(Medicare Benefit Policy Manual)

 Develop goals (to be approved by the physician);   Manufacture or adapt the needed equipment to the patient's use;   Teach compensatory techniques;   Strengthen the patient as necessary to permit use of compensatory techniques; and    Provide activities that are directed towards meeting the goals governing increased perceptual and cognitive function.  Occupational therapy services would be covered at a duration and intensity appropriate to the severity of the impairment and the patient's response to treatment.  Such visits would be considered covered therapy services when the skills of a therapist are r equired to perform the services.  The patients needs, course of therapy and response to therapy must be documented.  50 - Coverage of Other Home Health Services  (Rev. 1, 10-01-03) A3-3119, HHA-206  50.1 - Skilled Nursing, Physical Therapy, Speech -Language Pathology Services, and Occupational Therapy  (Rev. 1, 10-01-03) A3-3119.1, HHA-206.1  Where the patient meets the qualifying criteria in 30, Medicare covers skilled nursing services that meet the requirements of 40.1 and 50.7, physical therapy that meets the requirements of 40.2 , speech -language pathology services that meets the requirements of 40.2, and occupational therapy that meets the requirements of 40.2.  Home health coverage is not available for services furnished to a qualified patient who is no longer in need of one of the qualifying skilled services specified in 30.  Therefore, dependent services furnished after the final qualifying skilled service are not covered under the home health benefit, except when the dependent service was followed by a qualifying skilled service as a result of the unexpected inpatient admission or death of the patient or due to some other unanticipated event.     50.2 - Home Health Aide Services  (Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)   For home health aide services to be covered:   The patient must meet the qualifying criteria as specified in 30 ;   The services provided by the home health aide must be part- time or intermittent as discussed in 50.7 ;   The services must meet the definition of home health aide services of this section; and    The services must be reasonable and necessary to the treatment of the patient's illness or injury.  NOTE:   A home health aide must be certified consistent the competency evaluation requirements.   The reason for the visits by the home health aide must be to provide hands-on personal care of the patient or services needed to maintain the patient's health or to facilitate treatment of the patient's illness or injury.   The physician or allowed practitioner's order should indicate the frequency of the home health aide services required by the patient. These services may include but are not limited to:   A.  Personal Care  Personal care means:   1. Bathing, dressing, grooming, caring for hair, nail, and oral hygiene which are needed to facilitate treatment or to prevent deterioration of the patient's health, changing the bed linens of an incontinent patient, shaving, deodorant application, skin care with lotions and/or powder, foot care, and ear care; and  2. Feeding, assistance with elimination (including enemas unless the skills of a licensed nurse are required due to the patient's condition, routine catheter care and routine colostomy care), assistance with ambulation, changing position in bed, assistance with transfers.   EXAMPLE 1:   A physician has ordered home health aide visits to assist the patient in personal care because the patient is recovering from a stroke and continues to have significant right side weakness that causes the patient to be unable to bathe, dress or perform hai r and oral care.  The plan of care established by the HHA nurse sets forth the specific tasks with which the patient needs assistance.  Home health aide visits at an appropriate frequency would be reasonable and necessary to assist in these tasks.  EXAMPLE 2:   A physician ordered four home health aide visits per week for personal care for a multiple sclerosis patient who is unable to perform these functions because of increasing debilitation.  The home health aide gave the patient a bath twice per week and washe d hair on the other two visits each week.  Only two visits are reasonable and necessary since the services could have been provided in the course of two visits.   EXAMPLE 3:   A physician ordered seven home health aide visits per week for personal care for a bed-bound, incontinent patient.  All visits are reasonable and necessary because the patient has extensive personal care needs.   EXAMPLE 4:   A patient with a well- established colostomy forgets to change the bag regularly and has difficulty changing the bag.  Home health aide services at an appropriate frequency to change the bag would be considered reasonable and necessary to the treatment of the illness or injury.  B.  Simple Dressing Changes That Do Not Require the Skills of a Licensed Nurse EXAMPLE 5:   A patient who is confined to the bed has developed a small reddened area on the buttocks.  The physician has ordered home health aide visits for more frequent repositioning, bathing and the application of a topical ointment and a gauze 4x4.  Home health ai de visits at an appropriate frequency would be reasonable and necessary.   C.  Assistance With Medications Which Are Ordinarily Self -Administered and Do Not Require the Skills of a Licensed Nurse to Be Provided Safely and Effectively   NOTE:  Prefilling of insulin syringes is ordinarily performed by the diabetic as part of the self -administration of the insulin and, unlike the injection of the insulin, does not require the skill of a licensed nurse to be performed properly.  Therefore, if HHA s taff performs the prefilling of insulin syringes, it is considered to be a home health aide service.  However, where State law precludes the provision of this service by other than a licensed nurse or physician, Medicare will make payment for this s ervice, when covered, as though it were a skilled nursing service.  Where the patient needs only prefilling of insulin syringes and does not need skilled nursing care on an intermittent basis, physical therapy, speech- language pathology services, or have a continuing need for occupational therapy, then Medicare cannot cover any home health services to the patient ( even if State law requires that the insulin syringes be filled by a licensed nurse).   Home health aide services are those services ordered in the plan of care that the aide is permitted to perform under State law.  Medicare coverage of the administration of insulin by a home health aide will depend on whether or not the agency is in complia nce with all Federal and State laws and regulations related to this task.  However, when the task of insulin administration has been delegated to the home health aide, the task must be considered and billed as a Medicare home health aide service.  By a State allowing the delegation of insulin administration to home health aides, the State has extended the role of aides, not equated aide services with the services of a registered nurse.   D.  