(Medicare Benefit Policy Manual)

A service that, by its nature, requires the skills of a nurse to be provided safely and effectively continues to be a skilled service even if it is taught to the patient, the patient's family, or other caregivers.  The skilled nursing service must be reasonable and necessary to the diagnosis and treatment of the patient's illness or injury within the context of the patient's unique medical condition.  To be considered reasonable and necessary for the diagnosis or treatment of the patient's illness or injury, the services must be consistent with the nature and severity of the illness or injury, the patient's particular medical needs, and accepted standards of medical and nursing practice.  The determination of whether the services are reasonable and necessary should be made in consideration that a physician or allowed practitioner has determined that the services ordered are reasonable and necessary.  The services must, therefore, be viewed from the perspective of the c ondition of the patient when the services were ordered and what was, at that time, reasonably expected to be appropriate treatment for the illness or injury throughout the certification period.  A patient's overall medical condition, without regard to whether the illness or injury is acute, chronic, terminal, or expected to extend over a long period of time, should be considered in deciding whether skilled services are needed.  A patient's diagnos is should never be the sole factor in deciding that a service the patient needs is either skilled or not skilled.  Skilled care may, depending on the unique condition of the patient, continue to be necessary for patients whose condition is stable. As is outlined in home health regulations, as part of the home health agency (HHA) Conditions of Participation (CoPs), the clinical record of the patient must contain progress and clinical notes.  Additionally, in Pub. 100- 04, Medicare Claims Processing Manual, Chapter 10; Home Health Agency Billing, instructions specify that for each claim, HHAs are required to report all services provided to the beneficiary during each 30-day period, which includes reporting each visit in line -item detail.  As such, it is expected that the home health records for every visit will reflect the need for the skilled medical care provided.  These clinical notes are also expected to provide important communication among all members of the home care team regarding the developme nt, course and outcomes of the skilled observations, assessments, treatment and training performed.  Taken as a whole then, the clinical notes are expected to tell the story of the patients achievement towards his/her goals as outlined in the Plan of Care .  In this way, the notes will serve to demonstrate why a skilled service is needed.   Therefore  the home health clinical notes must document as appropriate:    the history and physical exam pertinent to the days visit, (including the response or changes in behavior to previously administered skilled services) and the skilled services applied on the current visit, and   the patient/caregivers response to the skilled services provided, and    the plan for the next visit based on the rationale of prior results,    a detailed rationale that explains the need for the skilled service in light of the patients overall medical condition and experiences,   the complexity of the service to be performed, and    any other pertinent characteristics of the beneficiary or home   Clinical notes should be written so that they adequately describe the reaction of a patient to his/her skilled care.  Clinical notes should also provide a clear picture of the treatment, as well as next steps to be taken.  Vague or subjective description s of the patients care should not be used.  For example, terminology such as the following would not adequately describe the need for skilled care:    Patient tolerated treatment well  Caregiver instructed in medication management   Continue with POC   Objective measurements of physical outcomes of treatment should be provided and/or a clear description of the changed behaviors due to education programs should be recorded in order that all concerned can follow the results of the applied services.   EXAMPLE 1:   The presence of a plaster cast on an extremity generally does not indicate a need for skilled nursing care.  However, the patient with a preexisting peripheral vascular or circulatory condition might need skilled nursing care to observe for complications, monitor medication administration for pain control, and teach proper skin care to preserve skin integrity and prevent breakdown.  The documentation must support the severity of the circulatory condition that requires skilled care.  The clinical notes for each home health visit should document the patients skin and circulatory examination a s well as the patient and/or caregiver application of the educational principles taught since the last visit.  The plan for the next visit should describe the skilled services continuing to be required.   EXAMPLE 2:   The condition of a patient, who has irritable bowel syndrome or is recovering from rectal surgery, may be such that he or she can be given an enema safely and effectively only by a nurse.  If the enema were necessary to treat the illness or injury, then the visit would be covered as a skilled nursing visit.  The documentation must support the skilled need for the enema, and the plan for future visits based on this information.  EXAMPLE 3:   Giving a bath does not ordinarily require the skills of a nurse and, therefore, would not be covered as a skilled nursing service unless the patient's condition is such that the bath could be given safely and effectively only by a nurse (as discussed in 30.1 above).  EXAMPLE 4:   A patient with a well-established colostomy absent complications may require assistance changing the colostomy bag because they cannot do it themselves and there is no one else to change the bag.  Notwithstanding the need for the routine colostomy care, changing the colostomy bag does not become a skilled nursing service when the nurse provides it.  EXAMPLE 5:   A patient was discharged from the hospital with an open draining wound that requires irrigation, packing, and dressing twice each day.  The HHA has taught the family to perform the dressing changes.  The HHA continues to see the patient for the wound care that is needed during the time that the family is not available and willing to provide the dressing changes.  The wound care continues to be skilled nursing care, notwithstanding that the family provides it part of the time, and may be covered as long as t he patient requires it.   EXAMPLE 6:   A physician has ordered skilled nursing visits for a patient with a hairline fracture of the hip.  The home health record must document the reason skilled services are required and why the nursing visits are reasonable and necessary for treatment of the patient's hip injury.  EXAMPLE 7:   A physician has ordered skilled nursing visits for teaching of self -administration and self -management of the medication regimen for a patient, newly diagnosed, with diabetes mellitus in the home health plan of care.  Each visits documentation must describe the patients progress in this activity.   EXAMPLE 8:   Following a cerebrovascular accident (CVA), a patient has an in -dwelling Foley catheter because of urinary incontinence, and is expected to require the catheter for a long and indefinite period.  