Rev Code 193 for Level of Care 3; use Vent Rev Code 101, Rev Code 160 (AIDS), Rev Code 124 (Behavioral Health), Rev Code 199 (TBI), Rev Code 123 (Pediatric) where applicable.
Ensure clinical records show therapy type/frequency and skilled nursing hours above custodial care to support the billed level (see Level 1–3 thresholds and Level 4 ventilator service requirements).
Custodial care must be billed to Revenue Code 120 when applicable; intermediate care descriptions should match services provided.

Key Definitions

Definition of Skilled nursing service

Core definitionA skilled nursing service is a service that requires the skills of qualified technical or professional health personnel (e.g., RNs, LPNs, physical/occupational therapists, speech‑language pathologists) and must be provided directly by or under their general supervision to assure patient safety and achieve the medically desired result.

When skilled care is requiredServices are skilled when the patient’s medical complications or the complexity of needed care require the skills of a registered nurse or, when applicable by regulation, a licensed practical nurse to perform the service.

Supervision noteA service is not considered skilled solely because it is performed by or under the direct supervision of a nurse; necessity is based on complexity or medical need.

Definition of Custodial care

DefinitionCustodial care: assistance with activities of daily living (bathing, eating, dressing, toileting) that can be provided by non‑professional staff but is supervised by a physician.

BillingCustodial care must be billed to Revenue Code 120 (Custodial‑Intermediate Care).

Intermediate care distinctionIntermediate care involves occasional nursing and rehabilitative care provided by registered nurses and certain other medical personnel under physician supervision (distinct from non‑skilled custodial assistance).