Covered and Noncovered Services : Home Health Skilled Nursing Services

Catheters

Insertion and sterile irrigation and replacement of indwelling urinary catheters and care of suprapubic catheters are considered skilled nursing services. When the catheter is necessitated by a permanent or temporary loss of bladder control, medically necessary skilled nursing services that are provided at a frequency appropriate to the type of catheter in use are reimbursable.

When complications are absent, Foley catheters generally require skilled service once every 30 days and silicone catheters generally require skilled service once every 60-90 days. More frequent care may be reimbursed if documentation supports the medical necessity. This frequency of service is considered reasonable and medically necessary. In some instances, there are complications that require more frequent skilled services related to the catheter.

If intermittent catheterization is delegated to an LPN or home health aide by the RN, medical record documentation must support that the LPN or home health aide has been taught the procedure and has demonstrated competence in the procedure.

Determining Skilled Nursing Services

In determining whether a service is skilled (i.e., requires the skills of an RN or LPN), providers should consider the inherent complexity of the service, the condition of the member, and accepted standards of medical and nursing practice. Some services are classified as skilled nursing services on the basis of the complexity of the services alone, such as intravenous and intramuscular injections or insertion of catheters. However, the member's condition may be such that a service that would ordinarily be considered unskilled may be considered a skilled nursing service because the service can only be safely and effectively provided by a nurse.

Agencies should be aware that while some services may be provided by a licensed nurse, they may not be considered a Medicaid-covered service. For example, nonskilled services provided by a nurse due to the unavailability of a home health aide or PCW to provide the nonskilled services, regardless of the importance of the services to the member, are not reimbursable as skilled nursing services.

Examples of Circumstances in Which Skilled Nursing May Be Required

There may be circumstances in which skilled nursing services may be required for services that might ordinarily be considered unskilled care. For example:

• A broken leg does not necessarily indicate a need for skilled care. However, if the member has a pre-existing circulatory condition, skilled nursing services may be needed to check for complications, to monitor medication administration for pain control, and to teach proper ambulation techniques to ensure proper bone alignment and healing.
• The condition of a member who has irritable bowel syndrome or who is recovering from rectal surgery may be such that only a nurse can safely and effectively give the member an enema. If the enema is necessary to treat the medical condition, the visit may be covered as a skilled nursing visit.

However, a service that, by its nature, requires the skills of a licensed nurse to be provided safely and effectively, continues to be a skilled service even if it is taught to the member, the member's family, or other caregivers. For example, if a member is discharged from the hospital with an open draining wound that requires irrigation, packing, and dressing twice each day, the care is considered skilled nursing care, even if the family is taught to perform the care and provides it part or all of the time.

Home Health Skilled Nursing Visits

Wisconsin Medicaid reimburses only two types of home health skilled nursing visits:

• Home Health Skilled Nursing Initial Visit — the member's first home health skilled nursing visit of any duration by an RN or LPN in a calendar day. Only one initial visit is reimbursable per calendar day per member, regardless of the number of providers.
• Home Health Skilled Nursing Subsequent Visit — each additional home health skilled nursing visit of any duration following the initial visit per calendar day.

A visit begins when the RN or LPN enters the residence to provide a covered service. The visit ends when the RN or LPN leaves the residence at the conclusion of the covered service.

A visit made by a skilled nurse solely to train other home health providers is not a covered service. The home health agency is responsible for ensuring that its providers are properly trained to perform any service it furnishes. The cost of a skilled nurse's visit for the purpose of training home health agency staff is an administrative cost to the home health agency.

Intake Evaluations

Federal regulations require home health agencies to have written policies concerning the acceptance of members by the agency. When personnel of the agency make an intake evaluation visit, the cost of the visit is considered an administrative cost of the agency and is not reimbursable separately as a skilled nursing visit since, at this point, the member has not been accepted for care.

If, however, during the course of this intake evaluation visit, the member is determined suitable for home health care by the agency and is also provided the first skilled nursing service as ordered by the POC, the visit would become the first reimbursable home health skilled nursing visit.

Member Enrollment for Services

According to Wis. Admin. Code § DHS 107.11(2), a member is eligible for home health skilled nursing services if they:

• Require less than eight hours of direct, skilled nursing services in a 24-hour period according to the POC.
• Do not reside in a hospital or nursing facility.
• Require a considerable and taxing effort to leave the residence or cannot reasonably obtain services outside the residence.

