evekhm/cms_iom_500 huggingface dataset:
(Medicare Benefit Policy Manual)
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:
(Medicare Benefit Policy Manual)
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:   A patient has chronic non- healing skin ulcers, Diabetes Mellitus Type I, and spinal muscular atrophy.  In the past, the patients wounds have deteriorated, requiring the patient to be hospitalized.  Previously, a skilled nurse has trained the patients wife to perform wound care.  The treating physician orders a continuation of ski lled care for a subsequent 60- day certification period, at a frequency of one visit every 2 weeks to perform observation and assessment of the patients skin ulcers to make certain that they are not worsening.  This order is reasonable and necessary becaus e, although the unskilled family caregiver has learned to care for the wounds, the skilled nurse can use observation and assessment to determine if the condition is worsening.  40.1.2.2 - Management and Evaluation of a Patient Care Plan  (Rev. 265, Issued: 01- 10-20, Effective: 01 -01-20, Implementation: 02- 11-20)
(Medicare Benefit Policy Manual)
Skilled nursing visits for management and evaluation of the patient's care plan are also reasonable and necessary where underlying conditions or complications require that only a registered nurse can ensure that essential unskilled care is achieving its pu rpose.  For skilled nursing care to be reasonable and necessary for management and evaluation of the patient's plan of care, the complexity of the necessary unskilled services that are a necessary part of the medical treatment must require the involvement of skilled nursing personnel to promote the patient's recovery and medical safety in view of the patient's overall condition.  EXAMPLE 1:   An aged patient with a history of diabetes mellitus and angina pectoris is recovering from an open reduction of the neck of the femur.  He requires, among other services, careful skin care, appropriate oral medications, a diabetic diet, a therapeutic exercise program to preserve muscle tone and body condition, and observation to notice signs of deterioration in his condition or complications resulting from his restricted, but increasing mobility.  Although a properly instructed person could perform any of t he required services, that person would not have the capability to understand the relationship among the services and their effect on each other.  Since the combination of the patient's condition, age, and immobility create a high potential for serious com plications, such an understanding is essential to ensure the patient's recovery and safety.  The management of this plan of care requires skilled nursing personnel until nursing visits are not needed to observe and assess the effects of the non -skilled ser vices being provided to treat the illness or injury until the patient recovers.  Where nursing visits are not needed to observe and assess the effects of the non- skilled services being provided to treat the illness or injury, skilled nursing care would not  be considered reasonable and necessary, and the management and evaluation of the care plan would not be considered a skilled service.   EXAMPLE 2:
(Medicare Benefit Policy Manual)
EXAMPLE 2:   An aged patient with a history of mild dementia is recovering from pneumonia which has been treated at home.  The patient has had an increase in disorientation, has residual chest congestion, decreased appetite, and has remained in bed, immobile, throughout the period with pneumonia.  While the residual chest congestion and recovery from pneumonia alone would not represent a high risk factor, the patient's immobility and increase in confusion could create a high probability of a relapse.  In this situation, skilled oversight of the unskilled services would be reasonable and necessary pending the elimination of the chest congestion and resolution of the persistent disorientation to ensure the patient's medical safety.  For this determination to be made, the home health documentation must describe the complexity of the unskilled services that are a necessary part of the medical treatment and which require the involvement of a registered nurse in order to ensure that essential unskilled care is achieving its purpose.  Where visits by a licensed nurse are not needed to observe and assess the effects of the unskilled services being provided to treat the illness or injury, skilled nursing care would not be considered reasonable and necessary to treat the illness or injury.   EXAMPLE 3:   A physician orders one skilled nursing visit every 2 weeks and three home health aide visits each week for bathing and washing hair for a patient whose recovery from a CVA has left him with residual weakness on the left side.  The cardiovascular condition is stable and the patient has reached the maximum restoration potential.  There are no underlying conditions that would necessitate the skilled supervision of a licensed nurse in assisting with bathing or hair washing.  The skilled nursing visits are not necessary to manage and supervise the home health aide services and would not be covered.   40.1.2.3 - Teaching and Training Activities  (Rev. 179, Issued: 01- 14-14, Effective: 01 -07-14, Implementation: 01- 07-14) A3-3118.1.B.3, HHA -205.1.B.3
(Medicare Benefit Policy Manual)
