HI 00601.340 When Skilled Nursing Care is Reimbursable
Reimbursable skilled nursing care consists of those services reasonable and necessary to the treatment of an illness or injury (see F. below) which must be performed by, or under the direct supervision of, a licensed nurse (R.N., L.P.N. or L.V.N.) if the safety of the patient is to be assured and the medically desired result achieved.
B. Consideration is given to both the inherent complexity of the service and the condition of the patient
In many instances a service is classified as a skilled nursing service on the basis of its complexity alone, e.g., intravenous and intramuscular injections or insertion of catheters. In others, the classification requires a consideration of both the nature of the services and the condition of the patient, i.e., in a given case the patient's condition may be such that a service which would normally be classified as unskilled can only be provided safely and effectively by a skilled individual. For example, in some situations a patient who has had rectal surgery may be given an enema safely and effectively only by a nurse.
C. A service is not considered a skilled nursing service merely because it is performed by, or under the direct supervision of, a licensed nurse
When services can be safely and effectively performed (or self-administered) by the average, non-medical person without the direct supervision of a licensed nurse, the services cannot be regarded as a skilled nursing service. For example, the giving of a bath does not generally require the skills of a nurse. Consequently, it does not constitute a skilled nursing service even though it is performed by a nurse.
D. A skilled nursing service taught to the patient does not negate the skilled aspect of the service when performed by the nurse
It is customary to teach the patient and/or a family member the skills required to administer insulin injections safely and effectively. Once the patient or other nonmedical person has mastered these skills, he is to all intents and purposes functioning as a skilled person when administering or self-administering the injection. If a patient is unable to learn these skills or is physically or mentally incapable of performing the service for himself, e.g., he is blind, senile, or spastic, and there is no one else willing and able to learn and perform the service for him, the administration of the injection by a nurse constitutes a skilled nursing service.
E. A service which could be performed by the average nonmedical person is not converted to a skilled nursing service when a competent person is not available
For example, an individual who suffers from constipation requires an enema from time to time. There is no doubt that the enema is of great importance to him. However, since it can be performed by the average nonmedical person, the fact that no one is available in the home to provide this service does not change it to a skilled nursing service.
F. Reasonableness of, and necessity for, skilled nursing care
Program payment may be made for skilled nursing services required by an individual only if they are found to be reasonable and necessary for the treatment of the individual's illness of injury. To be considered reasonable and necessary for the treatment of an illness or injury, the services furnished must be consistent with the nature and severity of the individual's illness or injury, his particular medical needs and accepted standards of medical practice.
Services directed to the prevention of illness or injury are not covered under the program.
G. Observation and evaluation
Effective with services furnished on or after 5-17-78, observation and evaluation of a patient's condition is a skilled nursing service. The observation and evaluation services, including the frequency of the visits and any subsequent changes in the frequency, must be ordered by a physician. These services are considered reasonable and necessary when the possibility exists that significant changes (which may require institutionalization or changes in the treatment plan) may occur in the patient's condition.