evekhm/cms_iom_500 huggingface dataset:
(Medicare Benefit Policy Manual)
EXAMPLE 5:   A Parkinson's patient or a patient with rheumatoid arthritis who has not been under a restorative physical therapy program may require the services of a physical therapist to determine what type of exercises are required to maintain the patient's present l evel of function or to prevent or slow further deterioration.  The initial evaluation of the patient's needs, the designing of a maintenance program appropriate to the patients capacity and tolerance and to the treatment objectives of the physician, the instruction of the patient, family or caregivers to carry out the program safely and effectively, and such reevaluations as may be required by the patient's condition, would constitute skilled physical therapy.  Each component of this process must be documented in the home health record.   While a patient is under a restorative physical therapy program, the physical therapist should regularly reevaluate the patient's condition and adjust any exercise program the patient is expected to carry out alone or with the aid of supportive personnel t o maintain the function being restored.  Consequently, by the time it is determined that no further restoration is possible (i.e., by the end of the last restorative session) the physical therapist will already have designed the maintenance program required and instructed the patient or caregivers in carrying out the program.  F.  Ultrasound, Shortwave, and Microwave Diathermy Treatments  These treatments must always be performed by or under the supervision of a qualified physical therapist and are skilled therapy.  G.  Hot Packs, Infra-Red Treatments, Paraffin Baths and Whirlpool Baths  Heat treatments and baths of this type ordinarily do not require the skills of a qualified physical therapist.  However, the skills, knowledge, and judgment of a qualified physical therapist might be required in the giving of such treatments or baths in a particular case, e.g., where the patient's condition is complicated by circulatory deficiency, areas of desensitization, open wounds, fractures, or other complications.  There must be clear documentation in the home health record, of the special medical complications that describe the need for the skilled services provided by the therapist.   H.  Wound Care Provided Within Scope of State Practice Acts
(Medicare Benefit Policy Manual)
H.  Wound Care Provided Within Scope of State Practice Acts   If wound care falls within the auspice of a physical therapist's State Practice Act, then the physical therapist may provide the specific type of wound care services defined in the State Practice Act.  However, such visits in this specific situation would be a covered therapy service when there is documentation in the home health record that the skills of a therapist are required to perform the service.  The patients response to therapy must be documented.   40.2.3 - Application of the General Principles to Speech -Language Pathology Services (Rev. 179, Issued: 01- 14-14, Effective: 01 -07-14, Implementation: 01- 07-14)  The following discussion of skilled speech- language pathology services applies the principles to specific speech -language pathology services about which questions are most frequently raised.  Coverage of speech- language pathology services is not determined solely on the presence or absence of a beneficiarys potential for improvement from the therapy, but rather on the beneficiarys need for skilled care.  Assuming all other eligibility and coverage requirements have been met, skilled speech -language pathol ogy services are covered when the individualized assessment of the patients clinical condition demonstrates that the specialized judgment, knowledge, and skills of a qualified speech -language pathologist are necessary.  As described in 40.2.1(b), at defined points during a course of therapy, the qualified speech -language pathologist must perform the ordered therapy service visit, assess the patients function using a method which allows for objective measurement of funct ion and comparison of successive measurements, and document the results of the assessments, corresponding measurements, and effectiveness of therapy in the patients clinical record.  Refer to 40.2.1(b) for specific timing and documentation requirements associated with these requirements.   1.  The skills of a speech -language pathologist are required for the assessment of a patient's rehabilitation needs (including the causal factors and the severity of the speech and language disorders), and rehabilitation potential.  Reevaluation would be considered reasonable and necessary only if the patient exhibited:    A change in functional speech or motivation;    Clearing of confusion; or    The remission of some other medical condition that previously contraindicated speech -language pathology services.