Teaching and training activities that require skilled nursing personnel to teach a patient, the patient's family, or caregivers how to manage the treatment regimen would constitute skilled nursing services.  Where the teaching or training is reasonable and necessary to the treatment of the illness or injury, skilled nursing visits for teaching would be covered.  The test of whether a nursing service  is skilled relates to the skill required to teach and not to the nature of what is being taught.  Therefore, where skilled nursing services are necessary to teach an unskilled service, the teaching may be covered.  Skilled nursing visits for teaching and training activities are reasonable and necessary where the teaching or training is appropriate to the patient's functional loss, illness, or injury.   Where it becomes apparent after a reasonable period of time that the patient, family, or caregiver will not or is not able to be trained, then further teaching and training would cease to be reasonable and necessary.  The reason why the training was unsuccessful should be documented in the record.  Notwithstanding that the teaching or training was unsuccessful, the services for teaching and training would be considered to be reasonable and necessary prior to the point that it became apparent that the teachi ng or training was unsuccessful, as long as such services were appropriate to the patient's illness, functional loss, or injury.  In determining the reasonable and necessary number of teaching and training visits, consideration must be given to whether the teaching and training provided constitutes reinforcement of teaching provided previously in an institutional setting or in the home or whether it represents initial instruction.  Where the teaching represents initial instruction, the complexity of the activity to be taught and the unique abilities of the patient are to be considered.  Where the teaching constitutes reinforcement, an analysis of the patient's retained knowledge and anticipated learning progress is necessary to determine the appropriate number of visits.  Skills taught in a controlled institutional setting often need to be reinforced when the patient returns home.  Whe re the patient needs reinforcement of the institutional teaching, additional teaching visits in the home are covered.   Re-teaching or retraining for an appropriate period may be considered reasonable and necessary where there is a change in the procedure or the patient's condition that requires re-teaching, or where the patient, family, or caregiver is not properly carrying out the task.  The medical record should document the reason that the re -teaching or retraining is required and the patient/caregiver response to the education.  EXAMPLE 1:
(Medicare Benefit Policy Manual)
A physician has ordered skilled nursing care for teaching a diabetic who has recently become insulin dependent.  The physician has ordered teaching of self -injection and management of insulin, signs, and symptoms of insulin shock, and actions to take in emergencies.  The education is reasonable and necessary to the treatment of the illness or injury, and the teaching services and the patient/caregiver responses must be documented.   EXAMPLE 2:   A physician has ordered skilled nursing care to teach a patient to follow a new medication regimen in which there is a significant probability of adverse drug reactions due to the nature of the drug and the patient's condition, to recognize signs and sympt oms of adverse reactions to new medications, and to follow the necessary dietary restrictions.  After it becomes apparent that the patient remains unable to take the medications properly, cannot demonstrate awareness of potential adverse reactions, and is not following the necessary dietary restrictions, skilled nursing care for further teaching would not be reasonable and necessary, since the patient has demonstrated an inability to be taught.  The documentation must thoroughly describe all efforts that ha ve been made to educate the patient/caregiver, and their responses.  The health record should also describe the reason for the failure of the educational attempts.   EXAMPLE 3:   A physician has ordered skilled nursing visits to teach self -administration of insulin to a patient who has been self -injecting insulin for 10 years and there is no change in the patient's physical or mental status that would require re -teaching.  The skil led nursing visits would not be considered reasonable and necessary since the patient has a longstanding history of being able to perform the service.   EXAMPLE 4:   A physician has ordered skilled nursing visits to teach self -administration of insulin to a patient who has been self -injecting insulin for 10 years because the patient has recently lost the use of the dominant hand and must be retrained to use the other h and.  Skilled nursing visits to re -teach self -administration of the insulin would be reasonable and necessary.  The patients response to teaching must be documented at each home health visit, until the patient has learned how to self -administer.   EXAMPLE 5:
(Medicare Benefit Policy Manual)
