Summary Of Evidence

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Analysis of Evidence

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Skilled nursing services must be based on the patient's medical condition as described in the Centers for Medicare and Medicaid Services (CMS) Internet-Only Manual,(IOM),Medicare Benefit Policy Manual, Pub. 100-02, Chapter 7, §40.1.1.

The evaluation, psychotherapy and teaching activities needed by patients suffering from a diagnosed psychiatric disorder requiring active treatment by a psychiatrically trained nurse may be covered as skilled nursing services. Patients may also require medical social services, occupational therapy (OT), home health aide visits or other home health (HH) services related to the treatment of their psychiatric diagnosis.

If all other eligibility and coverage requirements under the HH benefit are met, skilled nursing services are covered when an individualized assessment of the patient’s clinical condition demonstrates that the specialized judgment, knowledge, and skills of a registered nurse (RN) are necessary.

HH clinical notes must document as appropriate the following:

1. The patient must be confined to the home.

The condition of these patients should be such that there exists a normal inability to leave home and, consequently, leaving the home would require a considerable and taxing effort.

A patient with a psychiatric disorder is considered to be homebound "... if his/her illness is manifested in part by a refusal to leave the home, or is of such a nature that it would not be considered safe for him/her to leave home unattended even if he/she has no physical limitations."

The following conditions support the homebound determination:

1. Agoraphobia, paranoia or panic disorder
2. Disorders of thought processes wherein the severity of delusions, hallucinations, agitation and/or impairment of thoughts/cognition grossly affect the patient’s judgment and decision making, and therefore the patient’s safety
3. Acute depression with severe vegetative symptom
4. Psychiatric problems associated with medical problems that render the patient homebound.

If a patient does in fact leave the home, the patient may, nevertheless, be considered homebound if the absences from the home are infrequent or for relatively short duration, or are attributable to the need to receive medical treatment.

2. Services must be provided under a HH Plan of Care (POC) approved and signed by the treating physician.

3. Nursing services provided must meet the part-time or intermittent requirements for HH services. "In most instances, this definition will be met if a patient requires a skilled nursing service at least every 60 days."

4. Services must be reasonable and necessary for treating the patient's psychiatric diagnosis and/or symptoms.

5. The services of a skilled psychiatric nurse must be required to provide the necessary care, i.e., observation/assessment, teaching/training activities, management and evaluation of a patient care plan, or direct patient care of a diagnosed psychiatric condition which may include behavioral/cognitive interventions.

6. Further guidance on required documentation may be found in the CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 7, §40.1.2.15.

Note: Psychiatric nursing must be furnished by an agency that does not primarily provide care and treatment of mental disorders. These agencies are precluded from participating as Medicare HH agencies.

QUALIFICATIONS FOR PSYCHIATRICALLY TRAINED NURSES PROVIDING PSYCHIATRIC EVALUATION AND THERAPY IN THE HOME

1. Psychiatrically trained nurses are nurses who have special training and/or experience beyond the standard curriculum required for a registered nurse (RN). The services of the psychiatric nurse are to be provided under a POC established and reviewed by a physician.

2. Palmetto GBA would consider the special training and/or experience requirements to be met, if the RN meets one of the following criteria:

1. A RN with a Master’s degree with a specialty in psychiatric or mental health nursing and licensed in the state where practicing would qualify. The RN must have nursing experience (recommended within the last 3 years) in an acute treatment unit in a psychiatric hospital, psychiatric home care, psychiatric partial hospitalization program or other outpatient psychiatric services.
2. A RN with a Bachelor’s degree in nursing and licensed in the state where practicing would qualify. The RN must have 1 year of recent nursing experience (recommended within the last 3 years) in an acute treatment unit in a psychiatric hospital, psychiatric home care, psychiatric partial hospitalization program or other outpatient psychiatric services.
3. A RN with a Diploma or Associate degree in nursing and licensed in the state where practicing would qualify. The RN must have 2 years of recent nursing experience (recommended within the last 3 years) in an acute treatment unit in a psychiatric hospital, psychiatric home care, psychiatric partial hospitalization program or other outpatient psychiatric services.

3. It is highly recommended that psychiatric RNs also have medical/surgical nursing experience, because many psychiatric patients meet homebound criteria due to a physical illness.

4. Nurses with these qualifications would meet the requirements necessary to provide psychiatric evaluation and therapy to Medicare HH patients. The services of a psychiatric nurse are to be provided under a POC established and reviewed by the treating physician.

5. For additional information, see the BILLING WHEN SEPARATE VISITS WERE MADE FOR MEDICAL AND PSYCHIATRIC NURSING CARE section of the Billing and Coding: Home Health - Psychiatric Care A56756 article.

Diagnostic Criteria

1. The patient must be under the care of a physician who is qualified to sign the physician’s certification and recertify the POC at least every 60 days (2 months). The physician's evaluation and subsequent recertifications must become part of the patient's medical record.

2. If the skills of a psychiatric RN are required, the service must be reasonable and necessary and intermittent.

3. Reasonable goals must be established, and there must be a reasonable expectation that the goals will be achieved. Decreasing and/or shortening inpatient and emergency room care may be a goal for the psychiatric patient's POC.

Home Health Plan of Care

The POC for a psychiatric patient must be completed. Emphasis must be placed on documentation of mental status and those skills necessary to treat the psychiatric diagnosis.