Assistance With Activities which Are Directly Supportive of Skilled Therapy Services but Do Not Require the Skills of a Therapist to Be Safely and Effectively Performed Such as Routine Maintenance Exercises and Repetitive Practice of Functional Communi cation Skills to Support Speech- Language Pathology Services   E.  Provision of Services Incidental to Personal Care Services not Care of Prosthetic and Orthotic Devices   When a home health aide visits a patient to provide a health related service as discussed above, the home health aide may also perform some incidental services which do not meet the definition of a home health aide service (e.g., light cleaning, preparation of a meal, taking out the trash, shopping, etc.)  However, the purpose of a home health aide visit may not be to provide these incidental services since they are not health related services, but rather are necessary household tasks that must be performed by anyone to maintain a home.   EXAMPLE 1:   A home health aide visits a recovering stroke patient whose right side weakness and poor endurance cause her to be able to leave the bed and chair only with extreme difficulty.  The physician has ordered physical therapy and speech- language pathology servi ces for the patient and home health aide services three or four times per week for personal care, assistance with ambulation as mobility increases, and assistance with repetitive speech exercises as her impaired speech improves.  The home health aide also provides incidental household services such as preparation of meals, light cleaning and taking out the trash.  The patient lives with an elderly frail sister who is disabled and who cannot perform either the personal care or the incidental tasks.  The home  health aide visits at a frequency appropriate to the performance of the health related services would be covered, notwithstanding the incidental provision of noncovered services (i.e., the household services) in the course of the visits.   EXAMPLE 2:   A physician orders home health aide visits three times per week.  The only services provided are light housecleaning, meal preparation and trash removal.  The home health aide visits cannot be covered, notwithstanding their importance to the patient, because the services provided  do not meet Medicare's definition of "home health aide services."  50.3 - Medical Social Services (Rev. 1, 10-01-03) A3-3119.3, HHA-206.3  Medical social services that are provided by a qualified medical social worker or a social work assistant under the supervision of a qualified medical social worker may be covered as home health services where the beneficiary meets the qualifying criteria specified in 30, and:  1. The services of these professionals are necessary to resolve social or emotional problems that are or are expected to be an impediment to the effective treatment of the patient's medical condition or rate of recovery; and  2. The plan of care indicates how the services which are required necessitate the skills of a qualified social worker or a social work assistant under the supervision of a qualified medical social worker to be performed safely and effectively.   Where both of these requirements for coverage are met, services of these professionals which may be covered include, but are not limited to:  1. Assessment of the social and emotional factors related to the patient's illness, need for care, response to treatment and adjustment to care;  2. Assessment of the relationship of the patient's medical and nursing requirements to the patient's home situation, financial resources and availability of community resources;   3. Appropriate action to obtain available community resources to assist in resolving the patient's problem ( NOTE:  Medicare does not cover the services of a medical social worker to complete or assist in the completion of an application for Medicaid because Federal regulations require the State to provide assistance in completing the application to anyone who chooses to apply for Medicaid.);  4. Counseling services that are required by the patient; and  5. Medical social services furnished to the patient's family member or caregiver on a short-term basis when the HHA can demonstrate that a brief intervention (that is, two or three visits) by a medical social worker is necessary to remove a clear and direct i mpediment to the effective treatment of the patient's medical condition or to the patient's rate of recovery.  To be considered "clear and direct," the behavior or actions of the family member or caregiver must plainly obstruct, contravene, or prevent the patient's medical treatment or rate of recovery.  Medical social services to address general problems that do not clearly and directly impede treatment or recovery as well as long -term social services furnished to family members, such as ongoing alcohol counseling, are not covered.   NOTE:   Participating in the development of the plan of care, preparing clinical and progress notes, participating in discharge planning and in- service programs, and acting as a consultant to other agency personnel are appropriate administrative costs to the HHA .  EXAMPLE 1:   The physician has ordered a medical social worker assessment of a diabetic patient who has recently become insulin dependent and is not yet stabilized.  The nurse, who is providing skilled observation and evaluation to try to restabilize the patient notice s during her visits that the supplies left in the home for the patient's use appear to be frequently missing, and the patient is not compliant with the regimen although she refuses to discuss the matter.  The assessment by a medical social worker would be reasonable and necessary to determine if there are underlying social or emotional problems impeding the patient's treatment.   EXAMPLE 2:   A physician ordered an assessment by a medical social worker for a multiple sclerosis patient who was unable to move anything but her head and who had an indwelling catheter.  The patient had experienced recurring urinary tract infections and multiple infected ulcers.  The physician ordered medical social services after the HHA indicated to him that the home was not well cared for, the patient appeared to be neglected much of the time, and the relationship between the patient and family was very poor.  The physician and HHA were concerned that social problems created by family caregivers were impeding the treatment of the recurring infections and ulcers.  The assessment and follow -up for counseling both the patient and the family by a medical social worker w ere reasonable and necessary.   EXAMPLE 3:   A physician is aware that a patient with atherosclerosis and hypertension is not taking medications as ordered and adhering to dietary restrictions because he is unable to afford the medication and is unable to cook.  The physician orders several visits by a medical social worker to assist in resolving these problems.  The visits by the medical social worker to review the patient's financial status, discuss options, and make appropriate contacts with social services agencies or other community resources to arrange for medications and meals would be a reasonable and necessary medical social service.   EXAMPLE 4: