(Medicare Benefit Policy Manual)

8. Teaching care for and maintenance of peripheral and central venous lines and administration of intravenous medications through such lines;   9. Teaching bowel or bladder training when bowel or bladder dysfunction exists;   10. Teaching how to perform the activities of daily living when the patient or caregiver must use special techniques and adaptive devices due to a loss of function;   11. Teaching transfer techniques, e.g., from bed to chair, that are needed for safe transfer;   12. Teaching proper body alignment and positioning, and timing techniques of a bed-bound patient;   13. Teaching ambulation with prescribed assistive devices (such as crutches, walker, cane, etc.) that are needed due to a recent functional loss;   14. Teaching prosthesis care and gait training;   15. Teaching the use and care of braces, splints and orthotics and associated skin care;   16. Teaching the preparation and maintenance of a therapeutic diet; and   17. Teaching proper administration of oral medication, including signs of side-effects and avoidance of interaction with other medications and food.  18. Teaching the proper care and application of any special dressings or skin treatments, (for example, dressings or treatments needed by patients with severe or widespread fungal infections, active and severe psoriasis or eczema, or due to skin deterioration due to radiation treatments)   40.1.2.4 - Administration of Medications  (Rev. 1, 10-01-03) A3-3118.1.B.4, HHA-205.1.B.4  Although drugs and biologicals are specifically excluded from coverage by the statute (1861(m)(5) of the Act, the services of a nurse that are required to administer the medications safely and effectively may be covered if they are reasonable and necessary to the treatment of the illness or injury.   A.  Injections   Intravenous, intramuscular, or subcutaneous injections and infusions, and hypodermoclysis or intravenous feedings require the skills of a licensed nurse to be performed (or taught) safely and effectively.  Where these services are reasonable and necessary to treat the illness or injury, they may be covered.  For these services to be reasonable and necessary, the medication being administered must be accepted as safe and effective treatment of the patient's illness or injury, and there must be a medical reason that the medication cannot be taken orally.  Moreover, the frequency and duration of the administration of the medication must be within accepted standards of medical practice, or there must be a valid explanation regarding the extenuating circumstances to justify the need for the additional injections.  1.  Vitamin B -12 injections are considered specific therapy only for the following conditions:   Specified anemias: pernicious anemia, megaloblastic anemias, macrocytic anemias, fish tapeworm anemia;    Specified gastrointestinal disorders: gastrectomy, malabsorption syndromes such as sprue and idiopathic steatorrhea, surgical and mechanical disorders such as resection of the small intestine, strictures, anastomosis and blind loop syndrome, and   Certain neuropathies: posterolateral sclerosis, other neuropathies associated with pernicious anemia, during the acute phase or acute exacerbation of a neuropathy due to malnutrition and alcoholism.  For a patient with pernicious anemia caused by a B -12 deficiency, intramuscular or subcutaneous injection of vitamin B-12 at a dose of from 100 to 1000 micrograms no more frequently than once monthly is the accepted reasonable and necessary dosage schedule for maintenance treatment.  More frequent injections would be appropriate in the initial or acute phase of the disease until it has been determined through laboratory tests that the patient can be sustained on a maintenance dose.   2.  Insulin Injections  Insulin is customarily self -injected by patients or is injected by their families.  However, where a patient is either physically or mentally unable to self- inject insulin and there is no other person who is able and willing to inject the patient, the inje ctions would be considered a reasonable and necessary skilled nursing service.   EXAMPLE:  A patient who requires an injection of insulin once per day for treatment of diabetes mellitus, also has multiple sclerosis with loss of muscle control in the arms and hands, occasional tremors, and vision loss that causes inability to fill syringes or self-inject insulin.  If there weren't an able and willing caregiver to inject her insulin, skilled nursing care would be reasonable and necessary for the injection of the insulin.  The prefilling of syringes with insulin (or other medication that is self-injected) does not require the skills of a licensed nurse and, therefore, is not considered to be a skilled nursing service.  If the patient needs someone only to prefill syringes (a nd therefore needs no skilled nursing care on an intermittent basis, physical therapy, or speech-language pathology services), the patient, therefore, does not qualify for any Medicare coverage of home health care.  Prefilling of syringes for self -administration of insulin or other medications is considered to be assistance with medications that are ordinarily self -administered and is an appropriate home health aide service.  (See 50.2.)  However, where State law requires that a licensed nurse prefill syringes, a skilled nursing visit to prefill syringes is paid as a skilled nursing visit (if the patient otherwise needs skilled nursing care, physical therapy, or speech-language pathology services), but is not considered to be a skilled nursing service.  B.  Oral Medications   The administration of oral medications by a nurse is not reasonable and necessary skilled nursing care except in the specific situation in which the complexity of the patient's condition, the nature of the drugs prescribed, and the number of drugs prescribed require the skills of a licensed nurse to detect and evaluate side effects or reactions.  The medical record must document the specific circumstances that cause administration of an oral medication to require skilled observation and assessment.  C.  Eye Drops and Topical Ointments  The administration of eye drops and topical ointments does not require the skills of a nurse.  Therefore, even if the administration of eye drops or ointments is necessary to the treatment of an illness or injury and the patient cannot self- administer the drops, and there is no one available to administer them, the visits cannot be covered as a skilled nursing service.  This section does not eliminate coverage for skilled nursing visits for observation and assessment of the patient's condition. (See 40.2.1.)  EXAMPLE 1:   A physician has ordered skilled nursing visits to administer eye drops and ointments for a patient with glaucoma.  