evekhm/cms_iom_500 huggingface dataset:
(Medicare Benefit Policy Manual)
Medical social services that are provided by a qualified medical social worker or a social work assistant under the supervision of a qualified medical social worker may be covered as home health services where the beneficiary meets the qualifying criteria specified in 30, and:  1. The services of these professionals are necessary to resolve social or emotional problems that are or are expected to be an impediment to the effective treatment of the patient's medical condition or rate of recovery; and  2. The plan of care indicates how the services which are required necessitate the skills of a qualified social worker or a social work assistant under the supervision of a qualified medical social worker to be performed safely and effectively.   Where both of these requirements for coverage are met, services of these professionals which may be covered include, but are not limited to:  1. Assessment of the social and emotional factors related to the patient's illness, need for care, response to treatment and adjustment to care;  2. Assessment of the relationship of the patient's medical and nursing requirements to the patient's home situation, financial resources and availability of community resources;   3. Appropriate action to obtain available community resources to assist in resolving the patient's problem ( NOTE:  Medicare does not cover the services of a medical social worker to complete or assist in the completion of an application for Medicaid because Federal regulations require the State to provide assistance in completing the application to anyone who chooses to apply for Medicaid.);  4. Counseling services that are required by the patient; and  5. Medical social services furnished to the patient's family member or caregiver on a short-term basis when the HHA can demonstrate that a brief intervention (that is, two or three visits) by a medical social worker is necessary to remove a clear and direct i mpediment to the effective treatment of the patient's medical condition or to the patient's rate of recovery.  To be considered "clear and direct," the behavior or actions of the family member or caregiver must plainly obstruct, contravene, or prevent the patient's medical treatment or rate of recovery.  Medical social services to address general problems that do not clearly and directly impede treatment or recovery as well as long -term social services furnished to family members, such as ongoing alcohol counseling, are not covered.
(Medicare Benefit Policy Manual)
NOTE:   Participating in the development of the plan of care, preparing clinical and progress notes, participating in discharge planning and in- service programs, and acting as a consultant to other agency personnel are appropriate administrative costs to the HHA .  EXAMPLE 1:   The physician has ordered a medical social worker assessment of a diabetic patient who has recently become insulin dependent and is not yet stabilized.  The nurse, who is providing skilled observation and evaluation to try to restabilize the patient notice s during her visits that the supplies left in the home for the patient's use appear to be frequently missing, and the patient is not compliant with the regimen although she refuses to discuss the matter.  The assessment by a medical social worker would be reasonable and necessary to determine if there are underlying social or emotional problems impeding the patient's treatment.   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:
(Medicare Benefit Policy Manual)
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:
(Medicare Benefit Policy Manual)
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.
(Medicare Benefit Policy Manual)
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)
(Medicare Benefit Policy Manual)
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)
(Medicare Benefit Policy Manual)
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.
(Medicare Benefit Policy Manual)
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.   There are occasions when the supplies listed in the above examples would be considered nonroutine and thus would be considered a billable supply, i.e., if they are required in quantity, for recurring need, and are included in the plan of care.  Examples include, but are not limited to, tape, and 4x4s for major dressings.   50.4.1.3 - Nonroutine Supplies (Reportable)  (Rev. 10438, Issued: 11- 06-20, Effective: 03 -01-20, Implementation: 01-  11-21)  Nonroutine supplies are identified by the following conditions:   1.  The HHA follows a consistent charging practice for Medicare and other patients receiving the item;
(Medicare Benefit Policy Manual)
Nonroutine supplies are identified by the following conditions:   1.  The HHA follows a consistent charging practice for Medicare and other patients receiving the item;   2.  The item is directly identifiable to an individual patient;  3.  The cost of the item can be identified and accumulated in a separate cost center; and  4.  The item is furnished at the direction of the patient's physician or allowed practitioner and is specifically identified in the plan of care.   All nonroutine supplies must be specifically ordered by the physician or allowed practitioner or the physician or allowed practitioner's order for services must require the use of the specific supplies to be effectively furnished.  The charge for nonroutine supplies is excluded from the per visit costs.  Examples of supplies that can be considered nonroutine include, but are not limited to:   1.  Dressings/Wound Care    Sterile dressings;  Sterile gauze and toppers;   Kling and Kerlix rolls;   Telfa pads;   Eye pads;   Sterile solutions, ointments;   Sterile applicators; and   Sterile gloves.   2.  I.V. Supplies   3.  Ostomy Supplies   4.  Catheters and Catheter Supplies    Foley catheters; and   Drainage bags, irrigation trays.  5.  Enemas and Douches   6.  Syringes and Needles   7.  Home Testing    Blood glucose monitoring strips; and   Urine monitoring strips.  Consider other items that are often used by persons who are not ill or injured to be medical supplies only where:    The item is recognized as having the capacity to serve a therapeutic or diagnostic purpose in a specific situation; and   The item is required as a part of the actual physician or allowed practitioner prescribed treatment of a patient's existing illness or injury.  For example, items that generally serve a routine hygienic purpose, e.g., soaps and shampoos and items that generally serve as skin conditioners, e.g., baby lotion, baby oil, skin softeners, powders, lotions, are not considered medical supplies unless the particular item is recognized as serving a specific therapeutic purpose in the physician or allowed practitioner's prescribed treatment of the patient's existing skin (scalp) disease or injury.
(Medicare Benefit Policy Manual)
Limited amounts of medical supplies may be left in the home between visits where repeated applications are required and rendered by the patient or other caregivers.  These items must be part of the plan of care in which the home health staff is actively in volved.  For example, the patient is independent in insulin injections but the nurse visits once a day to change wound dressings.  The wound dressings/irrigation solution may be left in the home between visits.  Supplies such as needles, syringes, and catheters that require administration by a nurse should not be left in the home between visits.   50.4.2 - Durable Medical Equipment  (Rev. 1, 10- 01-03) A3-3119.4.B, HHA -206.4.B   Durable medical equipment which meets the requirements of the Medicare Benefit Policy Manuals, Chapter 6, "Hospital Services Covered Under Part B," 80, and Chapter 15, Covered Medical and Other Health Services 110, is covered under the home health benefit with the beneficiary responsible for payment of a 20 percent coinsurance.   50.4.3  Covered Osteoporosis Drugs  (Rev. 10438, Issued: 11- 06-20, Effective: 03 -01-20, Implementation: 01-  11-21)  Sections 1861(m) and 1861(kk) of the Act provide for coverage of FDA approved injectable drugs for the treatment of osteoporosis.  These drugs are expected to be provided by an HHA to female beneficiaries who are currently receiving services under an open home health plan of care, who meet existing coverage criteria for the home health benefit and who meet the criteria listed below.  These drugs are covered on a cost basis when provided by an HHA under the circumstances listed below.   The home health visit (i.e., the skilled nurse's visit) to administer the drug is covered under all fee -for-service Medicare (Part A or Part B) home health coverage rules (see section 30 above).  Coverage of the drug is limited to female beneficiaries who meet each of the following criteria:   o The individual is eligible for Medicare Part B coverage of home health services (the nursing visit to perform the injection may be the individual's qualifying service);