EXAMPLE 5:   A patient recovering from pneumonia is being sent home requiring I.V. infusion of antibiotics four times per day.  The patient's spouse has been shown how to administer the drug during the hospitalization and has been told the signs and symptoms of infecti on.  The physician has ordered home health services for a nurse to teach the administration of the drug and the signs and symptoms requiring immediate medical attention.  EXAMPLE 6:   A spouse who has been taught to perform a dressing change for a post -surgical patient may need to be re -taught wound care if the spouse demonstrates improper performance of wound care.  The medical record should document the reason that the re- teaching or retraining is required and the patient/caregiver response to the education.   NOTE:  There is no requirement that the patient, family or other caregiver be taught to provide a service if they cannot or choose not to provide the care.   Teaching and training activities that require the skills of a licensed nurse include, but are not limited to , the following:   1. Teaching the self -administration of injectable medications, or a complex range of medications;   2. Teaching a newly diagnosed diabetic or caregiver all aspects of diabetes management, including how to prepare and to administer insulin injections, to prepare and follow a diabetic diet, to observe foot -care precautions, and to observe for and understand s igns of hyperglycemia and hypoglycemia;   3. Teaching self -administration of medical gases;   4. Teaching wound care where the complexity of the wound, the overall condition of the patient or the ability of the caregiver makes teaching necessary;   5. Teaching care for a recent ostomy or where reinforcement of ostomy care is needed;   6. Teaching self -catheterization;   7. Teaching self -administration of gastrostomy or enteral feedings;   8. Teaching care for and maintenance of peripheral and central venous lines and administration of intravenous medications through such lines;   9. Teaching bowel or bladder training when bowel or bladder dysfunction exists;   10. Teaching how to perform the activities of daily living when the patient or caregiver must use special techniques and adaptive devices due to a loss of function;   11. Teaching transfer techniques, e.g., from bed to chair, that are needed for safe transfer;
(Medicare Benefit Policy Manual)
11. Teaching transfer techniques, e.g., from bed to chair, that are needed for safe transfer;   12. Teaching proper body alignment and positioning, and timing techniques of a bed-bound patient;   13. Teaching ambulation with prescribed assistive devices (such as crutches, walker, cane, etc.) that are needed due to a recent functional loss;   14. Teaching prosthesis care and gait training;   15. Teaching the use and care of braces, splints and orthotics and associated skin care;   16. Teaching the preparation and maintenance of a therapeutic diet; and   17. Teaching proper administration of oral medication, including signs of side-effects and avoidance of interaction with other medications and food.  18. Teaching the proper care and application of any special dressings or skin treatments, (for example, dressings or treatments needed by patients with severe or widespread fungal infections, active and severe psoriasis or eczema, or due to skin deterioration due to radiation treatments)   40.1.2.4 - Administration of Medications  (Rev. 1, 10-01-03) A3-3118.1.B.4, HHA-205.1.B.4  Although drugs and biologicals are specifically excluded from coverage by the statute (1861(m)(5) of the Act, the services of a nurse that are required to administer the medications safely and effectively may be covered if they are reasonable and necessary to the treatment of the illness or injury.   A.  Injections
(Medicare Benefit Policy Manual)
of the Act, the services of a nurse that are required to administer the medications safely and effectively may be covered if they are reasonable and necessary to the treatment of the illness or injury.   A.  Injections   Intravenous, intramuscular, or subcutaneous injections and infusions, and hypodermoclysis or intravenous feedings require the skills of a licensed nurse to be performed (or taught) safely and effectively.  Where these services are reasonable and necessary to treat the illness or injury, they may be covered.  For these services to be reasonable and necessary, the medication being administered must be accepted as safe and effective treatment of the patient's illness or injury, and there must be a medical reason that the medication cannot be taken orally.  Moreover, the frequency and duration of the administration of the medication must be within accepted standards of medical practice, or there must be a valid explanation regarding the extenuating circumstances to justify the need for the additional injections.  1.  Vitamin B -12 injections are considered specific therapy only for the following conditions:   Specified anemias: pernicious anemia, megaloblastic anemias, macrocytic anemias, fish tapeworm anemia;    Specified gastrointestinal disorders: gastrectomy, malabsorption syndromes such as sprue and idiopathic steatorrhea, surgical and mechanical disorders such as resection of the small intestine, strictures, anastomosis and blind loop syndrome, and   Certain neuropathies: posterolateral sclerosis, other neuropathies associated with pernicious anemia, during the acute phase or acute exacerbation of a neuropathy due to malnutrition and alcoholism.  For a patient with pernicious anemia caused by a B -12 deficiency, intramuscular or subcutaneous injection of vitamin B-12 at a dose of from 100 to 1000 micrograms no more frequently than once monthly is the accepted reasonable and necessary dosage schedule for maintenance treatment.  More frequent injections would be appropriate in the initial or acute phase of the disease until it has been determined through laboratory tests that the patient can be sustained on a maintenance dose.