(Medicare Benefit Policy Manual)
 A change in functional speech or motivation;    Clearing of confusion; or    The remission of some other medical condition that previously contraindicated speech -language pathology services.   Where a patient is undergoing restorative speech- language pathology services, routine reevaluations are considered to be a part of the therapy and cannot be billed as a separate visit.   2.  The services of a speech -language pathologist would be covered if they are needed as a result of an illness or injury and are directed towards specific speech/voice production.  3.  Speech -language pathology would be covered where a skilled service can only be provided by a speech- language pathologist and where it is reasonably expected that the skilled service will improve, maintain, or prevent or slow further deterioration in the patients ability to carry out communication or feeding activities.   4.  The services of a speech -language pathologist to establish a hierarchy of speech-voice -language communication tasks and cueing that directs a patient toward speech -language communication goals in the plan of care would be covered speech -language pathol ogy.  5.  The services of a speech -language pathologist to train the patient, family, or other caregivers to augment the speech -language communication, treatment, to establish an effective maintenance program, or carry out a safe and effective maintenance progra m when the particular patients special medical complications require the skills of a qualified therapist (not an assistant) to perform a therapy service that would otherwise be considered unskilled or the needed therapy procedures are of such complexity t hat the skills of a qualified therapist are required to perform the procedures, would be covered speech- language pathology services.   6.  The services of a speech -language pathologist to assist patients with aphasia in rehabilitation of speech and language skills are covered when needed by a patient.  7.  The services of a speech -language pathologist to assist patients with voice disorders to develop proper control of the vocal and respiratory systems for correct voice production are covered when needed by a patient.   40.2.4 - Application of the General Principles to Occupational Therapy  (Rev. 179, Issued: 01- 14-14, Effective: 01 -07-14, Implementation: 01- 07-14) A3-3118.2.D, HHA -205.2.D
(Medicare Benefit Policy Manual)
The following discussion of skilled occupational therapy services applies the principles to specific occupational therapy services about which questions are most frequently raised.  Coverage of occupational therapy services is not determined solely on the presence or absence of a beneficiarys potential for improvement from the therapy, but rather on the beneficiarys need for skilled care.  Assuming all other eligibility and coverage requirements have been met, skilled occupational therapy services are cov ered when the individualized assessment of the patients clinical condition demonstrates that the specialized judgment, knowledge, and skills of a qualified occupational therapist are necessary.   40.2.4.1 - Assessment  (Rev. 179, Issued: 01- 14-14, Effective: 01 -07-14, Implementation: 01- 07-14)  Assuming all other eligibility and coverage requirements are met, the skills of an occupational therapist to assess and reassess a patient's rehabilitation needs and potential or to develop and/or implement an occupational therapy program are covered when they are reasonable and necessary because of the patient's condition.   As described in 40.2.1(b), at defined points during a course of therapy, the qualified occupational therapist (instead of an assistant) must perform the ordered therapy service visit, assess the patients function using a method which allows for objective  measurement of function and comparison of successive measurements, and document the results of the assessments, corresponding measurements, and effectiveness of therapy in the patients clinical record.  Refer to 40.2.1(b) for specific timing and documentation requirements associated with these requirements.   40.2.4.2 - Planning, Implementing, and Supervision of Therapeutic Programs  (Rev. 1, 10- 01-03) A3-3118.2.D.2, HHA -205.2.D.2  The planning, implementing, and supervision of therapeutic programs including, but not limited to those listed below are skilled occupational therapy services, and if reasonable and necessary to the treatment of the patient's illness or injury would be cov ered.   A.  Selecting and Teaching Task Oriented Therapeutic Activities Designed to Restore Physical Function.   EXAMPLE: Use of woodworking activities on an inclined table to restore shoulder, elbow, and wrist range of motion lost as a result of burns.  B.  Planning, Implementing, and Supervising Therapeutic Tasks and Activities Designed to Restore Sensory -Integrative Function.
(Medicare Benefit Policy Manual)
EXAMPLE:  Providing motor and tactile activities to increase sensory output and improve response for a stroke patient with functional loss resulting in a distorted body image.   C.  Planning, Implementing, and Supervising of Individualized Therapeutic Activity Programs as Part of an Overall "Active Treatment" Program for a Patient With a Diagnosed Psychiatric Illness.   EXAMPLE:  Use of sewing activities that require following a pattern to reduce confusion and restore reality orientation in a schizophrenic patient.   D.  Teaching Compensatory Techniques to Improve the Level of Independence in the Activities of Daily Living.   EXAMPLE:  Teaching a patient who has lost use of an arm how to pare potatoes and chop vegetables with one hand.  EXAMPLE:  Teaching a stroke patient new techniques to enable them to perform feeding, dressing, and other activities of daily living as independently as possible.  E.  The Designing, Fabricating, and Fitting of Orthotic and Self -Help Devices.   EXAMPLE:  Construction of a device which would enable a patient to hold a utensil and feed themselves independently.   EXAMPLE:  Construction of a hand splint for a patient with rheumatoid arthritis to maintain the hand in a functional position.   F.  Vocational and Prevocational Assessment and Training   Vocational and prevocational assessment and training that is directed toward the restoration of function in the activities of daily living lost due to illness or injury would be covered.  Where vocational or prevocational assessment and training is related  solely to specific employment opportunities, work skills, or work settings, such services would not be covered because they would not be directed toward the treatment of an illness or injury.  40.2.4.3 - Illustration of Covered Services  (Rev. 179, Issued: 01- 14-14, Effective: 01 -07-14, Implementation: 01- 07-14) A3-3118.2.D.3, HHA -205.2.D.3  EXAMPLE 1:
