• The inherent complexity of the service. Certain services are complex enough to be considered skilled (i.e. intravenous and intramuscular injections, catheter insertion).
• The condition of the patient. A patient’s condition may be such that a service which would normally be classified as unskilled can only be provided safely and effectively by a skilled person, (i.e. administering an enema to someone post rectal surgery).
• Accepted standards of practice..
• A skilled nursing service that is taught to a patient/caregiver does not become unskilled. It is still considered skilled when performed by the nurse.
• The skilled nursing service must be reasonable and necessary to the diagnosis and treatment of the beneficiary’s illness or injury within the context of the beneficiary’s unique medical condition.
• Diagnosis should never be the sole factor in determining medical necessity.
• Determination of medical necessity of services should be:
  • Based upon the patient’s unique condition and individual needs, and;
  • Without regard as to whether the condition is acute, chronic, terminal, or expected to continue over a long period of time and in some cases if the condition is stable.

A service is not “skilled” merely because it is performed by a nurse.

• If the service can be safely and effectively provided by the average non-medical person, without special training, it is not “skilled” even if performed by a nurse.
• An unskilled service does not become skilled when performed by a nurse because there is no one competent to perform the service