(Medicare Benefit Policy Manual)
2.  Insulin Injections  Insulin is customarily self -injected by patients or is injected by their families.  However, where a patient is either physically or mentally unable to self- inject insulin and there is no other person who is able and willing to inject the patient, the inje ctions would be considered a reasonable and necessary skilled nursing service.   EXAMPLE:  A patient who requires an injection of insulin once per day for treatment of diabetes mellitus, also has multiple sclerosis with loss of muscle control in the arms and hands, occasional tremors, and vision loss that causes inability to fill syringes or self-inject insulin.  If there weren't an able and willing caregiver to inject her insulin, skilled nursing care would be reasonable and necessary for the injection of the insulin.  The prefilling of syringes with insulin (or other medication that is self-injected) does not require the skills of a licensed nurse and, therefore, is not considered to be a skilled nursing service.  If the patient needs someone only to prefill syringes (a nd therefore needs no skilled nursing care on an intermittent basis, physical therapy, or speech-language pathology services), the patient, therefore, does not qualify for any Medicare coverage of home health care.  Prefilling of syringes for self -administration of insulin or other medications is considered to be assistance with medications that are ordinarily self -administered and is an appropriate home health aide service.  (See 50.2.)  However, where State law requires that a licensed nurse prefill syringes, a skilled nursing visit to prefill syringes is paid as a skilled nursing visit (if the patient otherwise needs skilled nursing care, physical therapy, or speech-language pathology services), but is not considered to be a skilled nursing service.  B.  Oral Medications   The administration of oral medications by a nurse is not reasonable and necessary skilled nursing care except in the specific situation in which the complexity of the patient's condition, the nature of the drugs prescribed, and the number of drugs prescribed require the skills of a licensed nurse to detect and evaluate side effects or reactions.  The medical record must document the specific circumstances that cause administration of an oral medication to require skilled observation and assessment.  C.  Eye Drops and Topical Ointments
(Medicare Benefit Policy Manual)
The administration of eye drops and topical ointments does not require the skills of a nurse.  Therefore, even if the administration of eye drops or ointments is necessary to the treatment of an illness or injury and the patient cannot self- administer the drops, and there is no one available to administer them, the visits cannot be covered as a skilled nursing service.  This section does not eliminate coverage for skilled nursing visits for observation and assessment of the patient's condition. (See 40.2.1.)  EXAMPLE 1:   A physician has ordered skilled nursing visits to administer eye drops and ointments for a patient with glaucoma.  The administration of eye drops and ointments does not require the skills of a nurse.  Therefore, the skilled nursing visits cannot be covered as skilled nursing care, notwithstanding the importance of the administration of the drops as ordered.  EXAMPLE 2:   A physician has ordered skilled nursing visits for a patient with a reddened area under the breast.  The physician instructs the patient to wash, rinse, and dry the area daily and apply vitamin A and D ointment.  Skilled nursing care is not needed to provi de this treatment and related services safely and effectively.   40.1.2.5 - Tube Feedings  (Rev. 1, 10-01-03) A3-3118.1.B.5, HHA-205.1.B.5  Nasogastric tube, and percutaneous tube feedings (including gastrostomy and jejunostomy tubes), and replacement, adjustment, stabilization. and suctioning of the tubes are skilled nursing services, and if the feedings are required to treat the patient's illness or injury, the feedings and replacement or adjustment of the tubes would be covered as skilled nursing services.  40.1.2.6 - Nasopharyngeal and Tracheostomy Aspiration  (Rev. 1, 10-01-03) A3-4118.1.B.6, HHA-205.1.B.6