Certified Revenue Cycle Representative (CRCR) Practice Exam

For skilled nursing facility care to be covered, what factors must be present?

1. The patient requires assistance with daily living activities

2. The patient requires skilled services on an inpatient basis

3. The facility is located within a certain distance from the home

4. The patient has recently had surgery

The correct answer is: The patient requires skilled services on an inpatient basis

The appropriate factor for skilled nursing facility care coverage is that the patient requires skilled services on an inpatient basis. This means that the care provided must involve medically necessary rehabilitation or skilled nursing services that cannot be effectively delivered in a less intensive setting, such as at home or in an outpatient program. Skilled services typically include tasks performed by licensed nursing staff or therapists, such as wound care, administering medications, physical therapy, and more. For insurance companies, these services must be necessary for recovery after a qualifying hospital stay, as part of the criteria for coverage. Other factors such as the patient's need for assistance with daily living activities or proximity of the facility to the patient's home do not independently determine coverage criteria; they may be important for the patient's overall care but do not fulfill the specific requirement for skilled nursing facility coverage. Additionally, while a recent surgery may warrant a need for skilled care, simply having had surgery does not automatically guarantee coverage unless the subsequent care meets the skilled service requirement.