Nasopharyngeal and Tracheostomy Suctioning

Nasopharyngeal and tracheostomy suctioning are skilled nursing services and are covered as skilled nursing services if they are required to treat the member's medical condition.

Ostomy Care

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 of ostomy care is reimbursable during the time that a skilled assessment or another covered skilled nursing care is required.

Qualifying Hours of Care

A maximum of 30 calendar days of skilled nursing care may continue to be reimbursed as home health services, beginning on the day eight hours or more of skilled nursing services became necessary. To continue medically necessary services after 30 days, PA for PDN is required under Wis. Admin. Code § DHS 107.12(2).

To determine if a member receives less than eight hours of direct skilled nursing services, add up the total hours of direct skilled nursing care provided by all caregivers, including home health agencies, independent nurses, and skilled cares provided by family or friends. If this adds up to less than eight hours, the member may enroll for home health skilled nursing services.

If the member requires eight or more hours of direct skilled nursing services in a 24-hour period, they may enroll for PDN services. A member cannot be enrolled for both home health skilled nursing services and PDN services.

Reimbursable Assessments

Assessment of a member's condition is always a part of required nursing supervision. However, the assessment of the member's condition may be reimbursable as a skilled nursing service when:

• The member's medical condition requires a nurse to identify and evaluate the need for possible modification of treatment. This may include when the following indications are present and documented:
  • Abnormal or fluctuating vital signs
  • Weight changes
  • Edema
  • Symptoms of drug toxicity
  • Abnormal or fluctuating lab values
  • Respiratory changes on auscultation

  A one-time visit by an RN may be medically necessary to assess and evaluate the medical condition of the member in response to a home health aide, PCW, the member or the member's family, or another person expressing concern that the member's medical condition may have changed. This assessment visit may be covered whether or not the visit results in intervention or a change in the POC. Providers may request an amendment to a PA to cover this visit.

The member's medical condition requires a nurse to initiate additional medical procedures until the member's treatment regimen stabilizes but is not part of an established pattern of care.

A member often requires a skilled nursing assessment during the first 30 days following hospital discharge or until the member's medical condition and treatment regimen stabilizes.

• There is a likelihood of complications or an acute episode requiring a nurse to identify and evaluate the member's need for possible modification of treatment or initiation of additional medical procedures until the member's treatment regimen is essentially stabilized.

  When a member is admitted to home health care for assessment because there is reasonable potential of a complication or further acute episode, the skilled assessment services are covered only for as long as there remains a reasonable potential for such a complication or acute episode. Medical record documentation must support the likelihood of a future complication or acute episode.

Examples of Reimbursable Assessments

The following are examples of reimbursable assessments:

• A member with arteriosclerotic heart disease with unstable congestive heart failure requires close observation by skilled nursing personnel for signs of decompensation or adverse affects from prescribed medication. Skilled assessment is needed to determine whether the drug regimen should be modified or whether other therapeutic measures should be considered until the member's treatment regimen is essentially stabilized.
• A member has undergone peripheral vascular disease treatment, including a bypass. The incision area is showing signs of potential infection, and the member has an elevated temperature. Skilled assessment of the perfusion of the legs and the integrity of the incision site is necessary until the signs of potential infection have abated.

Reimbursable Ongoing Assessment Visits

When an assessment visit does not meet the guidelines for medical necessity, it may be reimbursed as an ongoing assessment (Title 19 re-evaluation) visit if all of the following criteria are met:

• The member's medical condition is stable. (A medical condition is considered stable when the member's physical condition is non-acute and without substantial variability at the current time.)
• The member has not received a covered skilled nursing service (including medication management), covered personal care service, or covered home visit by a physician within the past 62 days.
• A skilled assessment is required to re-evaluate the continuing appropriateness of the POC.

In accordance with federal Medicaid regulations, the visit must be ordered by a physician in order to be covered. In the ongoing assessment visit, the RN is required to do the following:

• Assess the member's current medical condition (including systems assessment, environmental assessment, psychosocial assessment, and functional assessment)
• Evaluate the member's progress or lack of progress towards meeting established goals
• Modify the POC as needed

The ongoing assessment visit is to be used to assess the member who is only receiving home health aide services or home health aide and home health therapy services. Persons receiving covered skilled nursing visits must be assessed during those covered visits. Skilled nursing services include the following:

• PDN provided by an RN or LPN
• PDN for ventilator-dependent members provided by an RN or LPN
• Initial or subsequent home health nursing visits
• Personal care supervisory visits

Wisconsin Medicaid may reimburse for ongoing skilled nursing assessments and visits provided once every 55 calendar days.

