Whether a particular service constitues a skilled nursing service is ordinarily determined
on a case-to-case basis. As a general rule, however, the counselling and evaluation
services required by an elderly patient suffering from a diagnosed psychiatric disorder
that required active treatment in a psychiatric institution requires the skills of
a psychiatrically trained nurse. (A psychiatrically trained nurse is a nurse who has special training and/or experience beyond the standard curriculum required for the R.N.)
The special training of such nurses enables them to interpret the underlying meaning
in the patient"s actions and to evaluate the need for the psychiatrist to change the
plan of treatment or to reschedule visits to the psychiatrist"s office. Conversely,
if the visiting nurse has not been trained in psychiatric care, her visits would not
be reimbursable since they are not deemed “reasonable” to the treatment of the patient"s illness, unless the entire plan of treatment consists
solely of injections of fluphenazine, a behavior modifier, which can be furnished
by a nurse, that has not been “psychiatrically” trained. It is expected that an individual whose psychiatric disorder is severe enough
to require the special skills of a psychiatric nurse will be under the care of a psychiatrist
and that the plan of treatment calling for the services of a psychiatric nurse will
be established and reviewed by the psychiatrist.
In effect the law precludes an HHA which is primarily for the care and treatment of mental diseases from participating in the program.
However, this exclusion does not preclude payment where psychiatric nursing is furnished
by an agency which is not primarily for the care and treatment of mental diseases. Should the intermediary find that
the number of bills submitted for individuals with mental disorders is significant
enough to raise the possibility that an HHA is primarily for the care and treatment
of mental diseases, it notifies the CMS RO.