evekhm/cms_iom_500 huggingface dataset:
(Medicare Benefit Policy Manual)
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.
(Medicare Benefit Policy Manual)
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.
(Medicare Benefit Policy Manual)
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:   A patient has a second -degree burn with full thickness skin damage on the back.  The wound is cleansed, followed by an application of Sulfamylon.  While the wound requires skilled monitoring for signs and symptoms of infection or complications, the dressing change requires skilled nursing services.  The home health record at each visit must document the need for the skilled nursing services.  EXAMPLE 2:
(Medicare Benefit Policy Manual)
A patient experiences a decubitus ulcer where the full thickness tissue loss extends through the dermis to involve subcutaneous tissue.  The wound involves necrotic tissue with a physician's order to apply a covering of a debriding ointment following vigorous irrigation.  The wound is then packed loosely with wet to dry dressings or continuous moist dressing and covered with dry sterile gauze.  Skilled nursing care is necessary for proper treatment.  The home health record at each visit must document the ne ed for the skilled nursing services.  NOTE:  This section relates to the direct, hands on skilled nursing care provided to patients with wounds, including any necessary dressing changes on those wounds.  While a wound might not require this skilled nursing care, the wound may still require skilled monitoring for signs and symptoms of infection or complication (see 40.1.2.1) or for skilled teaching of wound care to the patient or the patient's family (see 40.1.2.3 ).  For an example of when wound care is provided separately from the furnishing of NPWT using a disposable device, see 50.4.4.  40.1.2.9 - Ostomy Care  (Rev. 179, Issued: 01-14-14, Effective: 01-07-14, Implementation: 01-07-14) A3-3118.1.B.9, HHA-205.1.B.9  Ostomy care during the post-operative period and in the presence of associated complications where the need for skilled nursing care is clearly documented is a skilled nursing service.  Teaching ostomy care remains skilled nursing care regardless of the presence of complications.  The teaching services and the patient/care giver responses must be documented.  40.1.2.10 - Heat Treatments  (Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)  Heat treatments that have been specifically ordered by a physician or allowed practitioner as part of active treatment of an illness or injury and require observation by a licensed nurse to adequately evaluate the patient's progress would be considered a skilled nursing service.   40.1.2.11 - Medical Gases (Rev. 1, 10-01-03) A3-3118.1.B.11, HHA -205.1.B.11
(Medicare Benefit Policy Manual)
40.1.2.11 - Medical Gases (Rev. 1, 10-01-03) A3-3118.1.B.11, HHA -205.1.B.11  Initial phases of a regimen involving the administration of medical gases that are necessary to the treatment of the patient's illness or injury, would require skilled nursing care for skilled observation and evaluation of the patient's reaction to the gases, and to teach the patient and family when and how to properly manage the administration of the gases.   40.1.2.12 - Rehabilitation Nursing  (Rev. 1, 10-01-03) A3-3118.1.B.12, HHA-205.1.B.12  Rehabilitation nursing procedures, including the related teaching and adaptive aspects of nursing that are part of active treatment (e.g., the institution and supervision of bowel and bladder training programs) would constitute skilled nursing services.  40.1.2.13 - Venipuncture  (Rev. 10438, Issued: 11 -06-20, Effective: 03-01-20, Implementation: 01- 11-21)   Effective February 5, 1998, venipuncture for the purposes of obtaining a blood sample can no longer be the sole reason for Medicare home health eligibility.  However, if a beneficiary qualifies for home health eligibility based on a skilled need other than solely venipuncture (e.g., eligibility based on the skilled nursing service of wound care and meets all other Medicare home health eligibility criteria), medically reasonable and necessary venipuncture coverage may continue under a home health plan of car e.  Sections 1814(a)(2)(C)  and 1835(a)(2)(A) of the Act specifically exclude venipuncture, as a basis for qualifying for Medicare home health services if this is the sole skilled service the beneficiary requires.  However, the Medicare home health benefit will continue to pay for a blood draw if the beneficiary has a need for another qualified skilled service and meets all home health eligibility criteria.  This specific requirement applies to home health services furnished on or after February 5, 1998.