(Medicare Benefit Policy Manual)
EXAMPLE 1:   A physician orders occupational therapy for a patient who is recovering from a fractured hip and who needs to be taught compensatory and safety techniques with regard to lower extremity dressing, hygiene, toileting, and bathing.  The occupational therapist  will establish goals for the patient's rehabilitation (to be approved by the physician), and will undertake teaching techniques necessary for the patient to reach the goals.  Occupational therapy services would be covered at a duration and intensity appropriate to the severity of the impairment and the patient's response to treatment.  Such visits would be considered covered when the skills of a therapist are required to perform the services.  The patients needs in response to therapy must be documented.   EXAMPLE 2:   A physician has ordered occupational therapy for a patient who is recovering from a CVA.  The patient has decreased range of motion, strength, and sensation in both the upper and lower extremities on the right side.  In addition, the patient has perceptual  and cognitive deficits resulting from the CVA.  The patient's condition has resulted in decreased function in activities of daily living (specifically bathing, dressing, grooming, hygiene, and toileting).  The loss of function requires assistive devices to ena ble the patient to compensate for the loss of function and maximize safety and independence.  The patient also needs equipment such as himi-slings to prevent shoulder subluxation and a hand splint to prevent joint contracture and deformity in the right hand.  The services of an occupational therapist would be necessary to:   Assess the patient's needs;    Develop goals (to be approved by the physician);   Manufacture or adapt the needed equipment to the patient's use;   Teach compensatory techniques;   Strengthen the patient as necessary to permit use of compensatory techniques; and    Provide activities that are directed towards meeting the goals governing increased perceptual and cognitive function.  Occupational therapy services would be covered at a duration and intensity appropriate to the severity of the impairment and the patient's response to treatment.  Such visits would be considered covered therapy services when the skills of a therapist are r equired to perform the services.  The patients needs, course of therapy and response to therapy must be documented.  50 - Coverage of Other Home Health Services  (Rev. 1, 10-01-03) A3-3119, HHA-206
(Medicare Benefit Policy Manual)
50.1 - Skilled Nursing, Physical Therapy, Speech -Language Pathology Services, and Occupational Therapy  (Rev. 1, 10-01-03) A3-3119.1, HHA-206.1  Where the patient meets the qualifying criteria in 30, Medicare covers skilled nursing services that meet the requirements of 40.1 and 50.7, physical therapy that meets the requirements of 40.2 , speech -language pathology services that meets the requirements of 40.2, and occupational therapy that meets the requirements of 40.2.  Home health coverage is not available for services furnished to a qualified patient who is no longer in need of one of the qualifying skilled services specified in 30.  Therefore, dependent services furnished after the final qualifying skilled service are not covered under the home health benefit, except when the dependent service was followed by a qualifying skilled service as a result of the unexpected inpatient admission or death of the patient or due to some other unanticipated event.     50.2 - Home Health Aide Services  (Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)   For home health aide services to be covered:   The patient must meet the qualifying criteria as specified in 30 ;   The services provided by the home health aide must be part- time or intermittent as discussed in 50.7 ;   The services must meet the definition of home health aide services of this section; and    The services must be reasonable and necessary to the treatment of the patient's illness or injury.  NOTE:   A home health aide must be certified consistent the competency evaluation requirements.   The reason for the visits by the home health aide must be to provide hands-on personal care of the patient or services needed to maintain the patient's health or to facilitate treatment of the patient's illness or injury.   The physician or allowed practitioner's order should indicate the frequency of the home health aide services required by the patient. These services may include but are not limited to:   A.  Personal Care  Personal care means:
(Medicare Benefit Policy Manual)