The administration of eye drops and ointments does not require the skills of a nurse.  Therefore, the skilled nursing visits cannot be covered as skilled nursing care, notwithstanding the importance of the administration of the drops as ordered.  EXAMPLE 2:   A physician has ordered skilled nursing visits for a patient with a reddened area under the breast.  The physician instructs the patient to wash, rinse, and dry the area daily and apply vitamin A and D ointment.  Skilled nursing care is not needed to provi de this treatment and related services safely and effectively.   40.1.2.5 - Tube Feedings  (Rev. 1, 10-01-03) A3-3118.1.B.5, HHA-205.1.B.5  Nasogastric tube, and percutaneous tube feedings (including gastrostomy and jejunostomy tubes), and replacement, adjustment, stabilization. and suctioning of the tubes are skilled nursing services, and if the feedings are required to treat the patient's illness or injury, the feedings and replacement or adjustment of the tubes would be covered as skilled nursing services.  40.1.2.6 - Nasopharyngeal and Tracheostomy Aspiration  (Rev. 1, 10-01-03) A3-4118.1.B.6, HHA-205.1.B.6  Nasopharyngeal and tracheostomy aspiration are skilled nursing services and, if required to treat the patient's illness or injury, would be covered as skilled nursing services.  40.1.2.7 - Catheters  (Rev. 179, Issued: 01-14-14, Effective: 01-07-14, Implementation: 01-07-14) A3-3118.1.B.7, HHA-205.1.B.7  Insertion and sterile irrigation and replacement of catheters, care of a suprapubic catheter, and in selected patients, urethral catheters, are considered to be skilled nursing services.  Where the catheter is necessitated by a permanent or temporary loss of bladder control, skilled nursing services that are provided at a frequency appropriate to the type of catheter in use would be considered reasonable and necessary.  Absent complications , Foley catheters generally require skilled care once approximately every 30 days and silicone catheters generally require skilled care once every 60 -90 days and this frequency of service would be considered reasonable and necessary.  However, where there are complications that require more frequent skilled care related to the catheter, such care would, with adequate documentation, be covered.   EXAMPLE:  A patient who has a Foley catheter due to loss of bladder control because of multiple sclerosis has a history of frequent plugging of the catheter and urinary tract infections.  The physician has ordered skilled nursing visits once per month to change the catheter, and has left a "PRN" order for up to three additional visits per month for skilled observation and evaluation and/or catheter changes if the patient or caregiver reports signs and symptoms of a urinary tract infection or a plugged cathe ter.  During the certification period, the patient's family contacts the HHA because the patient has an elevated temperature, abdominal pain, and scant urine output.  The nurse visits the patient and determines that the catheter is plugged and there are sy mptoms of a urinary tract infection.  The nurse changes the catheter and contacts the physician to report findings and discuss treatment.  The skilled nursing visit to change the catheter and to evaluate the patient would be reasonable and necessary to the  treatment of the illness or injury.  The need for the skilled services must be documented.   40.1.2.8 - Wound Care  (Rev. 10438, Issued: 11- 06-20, Effective: 03 -01-20, Implementation: 01-  11-21)  Care of wounds, (including, but not limited to, ulcers, burns, pressure sores, open surgical sites, fistulas, tube sites, and tumor erosion sites) when the skills of a licensed nurse are needed to provide safely and effectively the services necessary to tr eat the illness or injury, is considered to be a skilled nursing service.  For skilled nursing care to be reasonable and necessary to treat a wound, the size, depth, nature of drainage (color, odor, consistency, and quantity), and condition and appearance of the skin surrounding the wound must be documented in the clinical findings so that an assessment of the need for skilled nursing care can be made.  This includes whether wound care is performed via dressing changes, NPWT using conventional DME systems or NPWT using a disposable device.  Coverage or denial of skilled nursing visits for wound care may not be based solely on the stage classification of the wound, but rather must be based on all of the documented clinical findings.  Moreover, the plan of car e must contain the specific instructions for the treatment of the wound.  Where the physician or allowed practitioner has ordered appropriate active treatment (e.g., sterile or complex dressings, NPWT, administration of prescription medications, etc.) of w ounds with the following characteristics, the skills of a licensed nurse are usually reasonable and necessary:    Open wounds which are draining purulent or colored exudate or have a foul odor present or for which the patient is receiving antibiotic therapy;    Wounds with a drain or T -tube that require shortening or movement of such drains;    Wounds which require irrigation or instillation of a sterile cleansing or medicated solution into several layers of tissue and skin and/or packing with sterile gauze;    Recently debrided ulcers;    Pressure sores (decubitus ulcers) with the following characteristics:   o There is partial tissue loss with signs of infection such as foul odor or purulent drainage; or   o There is full thickness tissue loss that involves exposure of fat or invasion of other tissue such as muscle or bone.   NOTE:  Wounds or ulcers that show redness, edema, and induration, at times with epidermal blistering or desquamation do not ordinarily require skilled nursing care.    Wounds with exposed internal vessels or a mass that may have a proclivity for hemorrhage when a dressing is changed (e.g., post radical neck surgery, cancer of the vulva);    Open wounds or widespread skin complications following radiation therapy, or which result from immune deficiencies or vascular insufficiencies;    Post-operative wounds where there are complications such as infection or allergic reaction or where there is an underlying disease that has a reasonable potential to adversely affect healing (e.g., diabetes);    Third degree burns, and second degree burns where the size of the burn or presence of complications causes skilled nursing care to be needed;    Skin conditions that require application of nitrogen mustard or other chemotherapeutic medication that present a significant risk to the patient;   Other open or complex wounds that require treatment that can only be provided safely and effectively by a licensed nurse.   EXAMPLE 1: