(Medicare Benefit Policy Manual)

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:   A physician has ordered counseling by a medical social worker for a patient with cirrhosis of the liver who has recently been discharged from a 28- day inpatient alcohol treatment program to her home which she shares with an alcoholic and neglectful adult child.  The physician has ordered counseling several times per week to assist the patient in remaining free of alcohol and in dealing with the adult child.  The services of the medical social worker would be covered until the patient's social situation cea sed to impact on her recovery and/or treatment.   EXAMPLE 5:   A physician has ordered medical social services for a patient who is worried about his financial arrangements and payment for medical care.  The services ordered are to arrange Medicaid if possible and resolve unpaid medical bills.  There is no evidence that the patient's concerns are adversely impacting recovery or treatment of his illness or injury.  Medical social services cannot be covered.   EXAMPLE 6:   A physician has ordered medical social services for a patient of extremely limited income who has incurred large unpaid hospital and other medical bills following a significant illness.  The patient's recovery is adversely affected because the patient is n ot maintaining a proper therapeutic diet, and cannot leave the home to acquire the medication necessary to treat their illness.  The medical social worker reviews the patient's financial status, arranges meal service to resolve the dietary problem, arranges for home delivered medications, gathers the information necessary for application to Medicaid to acquire coverage for the medications the patient needs, files the application on behalf of the patient, and follows up repeatedly with the Medicaid State age ncy.  The medical social services that are necessary to review the financial status of the patient, arrange for meal service and delivery of medications to the home, and arrange for the Medicaid State agency to assist the patient with the application for Medicai d are covered.  The services related to the assistance in filing the application for Medicaid and the follow -up on the application are not covered since they must be provided by the State agency free of charge, and hence the patient has no obligation to pa y for such assistance.   EXAMPLE 7:   A physician has ordered medical social services for an insulin dependent diabetic whose blood sugar is elevated because she has run out of syringes and missed her insulin dose for two days.  Upon making the assessment visit, the medical social worker learns that the patient's daughter, who is also an insulin dependent diabetic, has come to live with the patient because she is out of work.  The daughter is now financially dependent on the patient for all of her financial needs and has been using the patient's insulin syringes.  The social worker assesses the patient's financial resources and determines that they are adequate to support the patient and meet her own medical needs, but are not sufficient to support the daughter.  She also counsels the daughter a nd helps her access community resources.  These visits would be covered, but only to the extent that the services are necessary to prevent interference with the patient's treatment plan.   EXAMPLE 8:   A wife is caring for her husband who is an Alzheimer's patient.  The nurse learns that the wife has not been giving the patient his medication correctly and seems distracted and forgetful about various aspects of the patient's care.  In a conversation with  the nurse, the wife relates that she is feeling depressed and overwhelmed by the patient's illness.  The nurse contacts the patient's physician who orders a social work evaluation.  In her assessment visit, the social worker learns that the patient's wife  is so distraught over her situation that she cannot provide adequate care to the patient.  While there, the social worker counsels the wife and assists her with referrals to a support group and her private physician for evaluation of her depression.  The services would be covered.   EXAMPLE 9:   The parent of a dependent disabled child has been discharged from the hospital following a hip replacement.  Although arrangements for care of the disabled child during the hospitalization were made, the child has returned to the home.  During a visit to t he patient, the nurse observes that the patient is transferring the child from bed to a wheelchair.  In an effort to avoid impeding the patient's recovery, the nurse contacts the patient's physician to order a visit by a social worker to mobilize family me mbers or otherwise arrange for temporary care of the disabled child.  The services would be covered.   50.4 - Medical Supplies (Except for Drugs and Biologicals Other Than Covered Osteoporosis Drugs), the Use of Durable Medical Equipment and Furnishing Negative Pressure Wound Therapy Using a Disposable Device  (Rev.  233, Issued: 02- 24-17, Effective: 01 -01-17, Implementation: 03- 27-17)  50.4.1 - Medical Supplies  (Rev. 10438, Issued: 11- 06-20, Effective: 03 -01-20, Implementation: 01-  11-21)  Medical supplies are items that, due to their therapeutic or diagnostic characteristics, are essential in enabling HHA personnel to conduct home visits or to carry out effectively the care the physician has ordered for the treatment or diagnosis of the pat ient's illness or injury.  All supplies which would have been covered under the cost -based reimbursement system are bundled under home health PPS.  Payment for the cost of supplies has been incorporated into the per visit and 30- day period payment rates.  Supplies fit into two categories. They are classified as:    Routine -  because they are used in small quantities for patients during the usual course of most home visits; or    Nonroutine -  because they are needed to treat a patient's specific illness or injury in accordance with the physician or allowed practitioner's plan of care and meet further conditions discussed in more detail below.   