PA is not required for an ongoing assessment visit. Providers are required to submit claims using the ongoing assessment visit procedure code.

Examples of Non-Reimbursable Ongoing Assessments

The following are examples of non-reimbursable ongoing assessments:

• A physician orders one skilled nursing visit every two weeks and three PCW visits each week for bathing and washing hair for a member whose recovery from a cerebral vascular accident has caused a residual weakness on the left side. The member's condition is stable and the member has reached the maximum functional independence. There are currently no underlying conditions that would necessitate a skilled assessment, therefore, an ongoing assessment visit would not be covered in this situation because a personal care visit is more appropriate.
• A visit that is made specifically for filling out paperwork, such as an OASIS, is not covered.

Reimbursable Teaching and Training Activities

Teaching and training activities that require skilled nursing personnel to teach a member, the member's family, or unpaid caregivers how to manage the treatment regimen would constitute skilled nursing services only when provided to a member in conjunction with other reimbursable skilled nursing services.

When it becomes apparent after a reasonable period of time that the member, family, or caregiver is unwilling or unable to learn or be trained, further teaching and training ceases to be reasonable and medically necessary. The reason that the member, family, or caregiver is unwilling or unable to be trained should be documented in the medical record.

Examples of Reimbursable Teaching and Training Activities

The following are examples of reimbursable teaching and training activities:

• A physician has ordered skilled nursing services for a man who was hospitalized for a broken hip and has now been discharged to home. While hospitalized, the member was newly diagnosed with diabetes. Skilled nursing care is ordered to closely monitor blood glucose levels until the levels stabilize and to assess understanding of and compliance with a diabetic diet. In this case, teaching of self-injection and management of insulin, signs and symptoms of insulin shock, and actions to take in emergencies is reasonable and necessary to the treatment of the medical condition, since the member is receiving skilled care and cannot reasonably be expected to go to his physician for the instruction.
• A member with arteriosclerotic heart disease and congestive heart failure requires close observation by a nurse for signs of decompensation or adverse affects resulting from newly prescribed medication. When visiting the member to assess his or her medical condition, teaching about the medication regimen is appropriate. (Under Wisconsin pharmacy law and Wisconsin Medicaid regulations, pharmacists are required to instruct the person picking up a prescription about the medication, including instructions for administration and signs of adverse reactions. In most cases, the person obtaining the prescription may also obtain this information over the telephone.)

Reimbursable Venipunctures

Venipuncture is a skilled nursing service when the collection of the specimen is necessary to the diagnosis and treatment of the member's medical condition and when the venipuncture cannot be performed in the course of regularly scheduled absences from the home to acquire medical treatment. The frequency of visits for venipuncture must be reasonable within accepted standards of medical practice for treatment of the medical condition. Venipuncture is reasonable and necessary when the following occurs:

• The treatment is recognized as being reasonable and medically necessary to the treatment of the medical condition. The physician order for the venipuncture should clarify the need for the test when it is not diagnosis/illness specific.
• The frequency of the testing is consistent with accepted standards of medical practice for continued monitoring and assessment of a diagnosis, medical problem, or treatment regimen. Even when the laboratory results are consistently stable, periodic venipunctures may be reasonable and necessary because of the nature of the treatment.

Reimbursable Venipuncture for Prothrombin

Venipuncture may be reimbursable when the following is true:

• Documentation shows that the dosage is being adjusted and ongoing monitoring is ordered by the physician.
• The results are stable within non-therapeutic ranges. There must be documentation of other factors that would indicate why continued monitoring is reasonable and medically necessary.
• The results are stable within the therapeutic ranges. Monthly monitoring may be reasonable and necessary.