Psychiatric Interdisciplinary Team's Role

Physician

1. Certifies/Recertifies the patient’s homebound status.

2. Approves HH POC, which must be signed and dated prior to the HH agency billing for services.

3. Prescribes medications as necessary.

4. Provides supplemental orders when medically necessary.

Skilled Nursing Care

Registered Psychiatric Nurse

1. Makes initial assessment visit utilizing observation/assessment skills.

2. Manages medical illness per POC; performs psycho-biological interventions.

3. Evaluates, teaches and reviews medications and compliance; administers intramuscular (IM) or intravenous (IV) medication.

4. Manages situational or other crises; performs assessments of potential self-harm or harm to others, and refers to the treating physicians as necessary.

5. 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.

• Teaches self-care, mental and physical well-being, promotes independence and patient’s rights.

The CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 7, §40.1.2.3 provides guidance in determining the reasonableness and necessity of the number of training visits and the appropriateness of re-teaching and re-training.

6. Promotes and encourages patient/caregiver to maintain a therapeutic environment.

7. Provides supportive counseling psychotherapy and psycho-therapeutic interventions according to education and licensure. Provides psycho-education, such as teaching/training with disease process, symptom and safety management, coping skills and problem solving.

8. Provides evaluation and management of the patient's care plan.

9. Counseling services may be rendered by either a trained psychiatric nurse or a social worker. These services should not be duplicative. Concurrent counseling or psychotherapy services by multiple providers are not medically necessary.

10. Although intervention with family members may be appropriate on occasion, services by a trained psychiatric nurse to family members are not covered as a HH benefit, even if the patient will benefit.

Medical Social Services

Medical social services provided by a qualified medical social worker (MSW) or a social work assistant under the supervision of a qualified MSW, may be covered as HH services when all of the following apply:

1. The patient meets the qualifying criteria for coverage of HH services.
2. The services of these professionals are necessary to resolve social or emotional problems which are, or are expected to be, an impediment to the effective treatment of the patient's psychiatric condition or his/her rate of recovery.
3. The POC clearly indicates that the skills of a qualified MSW (or a social worker assistant under the supervision of a qualified MSW) are required to safely and effectively provide the needed care.

When the above requirements are met, coverage for social worker visits may include, but are not limited to the following:

1. Assessment of the need for care related to the social and emotional factors associated with the patient's illness, the actual need for care, adjustment to the care and the response to the treatment along with the assessment of the patient's financial resources, home situation, and the availability of community resources.
2. Counseling services that are required by the patient for the treatment of their psychiatric condition (Psychotherapy services, constituting active treatment of the psychiatric condition, may be provided by MSWs).
3. Brief counseling (2 or 3 visits) of the patient's family or care-giver(s) when they are reasonable and necessary to resolve problems that are a clear and direct impediment to the treatment of patient's illness or injury or rate of recovery.
4. Appropriate action to obtain available community resources to assist in resolving the patient's problem.

Note: Medicare does not cover the services of an MSW to assist in filing the application for Medicaid or follow up on the application. Federal regulation requires the state to provide assistance in completing the application to anyone who chooses to apply for Medicaid.

Note: A patient may require separate and distinct services provided by a skilled psychiatric nurse and a MSW. However, care must be used to avoid duplication of services that could be provided by both of these disciplines, e.g., counseling of the patient.

Home Health Aide (HHA)

Home health aides may perform personal care or other covered HHA services.

Occupational Therapist (OT)

1. The skills of an occupational therapist may be required to decrease or eliminate limitations in functional activity imposed by psychiatric illness or disability. OTs may address factors which interfere with the performance of specific functional activities due to cognitive, sensory, psychosocial or perceptual deficits.

Additional guidance on these services and the accepted standards may be found in the CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 7, §40.2.1.

2. The skills of an OT to assess and reassess a patient’s rehabilitation needs and potential, or to develop and/or implement an OT plan are covered when they are reasonable and necessary because of the patient’s condition.

3. The planning, implementing and supervision of therapeutic programs (including, but not limited to those listed below) are skilled OT services. As such, these services are covered, if they are reasonable and necessary for the treatment of the patient's illness or injury.

a. Selecting and teaching task oriented, therapeutic activities designed to restore and increase cognitive abilities and functional participation in Activities of Daily Living (ADLs) and advanced ADLs

b. Planning, implementing and supervising therapeutic tasks and activities designed to restore sensory-integrative function

c. Planning, implementing and supervising of individualized therapeutic activity programs (as well as, adapting the environment) as part of an overall “active treatment” program for a patient with a diagnosed psychiatric illness

d. Assessing and planning for improved home safety.

Maintenance Program

Coverage of therapy services, including OT services, for a maintenance program is based on the individual's need for skilled care in that maintenance program as described in the CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 7, §40.2.1.

Concurrent Admission to Home Health and Partial Hospitalization Program

Because partial hospitalization services are intended to meet all of the patient's psychiatric care needs, patients admitted to a partial hospitalization program (PHP) are not generally considered appropriate for psychiatric HH services. Medical necessity must be substantiated on a case by case basis. If there are concurrent admissions, the HH claims will be reviewed to verify the medical necessity of the service(s) provided and that the homebound criterion is met.

Discharge Criteria

Patients should cease receiving psychiatric HH services when:

1. Physician orders discharge

2. Patient discontinues/refuses service with physician or nurse

3. Patient is not compliant with the treatment plan, despite appropriate provider interventions

4. Patient/family requests discharge

5. The treatment objectives and stated functional outcome goals have been attained or are no longer attainable

6. The patient is no longer homebound

7. Other appropriate discharge protocols, e.g., the patient moves or is transferring to another agency, etc.

8. A maintenance program is established, if appropriate.

Psychiatric Nursing in Group Setting
Group interventions for psychiatric HH patients are not covered under the HH benefit. The POC and treatment must be individualized.