All HHAs are expected to separately identify in their records the cost of medical and surgical supplies that are not routinely furnished in conjunction with patient care visits and the use of which are directly identifiable to an individual patient. 50.4.1.1 - The Law, Routine and Nonroutine Medical Supplies, and the Patient's Plan of Care  (Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)   A.  The Law  The Medicare law governing the home health PPS is specific to the type of items and services bundled to the HHA and the time the services are bundled.  Medical supplies are bundled while the patient is under a home health plan of care.  If a patient is adm itted for a condition which is related to a chronic condition that requires a medical supply (e.g., ostomy patient) the HHA is required to provide the medical supply while the patient is under a home health plan of care during a 30-day period of care.  The physician or allowed practitioners orders in the plan of care must reflect all nonroutine medical supplies provided and used while the patient is under a home health plan of care.  The consolidated billing requirement is not superseded by the exclusion of certain medical supplies from the plan of care and then distinguishing between medical supplies that are related and unrelated to the plan of care.  Failure to include medical supplies on the plan of care does not relieve HHAs from the obligation to comply with the consolidated billing requirements.  The comprehensive nature of the current patient assessment and plan of care requirements looks at the totality of patient needs.  However, there could be a circumstance where a physician or allowed practition er could be uncomfortable with writing orders for a preexisting condition unrelated to the reason for home health care.  In those circumstances, PRN orders for such supplies may be used in the plan of care by a physician or allowed practitioner.  Thus, all medical supplies are bundled while the patient is under a home health plan of care.  This includes, but is not limited to, the above listed medical supplies as well as the Part B items provided in the final PPS rule.  The latter item lists are su bsequently updated in accordance with the current process governing the deletion, replacement and revision of Medicare Part B codes.  Parenteral and enteral nutrition, prosthetics, orthotics, DME and DME supplies are not considered medical supplies and the refore not subject to bundling while the patient is under a home health plan of care.  However, 1834(h)(4)(c) of the Act specifically excludes from the term "orthotics and prosthetics" medical supplies including catheters, catheter supplies, ostomy bags and supplies related to ostomy care furnished by an HHA under 1861(m)  of the Act.  Therefore, these items are bundled while a patient is under a home health plan of care.  B.  Relationship Between Patient Choice and Veterans Benefits   For veterans, both Medicare and Veteran's Administration (VA) benefits are primary.  Therefore, the beneficiary who is a veteran has some choices in cases where the benefits overlap.  The beneficiary, however, must select one or the other program as primary when obtaining active care.  If the VA is selected as primary for home health care, then Medicare becomes a secondary payer. An HHA must provide the medical supplies a Medicare beneficiary needs no matter the payer; it is not obligated to provide medical supplies that are not needed.  If a patient has medical supplies provided by the VA because of the patient's preference, then the HHA must not duplicate the supplies under Medicare.  The beneficiary's choice is controlling.  The HHA may not require the beneficiary to obtain or use medical supplies covered by the primary payer from any other source, including the VA.   C.  Medical Supplies Purchased by the Patient Prior to the Start of Care   A patient may have acquired medical supplies prior to his/her Medicare home health start of care date.  If a patient prefers to use his or her own medical supplies after having been offered appropriate supplies by the HHA and it is determined by the HHA that the patient's medical supplies are clinically appropriate, then the patient's choice is controlling.  The HHA is not required to duplicate the medical supplies if the patient elects to use his or her own medical supplies.  However, if the patient prefer s to have the HHA provide medical supplies while the patient is under a Medicare home health plan of care, then the HHA must provide the medical supplies.  The HHA may not require that the patient obtain or use medical supplies from any other source.  Give n the possibility of subsequent misunderstandings arising between the HHA and the patient on this issue, the HHA should document the beneficiary's decision to decline HHA furnished medical supplies and use their own resources.   50.4.1.2 - Routine Supplies (Nonreportable)  (Rev. 10438, Issued: 11- 06-20, Effective: 03 -01-20, Implementation: 01-  11-21)  Routine supplies are supplies that are customarily used in small quantities during the course of most home care visits.  They are usually included in the staff's supplies and not designated for a specific patient.  These supplies are included in the cost p er visit of home health care services.  Routine supplies would not include those supplies that are specifically ordered by the physician or allowed practitioner or are essential to HHA personnel in order to effectuate the plan of care.   Examples of supplies which are usually considered routine include, but are not limited to:   A.  Dressings and Skin Care    Swabs, alcohol preps, and skin prep pads;   Tape removal pads;   Cotton balls;   Adhesive and paper tape;   Nonsterile applicators; and   4 x 4's.  B.  Infection Control Protection    Nonsterile gloves;   Aprons;   Masks; and   Gowns.   C.  Blood Drawing Supplies    Specimen containers.   D.  Incontinence Supplies    Incontinence briefs and Chux Covered in the normal course of a visit.  For example, if a home health aide in the course of a bathing visit to a patient determines the patient requires an incontinence brief change, the incontinence brief in this example would be covered as a routine m edical supply.   E.  Other   Thermometers; and   Tongue depressors.