(Medicare Benefit Policy Manual)
For venipuncture to be reasonable and necessary:  1.  The physician or allowed practitioner order for the venipuncture for a laboratory test should be associated with a specific symptom or diagnosis, or the documentation should clarify the need for the test when it is not diagnosis/illness specific.  In addition, the treatment must be recognized (in the Physician's Desk Reference, or other authoritative source) as being reasonable and necessary to the treatment of the illness or injury for venipuncture and monitoring the treatment must also be reasonable a nd necessary.  2.  The frequency of testing should be consistent with accepted standards of medical practice for continued monitoring of a diagnosis, medical problem, or treatment regimen.  Even where the laboratory results are consistently stable, periodic venipuncture may be reasonable and necessary because of the nature of the treatment.   3.  The home health record must document the rationale for the blood draw as well as the results.   Examples of reasonable and necessary venipuncture for stabilized patients include, but are not limited to those described below.  a. Captopril may cause side effects such as leukopenia and agranulocytosis and it is standard medical practice to monitor the white blood cell count and differential count on a routine basis (every 3 months) when the results are stable and the patient is asymptomatic.   b. In monitoring phenytoin (e.g., Dilantin) administration, the difference between a therapeutic and a toxic level of phenytoin in the blood is very slight and it is therefore appropriate to monitor the level on a routine basis (every 3 months) when the re sults are stable and the patient is asymptomatic.   c. Venipuncture for fasting blood sugar (FBS)    An unstable insulin dependent or noninsulin dependent diabetic would require FBS more frequently than once per month if ordered by the physician or allowed practitioner.   Where there is a new diagnosis or where there has been a recent exacerbation, but the patient is not unstable, monitoring once per month would be reasonable and necessary.    A stable insulin or noninsulin dependent diabetic would require monitoring every 2- 3 months.  d. Venipuncture for prothrombin   Where the documentation shows that the dosage is being adjusted, monitoring would be reasonable and necessary as ordered by the physician or allowed practitioner.
(Medicare Benefit Policy Manual)
d. Venipuncture for prothrombin   Where the documentation shows that the dosage is being adjusted, monitoring would be reasonable and necessary as ordered by the physician or allowed practitioner.   Where the results are stable within the therapeutic ranges, monthly monitoring would be reasonable and necessary.    Where the results remain within nontherapeutic ranges, there must be specific documentation of the factors that indicate why continued monitoring is reasonable and necessary.   EXAMPLE:  A patient with coronary artery disease was hospitalized with atrial fibrillation and subsequently discharged to the HHA with orders for anticoagulation therapy as well as other skilled nursing care.  If indicated, monthly venipuncture to report prothrombin (protime) levels to the physician or allowed practitioner would be reasonable and necessary even though the patient's prothrombin time tests indicate essential stability.  The home health record must document the rationale for the blood draw as well as the results.  40.1.2.14 - Student Nurse Visits  (Rev. 179, Issued: 01- 14-14, Effective: 01 -07-14, Implementation: 01- 07-14) A3-3118.1.B.14, HHA -205.1.B.14  Visits made by a student nurse may be covered as skilled nursing care when the HHA participates in training programs that utilize student nurses enrolled in a school of nursing to perform skilled nursing services in a home setting.  To be covered, the services must be reasonable and necessary skilled nursing care and must be performed under the general supervision of a registered or licensed nurse.  The supervising nurse need not accompany the student nurse on each visit.  All documentation requirements mus t be fulfilled by student nurses.  40.1.2.15 - Psychiatric Evaluation, Therapy, and Teaching (Rev.  12425; Issued: 12- 21-23: Effective: 01 -01-24; Implementation: 01- 02-24)     The evaluation, psychotherapy, and teaching needed by a patient suffering from a diagnosed psychiatric disorder that requires active treatment by a psychiatrically trained nurse and the costs of the psychiatric nurse's services may be covered as a skilled nursing service.  Psychiatrically trained nurses are nurses who have special training and/or experience beyond the standard curriculum required for a registered nurse.  The services of the psychiatric nurse are to be provided under a plan of care established and reviewed by a physician or allowed practitioner.
(Medicare Benefit Policy Manual)
Because the law precludes agencies that primarily provide care and treatment of mental diseases from participating as HHAs, psychiatric nursing must be furnished by an agency that does not primarily provide care and treatment of mental diseases.  If a subs tantial number of an HHA's patients attend partial hospitalization or intensive outpatient  programs or receive other outpatient mental health services, the Medicare contractor will verify whether the patients meet the eligibility requirements specified in 30 and whether the HHA is primarily engaged in care and treatment of mental disease.    Services of a psychiatric nurse would not be considered reasonable and necessary to assess or monitor use of psychoactive drugs that are being used for non- psychiatric diagnoses or to monitor the condition of a patient with a known psychiatric illness who is on treatment but is considered stable.  A person on treatment would be considered stable if their symptoms were absent or minimal or if symptoms were present but were relatively stable and did not create a significant disruption in the patient's normal living situation.    EXAMPLE 1:    A patient is homebound for medical conditions, but has a psychiatric condition for which he has been receiving medication.  The patient's psychiatric condition has not required a change in medication or hospitalization for over 2 years.  During a visit by the nurse, the patient's spouse indicates that the patient is awake and pacing most of the night and has begun ruminating about perceived failures in life.  The nurse observes that the patient does not exhibit an appropriate level of hygiene and is dressed inappropriately for the season.  The nurse comments to the patient about her observations and tries to solicit information about the patient's general medical condition and mental status.  The nurse advises the physician about the patient's general medical condition and the new symptoms and changes in the patient's behavior.  The physician orders the nurse to check blood levels of medication used to treat the patient's medical and psychiatric conditions.  The physician then orders the psychiatric nursing service to evaluate the patient's mental health and communicate with the physician about whether additional intervention to deal with the patient's symptoms and behaviors is warranted.  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.    EXAMPLE 2:
(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.)
(Medicare Benefit Policy Manual)
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.