Skilled Nursing Facility
Level I – Revenue Code 191
Minimal Care - Level 1 services include, but are not limited to:
- Room and board
- Prepared meals per therapeutic ordered diet
- Twenty-four hour nursing care
- Labs and radiology services
- Medication, oral (PO), intramuscular (IM), and subcutaneous (SQ)
- Oxygen and respiratory care for short-term therapy
- Peripheral IV therapy for hydration
- New and existing ostomy care, training, and supplies
- Patient and/or family education
- Diabetic care, management, and training
- Bowel and bladder training
- Wound management for simple wound care and/or stage I or II decubitus care
- Therapy: Two hours or less per day, five days per week for any combination of physical therapy (PT), occupational therapy (OT), speech therapy (ST), and respiratory therapy (RT)
Level II – Revenue Code 192
Moderate Care – Level II services include, but are not limited to:
- Level I services
- New and existing tube feedings (NG, gastrostomy, PEG) with nutritional supplements and supplies
- Wound management requiring sterile dressings
- Wound management and treatment for stage III or multiple stage II decubitus, including wound VAC treatment for short-term therapy (two weeks or less)
- Simple IV push meds for stable conditions
- Intramuscular/subcutaneous pain management supplies and medications
- Intramuscular antibiotics
- Stable trachs without inner cannulas
- Respiratory treatment and observation performed by nursing, aerosol, small-volume nebulizer, oximetry, high-flow oxygen (three liters minimum)
- Cognitive impairment management requiring secure units and wander-guard supervision
- Therapy: Two to three hours per day, five days per week for any combination of physical therapy (PT), occupational therapy (OT), speech therapy (ST), and respiratory therapy (RT)
Level III – Revenue Code 193
Extensive Care – Level III services include, but are not limited to:
- Level I and/or II services
- Complex wound management other than decubitus ulcers and treatment for stage IV or multiple stage III decubitus, including wound VAC treatment
- Complex intravenous therapies with multiple drug combinations (including subclavian, central, and PICC lines), antibiotics, pain management, toxic antibiotics, chemotherapy agents, total parental nutrition (TPN), lipids, and blood products
- Trachs with inner cannulas requiring frequent suctioning, mist and/or oxygen, and respiratory treatment and observation performed by nursing, aerosol, small-volume nebulizer, oximetry, high-flow oxygen (three liters minimum)
- Therapy: Three to four hours per day, five days per week for any combination of physical therapy (PT), occupational therapy (OT), speech therapy (ST), and respiratory therapy (RT)
Level IV – Revenue Code 194
Intensive Care – Level IV services include, but are not limited to:
- Level I, II, and/or II services
- Hemodialysis and/or peritoneal dialysis when provided by provider
- More than 12 hours of nursing care per day, including (but not limited to) one-on-one monitoring by a licensed LPN or RN
- Therapy: Four or more hours per day, five days per week for any combination of physical therapy (PT), occupational therapy (OT), speech therapy (ST), and respiratory therapy (RT)
Other Services
Please refer to the DMBA Facility Services Agreement for reimbursement rates of each level of care listed above. Rates for all services or combination of services not outlined in a particular level must be negotiated with a DMBA case manager before admission. Maintenance medications are covered by the participant’s prescription drugs benefit.
Specialty durable medical equipment, non-employee physician services and/or consultations, ambulance transportation, lab work, non-nursing respiratory services, and other diagnostic services will be reimbursed according to DMBA’s allowable amounts and appropriate benefit levels.