The physician or allowed practitioner's order should indicate the frequency of the home health aide services required by the patient. These services may include but are not limited to:   A.  Personal Care  Personal care means:   1. Bathing, dressing, grooming, caring for hair, nail, and oral hygiene which are needed to facilitate treatment or to prevent deterioration of the patient's health, changing the bed linens of an incontinent patient, shaving, deodorant application, skin care with lotions and/or powder, foot care, and ear care; and  2. Feeding, assistance with elimination (including enemas unless the skills of a licensed nurse are required due to the patient's condition, routine catheter care and routine colostomy care), assistance with ambulation, changing position in bed, assistance with transfers.   EXAMPLE 1:   A physician has ordered home health aide visits to assist the patient in personal care because the patient is recovering from a stroke and continues to have significant right side weakness that causes the patient to be unable to bathe, dress or perform hai r and oral care.  The plan of care established by the HHA nurse sets forth the specific tasks with which the patient needs assistance.  Home health aide visits at an appropriate frequency would be reasonable and necessary to assist in these tasks.  EXAMPLE 2:   A physician ordered four home health aide visits per week for personal care for a multiple sclerosis patient who is unable to perform these functions because of increasing debilitation.  The home health aide gave the patient a bath twice per week and washe d hair on the other two visits each week.  Only two visits are reasonable and necessary since the services could have been provided in the course of two visits.   EXAMPLE 3:   A physician ordered seven home health aide visits per week for personal care for a bed-bound, incontinent patient.  All visits are reasonable and necessary because the patient has extensive personal care needs.   EXAMPLE 4:   A patient with a well- established colostomy forgets to change the bag regularly and has difficulty changing the bag.  Home health aide services at an appropriate frequency to change the bag would be considered reasonable and necessary to the treatment of the illness or injury.  B.  Simple Dressing Changes That Do Not Require the Skills of a Licensed Nurse EXAMPLE 5:
(Medicare Benefit Policy Manual)
A patient who is confined to the bed has developed a small reddened area on the buttocks.  The physician has ordered home health aide visits for more frequent repositioning, bathing and the application of a topical ointment and a gauze 4x4.  Home health ai de visits at an appropriate frequency would be reasonable and necessary.   C.  Assistance With Medications Which Are Ordinarily Self -Administered and Do Not Require the Skills of a Licensed Nurse to Be Provided Safely and Effectively   NOTE:  Prefilling of insulin syringes is ordinarily performed by the diabetic as part of the self -administration of the insulin and, unlike the injection of the insulin, does not require the skill of a licensed nurse to be performed properly.  Therefore, if HHA s taff performs the prefilling of insulin syringes, it is considered to be a home health aide service.  However, where State law precludes the provision of this service by other than a licensed nurse or physician, Medicare will make payment for this s ervice, when covered, as though it were a skilled nursing service.  Where the patient needs only prefilling of insulin syringes and does not need skilled nursing care on an intermittent basis, physical therapy, speech- language pathology services, or have a continuing need for occupational therapy, then Medicare cannot cover any home health services to the patient ( even if State law requires that the insulin syringes be filled by a licensed nurse).   Home health aide services are those services ordered in the plan of care that the aide is permitted to perform under State law.  Medicare coverage of the administration of insulin by a home health aide will depend on whether or not the agency is in complia nce with all Federal and State laws and regulations related to this task.  However, when the task of insulin administration has been delegated to the home health aide, the task must be considered and billed as a Medicare home health aide service.  By a State allowing the delegation of insulin administration to home health aides, the State has extended the role of aides, not equated aide services with the services of a registered nurse.   D.  Assistance With Activities which Are Directly Supportive of Skilled Therapy Services but Do Not Require the Skills of a Therapist to Be Safely and Effectively Performed Such as Routine Maintenance Exercises and Repetitive Practice of Functional Communi cation Skills to Support Speech- Language Pathology Services
(Medicare Benefit Policy Manual)
E.  Provision of Services Incidental to Personal Care Services not Care of Prosthetic and Orthotic Devices   When a home health aide visits a patient to provide a health related service as discussed above, the home health aide may also perform some incidental services which do not meet the definition of a home health aide service (e.g., light cleaning, preparation of a meal, taking out the trash, shopping, etc.)  However, the purpose of a home health aide visit may not be to provide these incidental services since they are not health related services, but rather are necessary household tasks that must be performed by anyone to maintain a home.   EXAMPLE 1:   A home health aide visits a recovering stroke patient whose right side weakness and poor endurance cause her to be able to leave the bed and chair only with extreme difficulty.  The physician has ordered physical therapy and speech- language pathology servi ces for the patient and home health aide services three or four times per week for personal care, assistance with ambulation as mobility increases, and assistance with repetitive speech exercises as her impaired speech improves.  The home health aide also provides incidental household services such as preparation of meals, light cleaning and taking out the trash.  The patient lives with an elderly frail sister who is disabled and who cannot perform either the personal care or the incidental tasks.  The home  health aide visits at a frequency appropriate to the performance of the health related services would be covered, notwithstanding the incidental provision of noncovered services (i.e., the household services) in the course of the visits.   EXAMPLE 2:   A physician orders home health aide visits three times per week.  The only services provided are light housecleaning, meal preparation and trash removal.  The home health aide visits cannot be covered, notwithstanding their importance to the patient, because the services provided  do not meet Medicare's definition of "home health aide services."  50.3 - Medical Social Services (Rev. 1, 10-01-03) A3-3119.3, HHA-206.3  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: