2014 Medicare Benefit Policy Manual

Nancy Leveille and Karen Morris in Clinical & Quality

For your convenience, we have attached a copy of the revised Medicare Benefit Policy Manual (Chapter 8.)  This manual includes all of the most up to date information for determining skilled care and Medicare Part A billing. This latest revision went into effect January 14, 2014.  All changes in the manual are noted in italics.  Of particular note are the following (not an all-inclusive list of the changes):

  • Page 17    #30 – Lists the four factors that must be met for care to be paid under skilled part A services (nursing or rehab)

  • Pages 23 -25    # – Documentation to Support Skilled Care Determinations - This section has been totally rewritten to clarify documentation requirements. Subsequent pages contain numerous examples useful for training purposes.  Suggest making copies of this manual accessible to all staff responsible for Medicare determinations, services and documentation.  

  • Page 33    # - Lists the five conditions that must be met for care to be paid under skilled physical therapy services

  • Page 35     E. Maintenance Therapy – Addresses the findings from the Jimmo v Sebelius case. 

  • Page 43    #40 and #40.1 – Physician Certification and Recertification requirements – there are no changes to this section but we suggest this be reviewed with appropriate staff as this continues to be problem on audits.  Strongly suggest one person (with backup) be ultimately responsible for insuring these are completed timely and that the originals (auditors need the originals) can be retrieved as needed.

The manual is also available on the NYSHFA website under Facility Resources/Clinical Practice/Regulatory Links/Medicare Benefit Policy Manual 2014.  If you have any questions, please contact Karen or Nancy.

NYSHFA contacts: 

Nancy Leveille
Sr. Director, Member Operational Support Services
518-462-4800 ext 20 


Karen Morris
Director, Clinical & Quality Services
518-462-4800 ext 15