The medical condition of the patient must be described and documented to support the need for nursing skilled services in the home health plan of care.  Periodic visits to change the catheter as needed, treat the symptoms of catheter malfunction, and teach proper catheter care would be covered as long as they are reasonable and necessary, although the patient is stable, even if there is an expectation that the care will be needed for a long and indefinite period.  However, at every home health visit, the patients current medical condition must be described and ther e must be documentation to support the need for continued skilled nursing services.  EXAMPLE 9:   A patient with advanced multiple sclerosis undergoing an exacerbation of the illness needs skilled teaching of medications, measures to overcome urinary retention, and the establishment of a program designed to minimize the adverse impact of the exacerbati on.  The clinical notes for each home health visit must describe why skilled nursing services were required.  The skilled nursing care received by the patient would be covered despite the chronic nature of the illness.  EXAMPLE 10:   A patient with malignant melanoma is terminally ill, and requires skilled observation, assessment, teaching, and treatment.  The patient has not elected coverage under Medicare's hospice benefit.  The documentation should describe the goal of the skilled nursing intervention, and at each visit the services provided should support that goal.  The skilled nursing care that the patient requires would be covered, notwithstanding that the condition is terminal, because the documentation and description must support that the needed services required the skills of a nurse.   40.1.2 - Application of the Principles to Skilled Nursing Services  (Rev. 1, 10- 01-03) A3-3118.1.B, HHA -205.1.B   The following discussion of skilled nursing services applies the foregoing principles to specific skilled nursing services about which questions are most frequently raised.   40.1.2.1 - Observation and Assessment of the Patient's Condition When Only the Specialized Skills of a Medical Professional Can Determine Patient's Status  (Rev. 265, Issued: 01- 10-20, Effective: 01 -01-20, Implementation: 02- 11-20)  Observation and assessment of the patient's condition by a nurse are reasonable and necessary skilled services where there is a reasonable potential for change in a patient's condition that requires skilled nursing personnel to identify and evaluate the pa tient's need for possible modification of treatment or initiation of additional medical procedures until the patient's clinical condition and/or treatment regimen has stabilized.  Where a patient was admitted to home health care for skilled observation bec ause there was a reasonable potential of a complication or further acute episode, but did not develop a further acute episode or complication, the skilled observation services are still covered for 3 weeks or so long as there remains a reasonable potential  for such a complication or further acute episode.   Information from the patient's home health record must document the rationale that demonstrates that there is a reasonable potential for a future complication or acute episode and, therefore, may justify the need for continued skilled observation and assessment beyond the 3- week period.  Such signs and symptoms as abnormal/fluctuating vital signs, weight changes, edema, symptoms of drug toxicity, abnormal/fluctuating lab values, and respiratory changes on auscultation may justify skilled observation and assessment.  Where these signs and symptoms are such that there is a reasonable potential that skilled observation and assessment by a licensed nurse will result in changes to the treatment of the patient, then the services would be covered.  However, observation and assessment by a nurse is not reasonable and necessary for the treatment of the illness or injury where fluctuating signs and symptoms are part of a longstanding pattern of the patient's condition which has not previously required a change in the prescribed treatment.   EXAMPLE 1:   A patient with atherosclerotic heart disease with congestive heart failure requires observation by skilled nursing personnel for signs of decompensation or adverse effects resulting from newly prescribed medication.  Skilled observation is needed to determ ine whether the new drug regimen should be modified or whether other therapeutic measures should be considered until the patient's clinical condition and/or treatment regimen has stabilized.  The clinical notes for each home health visit should reflect the  deliberations and their outcome.   EXAMPLE 2:   A patient has undergone peripheral vascular disease treatment including a revascularization procedure (bypass).  The incision area is showing signs of potential infection, (e.g., heat, redness, swelling, drainage) and the patient has elevated body temperat ure.  For each home health visit, the clinical notes must demonstrate that the skilled observation and monitoring is required.  EXAMPLE 3:   A patient was hospitalized following a heart attack.  Following treatment he was discharged home.  Because it is not known whether increasing exertion will exacerbate the heart disease, skilled observation is reasonable and necessary as mobilization is initiated in the patients home. The patients necessity for skilled observation must be documented at each home health visit until the patient's clinical condition and/or treatment regimen has stabilized.   EXAMPLE 4:   A frail 85 -year old man was hospitalized for pneumonia.  The infection was resolved, but the patient, who had previously maintained adequate nutrition, will not eat or eats poorly.  The patient is discharged to the HHA for monitoring of fluid and nutrient intake and assessment of the need for tube feeding.  Observation and monitoring by skilled nurses of the patient's oral intake, output and hydration status is required to determine what further treatment or other intervention is needed.  The patients nece ssity for skilled observation and treatment must be documented at each home health visit, until the patient's clinical condition and/or treatment regimen has stabilized.    EXAMPLE 5:   A patient with glaucoma and a cardiac condition has a cataract extraction.  Because of the interaction between the eye drops for the glaucoma and cataracts and the beta -blocker for the cardiac condition, the patient is at risk for serious cardiac arrhythmi a.  Skilled observation and monitoring of the drug actions is reasonable and necessary until the patient's condition is stabilized.  The patients necessity for skilled observation must be documented at each home health visit, until the clinical condition and/or patient's treatment regimen has stabilized.   EXAMPLE 6:   A patient with hypertension suffered dizziness and weakness.  The physician found that the blood pressure was too low and discontinued the hypertension medication.  Skilled observation and monitoring of the patient's blood pressure and medication regimen i s required until the blood pressure remains stable and in a safe range.  The patients necessity for skilled observation must be documented at each home health visit, until the patient's clinical condition and/or treatment regimen has stabilized.   EXAMPLE 7: