OAR 411-070-0091: Complex Medical Add-On Services

(1) LICENSED NURSING SERVICES. If a Medicaid resident qualifies for payment at the basic rate and if the resident’s condition or service needs are determined to meet one or more of the procedures, routines, or services listed in this rule, and the nursing facility maintains documentation per OAR 411-070-0027, APD may pay a complex medical add-on payment (in addition to the basic rate) for the additional licensed nursing services needed to meet the resident’s increased needs. (a) Medication Procedures. (A) M-1 -- Administration of medication, at least daily, requiring skilled observation and judgment for necessity, dosage, and effect, for example new anticoagulants. (This category is limited to non-routine subcutaneous injections and does not include insulin, or the infrequent adjustments of current medications). The facility must maintain a daily nursing note. (B) M-2 -- Intravenous injections or infusions, heparin locks used daily or continuously for hydration or medication. The facility must maintain a daily nursing note. For total parenteral nutrition (TPN) the facility must maintain daily documentation on a flow sheet and must maintain a weekly nursing note. (C) M-4 -- Intramuscular medications for unstable condition used at least daily. The facility must maintain a daily nursing note. (D) M-5 -- External infusion pumps used at least daily. This does not include external infusion pumps when the resident is able to self bolus. The facility must maintain a daily nursing note. (E) M-6 -- Hypodermoclysis - daily or continuous use. The facility must maintain a daily nursing note. (F) M-7 -- Peritoneal dialysis, daily, and Hemodialysis, at least 2-3 times a week for in-house dialysis. This does not include residents who can do their own exchanges. The facility must maintain a daily nursing note. (b) Treatment Procedures. (A) T-1 -- Nasogastric, Gastrostomy or Jejunostomy tubes used daily for feedings. The facility must maintain daily information on a flow sheet and a weekly nursing note. (B) T-2 -- Nasopharyngeal suctioning, twice a day or more. Tracheal suctioning, as required, for a resident who is dependent on nursing staff to maintain airway. The facility must maintain a daily nursing note. (C) T-3 -- Percussion, postural drainage, and aerosol treatment when all three are performed twice per day or more. The facility must maintain a daily nursing note. (D) T-4 -- Ventilator dependence. Services for a resident who is dependent on nursing staff for initiation, monitoring, and maintenance. The facility must maintain a daily nursing note. (c) Skin or Wound. (A) S-1 -- Is limited to visible Stage III or IV pressure ulcers that require aggressive treatment with documented expectation of ulcer resolution. The facility must maintain a weekly wound assessment and a weekly nursing note. A healing Stage III or IV pressure ulcer that has the visual appearance of a Stage II pressure ulcer cannot be considered eligible for purposes of complex medical criteria. The pressure ulcer is eligible for add-on until the last day the ulcer is visibly a Stage III pressure ulcer. For complex medical add-on, facilities must stage the ulcer as it is visualized in appearance in accordance to the below definitions for determining if a resident’s needs meet or continue to meet complex medical add-on criteria. (i) Pressure ulcer means any skin ulcer caused by pressure resulting in damage of underlying tissues. Other terms used to indicate this condition include decubitus ulcers. (ii) Stage II means a partial thickness loss of skin layers that presents clinically as an abrasion, blister, or shallow crater. (iii) Stage III means a full thickness of skin is lost, exposing the subcutaneous tissues. Presents as a deep crater with or without undermining adjacent tissue. (iv) Stage IV means a full thickness of skin and subcutaneous tissue is lost, exposing muscle or bone. (B) S-2 -- Open wounds as defined by dehisced surgical wounds or surgical wounds not closed primarily that require aggressive treatment and are expected to resolve. The facility must maintain a weekly wound assessment and a weekly nursing note. (C) S-3 -- Deep or infected stasis ulcers with tissue destruction equivalent to at least a Stage III. The facility must maintain a weekly wound assessment and a weekly nursing note. The stasis ulcer is eligible for add-on until the last day the ulcer is visually equivalent to a Stage III, or if the stasis ulcer is an infected, chronic Stage III or IV, it is eligible for add-on until it is no longer infected and returns to previous chronic Stage III or IV state. For complex medical add-on, facilities must stage the ulcer as it is visualized in appearance in accordance to