HI 00601.350 Skilled Nursing Services—Examples

A. Teaching and training activities

Teaching and training activities which require the skills or knowledge of a nurse constitute skilled nursing services. These include but are not limited to teaching or training the patient, a family member or others to:

  1. Give an injection;

  2. Irrigate a catheter;

  3. Care for a colostomy or ileostomy;

  4. Administer medical gases;

  5. Prepare and follow a therapeutic diet;

  6. Apply dressings to wounds involving prescription medications and aseptic techniques;

  7. Carry out bladder training;

  8. Carry out bowel training (only when bowel incontinency exists);

  9. Perform activities of daily living (dressing, eating, personal hygiene, etc.) for himself through use of special techniques and adaptive devices where he has suffered a loss of function;

  10. Align and position a bed-bound patient;

  11. Perform transfer activities, e.g., bed to chair or wheelchair, wheelchair to bathtub or toilet; and

  12. Ambulate by means of crutches, walker, cane, etc.

In determining the reasonable and necessary number of teaching visits consideration is given to whether the home teaching constitutes a reinforcement of that provided in an institution or is the initial instruction received by the patient.

B. Supervisory activities

A nurse performs various types of supervisory services. Those which require her particular skill, knowledge, and judgment constitute skilled nursing service.

1. Direct supervision of the performance of a skilled nursing service performed by other than a nurse

The direct supervision provided by a licensed nurse of the performance of a skilled nursing service by other than a nurse constitutes a skilled nursing service, e.g., supervising a student nurse in giving an intravenous or intramuscular injection.

2. Supervision by a registered nurse of home health aide services

The fact that the conditions of participation require a R.N. to visit the patient's home at least every 2 weeks in order to provide general supervision to the aide and to evaluate the patient's continuing personal care needs does not affect the unskilled nature of the service rendered by the home health aide. Nor do such activities of the supervising nurse represent skill nursing care. Such supervisory visits are not reimbursable as skilled nursing visits.

C. Insertion of a catheter

The insertion of a catheter is a skilled nursing service and is considered reasonable and necessary when the individual has suffered a permanent or temporary loss of bladder control.

1. Bladder training

When the loss of control necessitating the use of the catheter is temporary, visits made by the nurse to change the catheter must also include instruction of the patient and/or family in bladder training methods. (The actual carrying out of the bladder training, e.g., forcing fluids, or other measures does not require the skills of a nurse.) After the catheter has been removed a reasonable number of visits by the nurse may be necessary to observe and evaluate the effectiveness with which the bladder training has been carried out.

2. Use of male orderlies

It is established practice to have urinary catheters inserted in male patients by male orderlies. In recognition of this practice, this service by the male orderly may be considered a skilled nursing service even though not performed under the direct supervision of a licensed nurse. This constitutes an exception to the definition of skilled nursing care.

D. Administration of medications

1. Intravenous and intramuscular injections

Intramuscular and intravenous injections of medications constitute skilled nursing services. However, if the drug injected is not considered an effective treatment for the condition given, or a medical reason does not exist for providing it by injection rather than by mouth, the injection is not considered reasonable and necessary to the treatment of the individual's illness. Also, if the patient or a member of his family has been taught to administer an intramuscular injection it would not be deemed reasonable and necessary to have a nurse administer the injection. Intravenous injections may only be given by a professional medical person.

The drugs and biologicals injected are specifically excluded from coverage under the home health benefit.

a. Vitamin B-12 injections

Vitamin B-12 injections are considered specific therapy only for the following conditions:


    Pernicious anemia: megaloblastic anemias, macrocytic anemias; fish tapeworm anemia;


    Gastrectomy; malabsorption syndromes such as sprue and idiopathic steatorrhea; surgical and mechanical disorders such as resection of the small intestine, strictures, anastomoses and blind loop syndromes;


    Posterolaterial sclerosis; other neuropathies associated with pe