Skilled nursing services must be based on the patient's medical condition as
described in the Centers for Medicare and Medicaid Services (CMS) Internet-
Only Manual (IOM), Medicare Benefit Policy Manual, Pub. 100-02, Chapter 7,
40.1.1.

The evaluation, psychotherapy and teaching activities needed by patients
suffering from a diagnosed psychiatric disorder requiring active treatment by
a psychiatrically trained nurse may be covered as skilled nursing services.
Patients may also require medical social services, occupational therapy (OT),
home health aide visits or other home health (HH) services related to the
treatment of their psychiatric diagnosis.  
  
If all other eligibility and coverage requirements under the HH benefit are
met, skilled nursing services are covered when an individualized assessment of
the patient's clinical condition demonstrates that the specialized judgment,
knowledge, and skills of a registered nurse (RN) are necessary.  
  
HH clinical notes must document as appropriate the following:  
  
1\. The patient must be confined to the home.  
  
The condition of these patients should be such that there exists a normal
inability to leave home and, consequently, leaving the home would require a
considerable and taxing effort.  
  
A patient with a psychiatric disorder is considered to be homebound "... if
his/her illness is manifested in part by a refusal to leave the home, or is of
such a nature that it would not be considered safe for him/her to leave home
unattended even if he/she has no physical limitations."  
  
The following conditions support the homebound determination:

  1. Agoraphobia, paranoia or panic disorder
  2. Disorders of thought processes wherein the severity of delusions, hallucinations, agitation and/or impairment of thoughts/cognition grossly affect the patient's judgment and decision making, and therefore the patient's safety
  3. Acute depression with severe vegetative symptom
  4. Psychiatric problems associated with medical problems that render the patient homebound.

If a patient does in fact leave the home, the patient may, nevertheless, be
considered homebound if the absences from the home are infrequent or for
relatively short duration, or are attributable to the need to receive medical
treatment.  
  
2\. Services must be provided under a HH Plan of Care (POC) approved and
signed by the treating physician.  
  
3\. Nursing services provided must meet the part-time or intermittent
requirements for HH services. "In most instances, this definition will be met
if a patient requires a skilled nursing service at least every 60 days."  
  
4\. Services must be reasonable and necessary for treating the patient's
psychiatric diagnosis and/or symptoms.  
  
5\. The services of a skilled psychiatric nurse must be required to provide
the necessary care, i.e., observation/assessment, teaching/training
activities, management and evaluation of a patient care plan, or direct
patient care of a diagnosed psychiatric condition which may include
behavioral/cognitive interventions.  
  
6. _ _ Further guidance on required documentation may be found in the CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 7, 40.1.2.15.  
  
 **Note:** Psychiatric nursing must be furnished by an agency that does not
primarily provide care and treatment of mental disorders. These agencies are
precluded from participating as Medicare HH agencies.  
  
**QUALIFICATIONS FOR PSYCHIATRICALLY TRAINED NURSES PROVIDING PSYCHIATRIC
EVALUATION AND THERAPY IN THE HOME**  
  
1\. Psychiatrically trained nurses are nurses who have special training and/or
experience beyond the standard curriculum required for a RN. The services of
the psychiatric nurse are to be provided under a POC established and reviewed
by a physician.  
  
2\. This A/B HHH MAC would consider the special training and/or experience
requirements to be met, if the RN meets 1 of the following criteria:

  1. A RN with a Master's degree with a specialty in psychiatric or mental health nursing and licensed in the state where practicing would qualify. The RN must have nursing experience (recommended within the last 3 years) in an acute treatment unit in a psychiatric hospital, psychiatric home care, psychiatric partial hospitalization program or other outpatient psychiatric services.
  2. A RN with a Bachelor's degree in nursing and licensed in the state where practicing would qualify. The RN must have 1 year of recent nursing experience (recommended within the last 3 years) in an acute treatment unit in a psychiatric hospital, psychiatric home care, psychiatric partial hospitalization program or other outpatient psychiatric services.
  3. A RN with a Diploma or Associate degree in nursing and licensed in the state where practicing would qualify. The RN must have 2 years of recent nursing experience (recommended within the last 3 years) in an acute treatment unit in a psychiatric hospital, psychiatric home care, psychiatric partial hospitalization program or other outpatient psychiatric services.

