(Medicare Benefit Policy Manual)

EXAMPLE 2:    A patient is homebound after discharge following hip replacement surgery and is receiving skilled therapy services for range of motion exercise and gait training.  In the past, the patient had been diagnosed with clinical depression and was successfully stabilized on medication.  There has been no change in her symptoms.  The fact that the patient is taking an antidepressant does not indicate a need for psychiatric nursing services.    EXAMPLE 3:    A patient was discharged after 2 weeks in a psychiatric hospital with a new diagnosis of major depression.  The patient remains withdrawn; in bed most of the day, and refusing to leave home.  The patient has a depressed affect and continues to have thought s of suicide, but is not considered to be suicidal.  Psychiatric skilled nursing services are necessary for supportive interventions until antidepressant blood levels are reached and the suicidal thoughts are diminished further, to monitor suicide ideation, ensure medication compliance and patient safety, perform suicidal assessment, and teach crisis management and symptom management to family members.  The home health record at each visit should document the need for the psychiatric skilled nursing services and treatment.  The home health record must also reflect the patient/caregiver response to any interventions provided.   40.1.3 - Intermittent Skilled Nursing Care  (Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)   The law, at 1861(m)  of the Act defines intermittent, for the purposes of 1814(a)(2) and 1835(a)(2)(A), as skilled nursing care that is either provided or needed on fewer than 7 days each week, or less than 8 hours each day for periods of 21 days or less (with extensions in exceptional circumstances when the need for additional care is finite and predictable.)   To meet the requirement for "intermittent" skilled nursing care, a patient must have a medically predictable recurring need for skilled nursing services.  In most instances, this definition will be met if a patient requires a skilled nursing service at lea st once every 60 days.  The exception to the intermittent requirement is daily skilled nursing services for diabetics unable to administer their insulin (when there is no able and willing caregiver).  Since the need for "intermittent" skilled nursing care makes the patient eligible for other covered home health services, the Medicare contractor should evaluate each claim involving skilled nursing services furnished less frequently than once every 60 days.  In such cases, payment should be made only if documentation justifies a recurring need for reasonable, necessary, and medically predictable skilled nursing services.  The following are examples of the need for infrequent, yet intermittent, skilled nurs ing services:   1. The patient with an indwelling silicone  catheter who generally needs a catheter change only at 90- day intervals;   2. The patient who experiences a fecal impaction (i.e., loss of bowel tone, restrictive mobility, and a breakdown in good health habits) and must receive care to manually relieve the impaction.  Although these impactions are likely to recur, it is not poss ible to pinpoint a specific timeframe; or   3. The blind diabetic who self- injects insulin may have a medically predictable recurring need for a skilled nursing visit at least every 90 days.  These visits, for example, would be to observe and determine the need for changes in the level and type of care which have been prescribed thus supplementing the physician or allowed practitioner's contacts with the patient.   There is a possibility that a physician or allowed practitioner may order a skilled visit less frequently than once every 60 days for an eligible beneficiary if there exists an extraordinary circumstance of anticipated patient need that is documented in the patient's plan of care in accordance with 42 CFR 409.43(b).  A skilled visit frequency of less than once every 60 days would only be covered if it is specifically ordered by a physician or allowed practitioner in the patient's plan of care and is considered to be a reasonable, necessary, and medically predictable skilled need for the patient in the individual circumstance.   Where the need for "intermittent" skilled nursing visits is medically predictable but a situation arises after the first visit making additional visits unnecessary, e.g., the patient is institutionalized or dies, the one visit would be paid at the wage- adjusted LUPA amount for that discipline type.  However, a one-time order; e.g., to give gamma globulin following exposure to hepatitis, would not be considered a need for "intermittent" skilled nursing care since a recurrence of the problem that would requir e this service is not medically predictable.   Although most patients require services no more frequently than several times a week, Medicare will pay for part -time (as defined in 50.7) medically reasonable and necessary skilled nursing care 7 days a week for a short period of time (2 to 3 weeks).  There may also be a few cases involving unusual circumstances where the patient's prognosis indicates the medical need for daily skilled services will extend beyond 3 weeks.  As soon as the patient's physician makes this judgment, which usually should be made before  the end of the 3 -week period, the HHA must forward medical documentation justifying the need for such additional services and include an estimate of how much longer daily skilled services will be required.   A person expected to need more or less full -time skilled nursing care over an extended period of time, i.e., a patient who requires institutionalization, would usually not qualify for home health benefits.   40.2 - Skilled Therapy Services  (Rev. 179, Issued: 01- 14-14, Effective: 01 -07-14, Implementation: 01- 07-14) A3-3118.2, HHA -205.2   To be covered as skilled therapy, the services must require the skills of a qualified therapist and must be reasonable and necessary for the treatment of the patients illness or injury as discussed below.  Coverage does not turn on the presence or absence  of an individuals potential for improvement, but rather on the beneficiarys need for skilled care.   40.2.1 - General Principles Governing Reasonable and Necessary Physical Therapy, Speech -Language Pathology Services, and Occupational Therapy  (Rev. 10438, Issued: 11- 06-20, Effective: 03 -01-20, Implementation: 01-  11-21)  The service of a physical therapist, speech -language pathologist, or occupational therapist is a skilled therapy service if the inherent complexity of the service is such that it can be performed safely and/or effectively only by or under the general super vision of a skilled therapist.  To be covered, assuming all other eligibility and coverage criteria have been met, the skilled services must also be reasonable and necessary to the treatment of the patient's illness or injury or to the restoration or maint enance of function affected by the patient's illness or injury.  It is necessary to determine whether individual therapy services are skilled and whether, in view of the patient's overall condition, skilled management of the services provided is needed.   