Examples of Reasonable and Necessary Venipunctures

The following are examples of reasonable and necessary venipuctures:

• Many medications 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 three months) when the results are stable and the member is asymptomatic.
• In monitoring phenytoin (e.g., Dilantin ^®) administration, the difference between a therapeutic and a toxic level of phenytoin in the blood is very slight. It is therefore appropriate to monitor the level on a routine basis (every three months) when the results are stable and the member is asymptomatic.
• A member with coronary artery disease was hospitalized with atrial fibrillation and was subsequently discharged to the home health agency with orders for anticoagulation therapy. Monthly venipunctures as indicated are necessary to report prothrombin (protime) levels to the physician.

Supervision

In accordance with licensure requirements and as stated in Wis. Admin. Code ch. N 6, LPNs are required to be supervised by an RN or a physician. Ongoing supervision of a home health aide, LPN, or PCW must be provided in accordance with Wis. Admin. Code § DHS 105.16(2)(b).

Ongoing supervision of a home health aide, LPN, or PCW must be provided in accordance with Wis. Admin. Code § DHS 105.16(2)(b).

Supervisory visits must include:

• A review and evaluation of the member's medical condition and medical needs according to the written POC during the period in which agency care is being provided
• An evaluation of the appropriateness of the relationship between the direct care giver and the member
• An assessment of the extent to which the member's goals are being met
• A determination of whether or not the current level of home health services provided to the member continues to be appropriate to treat the member's medical condition
• A determination of whether or not the services are medically necessary
• A discussion and review with the member about the services received by the member

After each supervisory visit, the RN must discuss the results of the supervisory visits with the home health aide, LPN, or PCW. The results of each supervisory visit must be documented in the member's medical record.

Separate reimbursement for supervisory visits is limited to PCW supervisory visits. Specific information on the supervision of PCWs is available in the Personal Care area of the Online Handbook.

Tube Insertions and Feedings

Nasogastric, gastrostomy, and jejunostomy tube feeding are covered services. Replacement, stabilization, and suctioning of the tubes are also covered skilled nursing services.

If the feeding of a member via gastrostomy or jejunostomy tube is delegated to an LPN, home health aide, or PCW, medical record documentation must support that the caregiver has been instructed in all aspects of tube feeding. This delegation may occur only when deemed appropriate by the supervising RN after assessment of the member's medical condition.

Wound Care

Wound care relates to the direct, hands-on skilled nursing care provided to members with wounds, including any necessary dressing changes on those wounds.

Wound care, including, but not limited to, ulcers, burns, pressure sores, open surgical sites, fistulas, and tube sites, is a skilled nursing service when the skills of a licensed nurse are needed to safely and effectively care for the wound. For skilled nursing care to be reasonable and necessary to treat a wound, the grade, size, depth, nature of drainage (color, odor, consistency, and quantity), condition, and appearance of the surrounding skin of the wound must be documented in the POC. This allows an assessment of the need for skilled nursing to be made.

The POC must contain the specific instructions for the wound treatment. Where the physician has ordered appropriate active treatment (e.g., sterile or complex dressings, administration of prescription medications) of wounds with the following characteristics, the skills of a licensed nurse may be reasonable and necessary:

• Open wounds that are draining purulent exudate or that have a foul odor present and/or for which the member is receiving antibiotic therapy
• Wounds with a drain or T-tube that require interval position changes
• Wounds that 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) that present the following characteristics:
  • Partial tissue loss with signs of infection, such as foul odor or purulent drainage
  • Full thickness tissue loss that involves exposure of fat or invasion of other tissue, such as muscle or bone
• Wounds with exposed internal vessels or a mass that may have a proclivity for hemorrhage when a dressing is changed
• Open wounds or widespread skin complications following radiation therapy or that result from immune deficiencies or vascular insufficiencies
• Post-operative wounds where there are complications, such as infection or allergic reaction, or 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
• Other open or complex wounds that require treatment that can be safely and effectively provided only by a licensed nurse

For skilled nursing services to continue, there must be ongoing medical record documentation of the grade, size, depth, nature of drainage, and condition of the wound and appearance of surrounding skin.

Skilled nursing care is ordinarily not required for wounds or ulcers that show redness, edema and induration, at times with epidermal blistering or desquamation. Wounds that only require an antibacterial ointment, nonsterile covering, occlusive covering, opsite or duoderm, and wounds with minimal serous or serosanguinous drainage also do not require skilled nursing care.

However, while the initial care for a wound might not require the services of a skilled nurse, the wound may still require skilled monitoring and assessment for signs and symptoms of infection or complication.