3\. It is highly recommended that psychiatric RNs also have medical/surgical
nursing experience, because many psychiatric patients meet homebound criteria
due to a physical illness.  
  
4\. Nurses with these qualifications would meet the requirements necessary to
provide psychiatric evaluation and therapy to Medicare HH patients. The
services of a psychiatric nurse are to be provided under a POC established and
reviewed by the treating physician.  
  
5\. For additional information, see the _**Article Text**_ subsection
**BILLING WHEN SEPARATE VISITS WERE MADE FOR MEDICAL AND PSYCHIATRIC NURSING
CARE** section of the Billing and Coding: Home Health - Psychiatric Care
A56756 article.  
  
 **Diagnostic Criteria**  
  
1\. The patient must be under the care of a physician who is qualified to sign
the physician's certification and recertify the POC at least every 60 days (2
months). The physician's evaluation and subsequent recertifications must
become part of the patient's medical record.  
  
2\. If the skills of a psychiatric RN are required, the service must be
reasonable and necessary and intermittent.  
  
3\. Reasonable goals must be established, and there must be a reasonable
expectation that the goals will be achieved. Decreasing and/or shortening
inpatient and emergency room care may be a goal for the psychiatric patient's
POC.  
  
 **Home Health POC**  
  
The POC for a psychiatric patient must be completed. Emphasis must be placed
on documentation of mental status and those skills necessary to treat the
psychiatric diagnosis.  
  
 **Psychiatric Interdisciplinary Team's Role**  
  
 **Physician**  
  
1\. Certifies/Recertifies the patient's homebound status.  
  
2\. Approves HH POC, which must be signed and dated prior to the HH agency
billing for services.  
  
3\. Prescribes medications as necessary.  
  
4\. Provides supplemental orders when medically necessary.  
  
 **Skilled Nursing Care**  
  
Registered Psychiatric Nurse  
  
1\. Makes initial assessment visit utilizing observation/assessment skills.  
  
2\. Manages medical illness per POC; performs psycho-biological interventions.  
  
3\. Evaluates, teaches and reviews medications and compliance; administers
intramuscular (IM) or intravenous (IV) medication.  
  
4\. Manages situational or other crises; performs assessments of potential
self-harm or harm to others and refers to the treating physicians as
necessary.  
  
5\. Teaching and training activities that require skilled nursing personnel to
teach a patient, the patient's family, or caregivers how to manage the
treatment regimen would constitute skilled nursing services.

  * Teaches self-care, mental and physical well-being, promotes independence and patient's rights.

The CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual,
Chapter 7, 40.1.2.3 provides guidance in determining the reasonableness and
necessity of the number of training visits and the appropriateness of re-
teaching and re-training.  
  
6\. Promotes and encourages patient/caregiver to maintain a therapeutic
environment.  
  
7\. Provides supportive counseling psychotherapy and psycho-therapeutic
interventions according to education and licensure. Provides psychoeducation,
such as teaching/training with disease process, symptom and safety management,
coping skills and problem solving.  
  
8\. Provides evaluation and management of the patient's care plan.  
  
9\. Counseling services may be rendered by either a trained psychiatric nurse
or a social worker. These services should not be duplicative. Concurrent
counseling or psychotherapy services by multiple providers are not medically
necessary.  
  
10\. Although intervention with family members may be appropriate on occasion,
services by a trained psychiatric nurse to family members are not covered as a
HH benefit, even if the patient will benefit.  
  
 **Medical Social Services**  
  
Medical social services provided by a qualified medical social worker (MSW) or
a social work assistant under the supervision of a qualified MSW, may be
covered as HH services when **all** of the following apply _:_

  1. The patient meets the qualifying criteria for coverage of HH services.
  2. The services of these professionals are necessary to resolve social or emotional problems which are, or are expected to be, an impediment to the effective treatment of the patient's psychiatric condition or his/her rate of recovery.
  3. The POC clearly indicates that the skills of a qualified MSW (or a social worker assistant under the supervision of a qualified MSW) are required to safely and effectively provide the needed care.

When the above requirements are met, coverage for social worker visits may
include, but are not limited to the following:

  1. Assessment of the need for care related to the social and emotional factors associated with the patient's illness, the actual need for care, adjustment to the care and the response to the treatment along with the assessment of the patient's financial resources, home situation, and the availability of community resources.
  2. Counseling services that are required by the patient for the treatment of their psychiatric condition (Psychotherapy services, constituting active treatment of the psychiatric condition, may be provided by MSWs).
  3. Brief counseling (2 or 3 visits) of the patient's family or caregiver(s) when they are reasonable and necessary to resolve problems that are a clear and direct impediment to the treatment of the patient's illness or injury or rate of recovery.
  4. Appropriate action to obtain available community resources to assist in resolving the patient's problem.

**Note:** Medicare **does not** cover the services of a MSW to assist in
filing the application for Medicaid or follow up on the application. Federal
regulation requires the state to provide assistance in completing the
application to anyone who chooses to apply for Medicaid.  
  
 **Note:** A patient may require separate and distinct services provided by a
skilled psychiatric nurse and a MSW. However, care must be used to avoid
duplication of services that could be provided by both of these disciplines,
e.g., counseling of the patient.  
  
 **Home Health Aide (HHA)**  
  
HHAs may perform personal care or other covered HHA services.  
  
 **Occupational Therapist (OT)**  
  
1\. The skills of an OT may be required to decrease or eliminate limitations
in functional activity imposed by psychiatric illness or disability. OTs may
address factors which interfere with the performance of specific functional
activities due to cognitive, sensory, psychosocial or perceptual deficits.

Additional guidance on these services and the accepted standards may be found
in the CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual,
Chapter 7, 40.2.1.

2\. The skills of an OT to assess and reassess a patient's rehabilitation
needs and potential, or to develop and/or implement an OT plan are covered
when they are reasonable and necessary because of the patient's condition.  
  
3\. The planning, implementing and supervision of therapeutic programs
(including, but not limited to those listed below) are skilled OT services. As
such, these services are covered, if they are reasonable and necessary for the
treatment of the patient's illness or injury.  
  
a. Selecting and teaching task oriented, therapeutic activities designed to
restore and increase cognitive abilities and functional participation in
activities of daily living (ADLs) and advanced ADLs  
  
b. Planning, implementing and supervising therapeutic tasks and activities
designed to restore sensory-integrative function  
  
c. Planning, implementing and supervising of individualized therapeutic
activity programs (as well as, adapting to the environment) as part of an
overall "active treatment" program for a patient with a diagnosed psychiatric
illness  
  
d. Assessing and planning for improved home safety.  
  
 **Maintenance Program**  
  
Coverage of therapy services, including OT services, for a maintenance program
is based on the individual's need for skilled care in that maintenance program
as described in the CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit
Policy Manual, Chapter 7, 40.2.1.  
  
 **Concurrent Admission to HH and Partial Hospitalization Program (PHP)**  
  
Because partial hospitalization services are intended to meet all of the
patient's psychiatric care needs, patients admitted to a PHP are not generally
considered appropriate for psychiatric HH services. Medical necessity must be
substantiated on a case-by-case basis. If there are concurrent admissions, the
HH claims will be reviewed to verify the medical necessity of the service(s)
provided and that the homebound criterion is met.  
  
 **Discharge Criteria**  
  
Patients should cease receiving psychiatric HH services when:  
  
1\. Physician orders discharge  
  
2\. Patient discontinues/refuses service with physician or nurse  
  
3\. Patient is not compliant with the treatment plan, despite appropriate
provider interventions  
  
4\. Patient/family requests discharge  
  
5\. The treatment objectives and stated functional outcome goals have been
attained or are no longer attainable  
  
6\. The patient is no longer homebound  
  
7\. Other appropriate discharge protocols, e.g., the patient moves or is
transferring to another agency, etc.  
  
8\. A maintenance program is established, if appropriate.  
  
 **Psychiatric Nursing in Group Setting**  
Group interventions for psychiatric HH patients are **not** covered under the
HH benefit. The POC and treatment must be individualized.