The development, implementation, management, and evaluation of a patient care plan based on the physician or allowed practitioner's orders constitute skilled therapy services when, because of the patient's clinical condition, those activities require the s pecialized skills, knowledge, and judgment of a qualified therapist to ensure the effectiveness of the treatment goals and ensure medical safety.  Where the specialized skills, knowledge, and judgment of a therapist are needed to manage and periodically re evaluate the appropriateness of a maintenance program, such services would be covered, even if the skills of a therapist were not needed to carry out the activities performed as part of the maintenance program.   While a patient's particular medical condition is a valid factor in deciding if skilled therapy services are needed, a patient's diagnosis or prognosis should never be the sole factor in deciding that a service is or is not skilled.  The key issue is whether the skills of a therapist are needed to treat the illness or injury, or whether the services can be carried out by unskilled personnel.  A service that is ordinarily considered unskilled could be considered a skilled therapy service in cases where there is clear documentation that, because of special medical complications, skilled rehabilitation personnel are required to perform the service.  However, the importance of a particular service to a patient or the frequency with which it must be performed does not, by itself, make an unskilled service into a skilled service.  Assuming all other eligibility and coverage criteria have been met, the skilled therapy services must be reasonable and necessary to the treatment of the patient's illness or injury within the context of the patient's unique medical condition.  To be consi dered reasonable and necessary for the treatment of the illness or injury:  a. The services must be consistent with the nature and severity of the illness or injury, the patient's particular medical needs, including the requirement that the amount, frequency, and duration of the services must be reasonable; and  b. The services must be considered, under accepted standards of medical practice, to be specific, safe, and effective treatment for the patient's condition, meeting the standards noted below.  The home health record must specify the purpose of the skilled service provided.  To ensure therapy services are effective, at defined points during a course of treatment, for each therapy discipline for which services are provided, a qualified therapist (instead of an assistant) must perform the ordered therapy service.  During this visit, the therapist must assess the patient using a method which allows for objective measurement of function and successive comparison of measurements.  The therapist must document the measurement results in the clinical record.  Specifically:  i. Initial Therapy Assessment    For each therapy discipline for which services are provided, a qualified therapist (instead of an assistant) must assess the patients function using a method which objectively measures activities of daily living such as, but not limited to, eating, swallowing, bathing, dressing, toileting, walking, climbing stairs, using assistive devices, and mental and cognitive factors.  The measurement results must be documented in the clinical record.   Where more than one discipline of therapy is being provided, a qualified therapist from each of the disciplines must functionally assess the patient.  The therapist must document the measurement results which correspond to the therapists discipline and ca re plan goals in the clinical record.   ii. Reassessment at least every 30 days (performed in conjunction with an ordered therapy service)    At least once every 30 days, for each therapy discipline for which services are provided, a qualified therapist (instead of an assistant) must provide the ordered therapy service, functionally reassess the patient, and compare the resultant measurement to prior assessment measurements.  The therapist must document in the clinical record the measurement results along with the therapists determination of the effectiveness of therapy, or lack thereof.     For multi- discipline therapy cases, a qualified therapist from each of the disciplines must functionally reassess the patient.  The therapist must document the measurement results which correspond to the therapists discipline and care plan goals in the clinical record.    The 30-day clock begins with the first therapy service (of that discipline) and the clock resets with each therapists visit/assessment/measurement/documentation (of that discipline).   c. Services involving activities for the general welfare of any patient, e.g., general exercises to promote overall fitness or flexibility and activities to provide diversion or general motivation do not constitute skilled therapy.  Unskilled individuals without the supervision of a therapist can perform those services.  d. Assuming all other eligibility and coverage requirements have been met, in order for therapy services to be covered, one of the following three conditions must be met:  1. The skills of a qualified therapist, or by a qualified therapist assistant under the supervision of a qualified therapist, are needed to restore patient function:   To meet this coverage condition, therapy services must be provided with the expectation, based on the assessment made by the physician or allowed practitioner of the patient's restorative potential that the condition of the patient will improve materially in a reasonable and generally predictable period of time.  Improvement is evidenced by objective successive measurements.    Therapy is not considered reasonable and necessary under this condition if the patients expected restorative potential would be insignificant in relation to the extent and duration of therapy services required to reach such potential.   Therapy is not required to effect improvement or restoration of function where a patient suffers a transient or easily reversible loss of function (such as temporary weakness following surgery) which could reasonably be expected to improve spontaneously as the patient gradually resumes normal activities.  Therapy in such cases is not considered reasonable and necessary to treat the patients illness or injury, under this condition.  However, if the criteria for maintenance therapy described in (3) below is met, therapy could be covered under that condition.  2.  The patients clinical condition requires the specialized skills, knowledge, and judgment of a qualified therapist to establish or design a maintenance program, related to the patients illness or injury, in order to ensure the safety of the patient an d the effectiveness of the program, to the extent provided by regulation,   For patients receiving rehabilitative/restorative therapy services, if the specialized skills, knowledge, and judgment of a qualified therapist are required to develop a maintenance program, the expectation is that the development of that maintenance progr am would occur during the last visit(s) for rehabilitative/restorative treatment.  The goals of a maintenance program would be to maintain the patients current functional status or to prevent or slow further deterioration.    Necessary periodic reevaluations by a qualified therapist of the beneficiary and maintenance program are covered if the specialized skills, knowledge, and judgment of a qualified therapist are required.