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:
Give an injection;
Irrigate a catheter;
Care for a colostomy or ileostomy;
Administer medical gases;
Prepare and follow a therapeutic diet;
Apply dressings to wounds involving prescription medications and aseptic techniques;
Carry out bladder training;
Carry out bowel training (only when bowel incontinency exists);
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;
Align and position a bed-bound patient;
Perform transfer activities, e.g., bed to chair or wheelchair, wheelchair to bathtub or toilet; and
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;
CERTAIN GASTROINTESTINAL DISORDERS
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 pernicious anemia; during the acute phase or acute exacerbation of a neuropathy due to malnutrition and alcoholism.
b. Insulin injections
Insulin injections are specific therapy for diabetes. However, if the individual or a family member has been taught to give the injection it is not considered reasonable and necessary to the treatment of the individual's illness to have a nurse administer such injections. If the patient is mentally and physically able to be taught to give himself the injection but refuses to learn to do so, visits by a nurse to administer the injections are not considered reasonable and necessary and would not be reimbursable under the program. If a patient has a psychological block to giving himself an insulin injection, he would be considered mentally unable to be taught to render the self-injection.
2. Oral medications
Usually, the administration of oral medications does not require the skills of a licensed nurse in the home setting. However, this would not preclude payment in the unusual situation in which the complexity of the patient's condition and the number of drugs prescribed require the skills of a nurse to detect and evaluate side effects or reactions.
E. Intravenous and hypodermoclysis feedings
These feedings require the skills of a nurse. However, due to the time required for feedings and the fact that an individual requiring such feedings generally requires a higher level of care than can be provided in the home setting, it is expected that they will be furnished in the home only when the individual is waiting to be institutionalized or is in the terminal stages of an illness.
F. Skin care
1. Extensive decubitus ulcers or other widespread skin disorder
The existence of extensive decubitus ulcers or other widespread skin disorder may necessitate skilled care. The principal indication of whether skilled care is required is the physician's orders for treating the skin, rather than the patient's diagnosis.
2. Routine prophylactic and palliative skin care
Activities such as bathing the skin, applying creams, etc., do not constitute skilled services. Nor does the presence of a small decubitus ulcer, rash, or other relatively minor skin irritation generally indicate a need for skilled care.