the below definitions for determining if a resident's needs meet or continue to meet complex medical add-on criteria. (i) Stasis ulcer means a skin ulcer, usually in the lower extremities, caused by altered blood flow from chronic vascular insufficiency, also referred to as venous insufficiency, lymphedema, arterial insufficiency, or peripheral vascular disease. (ii) Stage II means a partial thickness loss of skin layers that presents clinically as an abrasion, blister, or shallow crater. (iii) Stage III means a full thickness of skin is lost, exposing the subcutaneous tissues. Presents as a deep crater with or without undermining adjacent tissue. (iv) Stage IV means a full thickness of skin and subcutaneous tissue is lost, exposing muscle or bone. (v) A healing Stage III or IV stasis ulcer that has the visual appearance of a Stage II stasis ulcer cannot be considered eligible for purposes of complex medical criteria. (vi) A chronic Stage III or IV stasis ulcer that is no longer infected and has returned to previous chronic Stage III or IV status cannot be considered eligible for purposes of complex medical criteria. (d) O-4 – Insulin Dependent Diabetes Mellitus (IDDM). (A) Unstable IDDM in a resident who requires sliding scale insulin; and (i) Exhibits signs or symptoms of hypoglycemia or hyperglycemia, or both; (ii) Requires nursing or medical interventions such as extra feeding, glucagon, or additional insulin, and transfer to emergency room; and (iii) Is having insulin dosage adjustments. (B) The facility must maintain a daily nursing note. A Medication Administration Record is required when sliding scale insulin or other medication related to the IDDM has been administered. While all three criteria do not need to be present on a daily basis, the resident must be considered unstable. A resident with erratic blood sugars, without a need for further interventions, does not meet this criteria. (e) Other. (A) O-1 -- Professional Teaching. Short term, daily teaching pursuant to discharge or a self-care plan. The facility must maintain a teaching plan and a weekly nursing note. (B) O-2 -- Emergent medical or surgical problems, requiring short term licensed nursing observation and assessment. Eligibility for the add-on will be until the resident no longer requires additional licensed nursing observation and assessment for this medical or surgical problem. The facility must maintain a nursing note every shift. (C) O-3 -- Emergent Behavior Problems -- Emergent behavior is a sudden, generally unexpected change or escalation in behavior of a resident that poses a serious threat to the safety of self or others and requires immediate intervention, consultation, and a care plan. Eligibility for the add-on will be until the resident no longer requires additional licensed nursing observation and assessment for this medical problem. The facility must maintain a nursing note every shift. (f) Effective September 1, 2012, the Department shall no longer provide the complex medical add-on for Provider Preventable Conditions (PPC). (A) Nursing facilities may not receive complex medical add-on if the need for the complex medical add-on was caused by a PPC and the need for complex medical add-on did not exist prior to treatment or intervention. (B) No reduction in payment for a PPC shall be imposed on a provider when the condition defined as a PPC for a particular individual occurred outside of the nursing facility or prior to admission. (C) Regardless of payment requests, a nursing facility must report each PPC event to the Department through a Department approved reporting system. (2) R-1 -- REHABILITATION SERVICES. (a) Physical Therapy -- At least five days every week. The facility must maintain the therapist's notes and a weekly nursing progress note related to the rehabilitation services being provided. (b) Speech Therapy -- At least five days every week. The facility must maintain the therapist's notes and a weekly nursing progress note related to the rehabilitation services being provided. (c) Occupational Therapy -- At least five days every week. The facility must maintain the therapist's notes and a weekly nursing progress note related to the rehabilitation services being provided. (d) Any combination of physical therapy, occupational therapy, and speech therapy at least five days every week qualifies. The facility must maintain the therapist's notes and a weekly nursing progress note related to the rehabilitation services being provided. (e) Respiratory Therapy -- At least five days every week by a respiratory therapist. These services must be authorized by Medicare, Medicaid Oregon Health Plan, or a third party payor. The facility must maintain the therapist's notes and a weekly nursing progress note.