Definition of Medically Necessary Nursing Facility Visits

Resolution and Position Statements
Centers for Medicare and Medicaid (CMS), Medicare, Medicaid, Change of Condition, Resident
Allied Health Professional, NP/PA, Patients & Families, Physician
December 30, 2015

Resolution D92
Becomes Policy March 1992

AMDA resolves that a "medically necessary" visit to a Medicare/Medicaid resident in a nursing facility be defined as a visit subsequent to the following circumstances or resident conditions:

  1. There is a change in a resident's status, such as, but not limited to:
    • development of fever
    • altered mental status
    • unexplained change in functional status, or
    • development of a new symptom, that would require in the physician's opinion a physical examination to evaluate.
  2. Any resident with an active problem, such as, but not limited to:
    • infection (pneumonia, symptomatic urinary tract infection, cellulites)
    • repeated falls or unexplained weakness
    • congestive heart failure
    • CVA
    • deterioration of pulmonary status
    • cardiac arrhythmia, or
    • acute changes in mental status that would require hospitalization if not seen by a physician.
  3. Any resident who is still actively recovering from problems such as those listed in 2.
  4. Also residents with the following characteristics:
    • New Stage I and II decubiti or progression
    • Decubiti Stage KKK and IV
    • Gastrostomy tube feeding, with complications or newly placed tube
    • Newly diagnosed diabetes, requiring monitoring and control of blood sugar with insulin or oral agents
    • Central venous lines or intravenous lines
    • Suctioning, nasopharyngeal or tracheal
    • Terminal patients, requiring clinical monitoring
    • Residents experiencing behavioral disturbances.
  5. The resident or the resident's family requests a physician visit or a physician examination which reflects a change or worsening of condition.
  6. The facility requests a physician visit or physician examination to determine whether a reported change in patient condition necessitates a change in medical therapy or level of care or to address a particular care concern.
  7. Any resident undergoing an active rehabilitation program which requires the physician to be present at the interdisciplinary team meeting.

AND BE IT FURTHER RESOLVED, that the American Medical Association pursue these definitions with the Health Care Financing Administration.