TN 12 (10-89)
HI 00620.130 Custodial Care
Custodial care is excluded from coverage. See HI 00610.180 for determining covered level of care in SNF'S.
Custodial care is care designed essentially to assist an individual to meet his activities of daily living, i.e., services which constitute personal care such as help in walking and getting in and out of bed, assistance in bathing, feeding, and using the toilet, preparation of special diets, and supervision of medication which can usually be self-administered—and which does not entail or require the continuing attention of trained medical or paramedical personnel.
The controlling factor in determining whether a person is receiving custodial care is the level of care and medical supervision that the patient requires, rather than considerations such as diagnosis, type of condition, or degree of functional limitation.
B. Criteria for applying definition of custodial care
Generally, the care furnished an individual requires the continuing attention of trained medical or paramedical personnel if: the individual's condition medically warrants skilled services and the need for such services constitutes the primary purpose of the total care furnished the individual.
1. Skilled services
A skilled service is one which must be furnished by or under the supervision of trained medical or paramedical personnel to assure the safety of the patient and achieve the medically desired result. A service which can be safely and adequately self-administered or performed by the average, rational, nonmedical person, without the supervision of trained medical or paramedical personnel, is a non-skilled service. For example, a patient, following instructions can normally take oral medication. Giving of oral medication by a nurse to a patient who is unable to take it himself because of senility would not change the service from a non-skilled to a skilled service.
2. Primary purpose of care furnished
If the primary purpose of the total care provided an individual is to assist him in meeting the activities of daily living, the custodial care exclusion applies.
However, if the skilled services furnished the patient are the primary purpose for the total care provided, the custodial care exclusion does not apply.
If it is medically necessary to have the services of a nurse available to the patient at all times, the need for this service alone establishes that the primary purpose of the total care is the provision of this skilled service.
When a patient does not require nursing services, the primary purpose of the total care furnished is generally to assist him in meeting his activities of daily living.
Where the need for nursing services is only minimal, the furnishing of skilled services is the primary purpose of the total care furnished only if all the skilled services furnished in view of the patient's condition are such that they could not be performed outside the institutional setting. These situations will probably be limited to those where an individual is hospitalized for the running of extensive diagnostic tests.
3. Significance of physicians' services
All physician services rendered to a patient are skilled services.
Many individuals who require only custodial care may need periodic physician visits for assessment of their medical status so a medical decision may be made as to whether changes are required in the type of care they are receiving. Nevertheless, periodic visits by a physician to a patient do not change the custodial character of the care when the primary purpose of the total care furnished the patient by the hospital or SNF is to assist him to meet his activities of daily living.
(Periodic visits by a physician to his patients are covered under Part B if reasonable and necessary to the treatment of the patient's illness or injury. Such physician services are reimbursable even though a finding has been made that the care furnished the patient in the hospital or SNF is custodial and therefore not covered. A finding that the level of care is non-covered does not preclude reimbursement for those ancillary services (see HI 01201.055) covered under Part B which are furnished to the patient provided they are medically necessary. Reimbursement for such services can be made only under Part B.)
C. Examples of custodial care in general hospital and SNF
A stroke patient who is ambulatory, has no bladder or bowel involvement, no serious associated or secondary illnesses and does not require medical or paramedical care but requires only the assistance of an aide in feeding, dressing, and bathing.
The cardiac patient who is stable and compensated and has reasonable cardiac reserve and no associated illnesses, but who, because of advanced age, has difficulty in managing alone in his home, and requires assistance in meeting the activities of daily living.
The senile patient who has diabetes which remains stabilized as long as someone sees to it that he takes his oral medication, and sticks to his prescribed diet.
D. Custodial care in psychiatric hospitals
The basic principle underlying the provisions for coverage of inpatient psychiatric hospital services is that payment is to be made by the program only for “active treatment” which can reasonably be expected to improve the patient's condition.
The law provides that payment may be made for services only if they were being furnished while the patient was receiving either active treatment or admission and related services necessary for diagnostic study. Thus, the period of time during which an individual receives inpatient psychiatric hospital services which meet the above requirements is, for the purposes of the Medicare program, considered a period of active treatment.
1. Definition of active treatment
For services in a psychiatric hospital to be designated as "active treatment," they must be provided under an individualized treatment or diagnostic plan, reasonably expected to improve the patient's condition or for the purpose of diagnois, and supervised and evaluated by a physician.
2. Individualized treatment or diagnostic plan
The services must be provided in accordance with an individualized program of treatment or diagnosis developed by a physician in conjunction with staff members on the basis of a thorough evaluation of the patient's restorative needs and potentialities. Thus, an isolated service, e.g., a single session with a psychiatrist, or a routine laboratory test not furnished under a planned program of therapy or diagnosis does not constitute active treatment, even though the service was therapeutic or diagnostic in nature.
3. Services expected to improve the condition or for purpose of diagnosis
The service must reasonably be expected to improve the patient's condition or must be for the purpose of diagnostic study. The treatment must, at a minimum, be designated both to reduce or control the patient's psychotic or neurotic symptoms which necessitated hospitalization and improve the patient's level of functioning.
If, however, the only activities prescribed for the patient are primarily diversional in nature, i.e., to provide some social or recreational outlet, it is not regarded as treatment to improve the patient's condition.
In accordance with the above definition of “improvement,” the administration of antidepressant or tranquilizing drugs which are expected to alleviate significantly a patient's psychotic or neurotic symptoms is termed active treatment (assuming that the other elements of the definition are met). The administration of a drug or drugs does not of itself necessarily constitute active treatment. Thus, the use of mild tranquilizers or sedatives solely for the purpose of relieving anxiety or insomnia does not constitute active treatment.
4. Services supervised and evaluated by physician
a. Participation requirement
Physician participation in the services is an essential ingredient of active treatment. The physician must serve as a source of information and guidance for all members of the therapeutic team who work directly with the patient in various roles. It is the responsibility of the physician to evaluate periodically the therapeutic program and to determine the extent to which treatment goals are being realized and whether changes in direction or emphasis are needed.
A finding that a patient is not receiving active treatment does not in itself preclude payment for physicians' services under Part B. As long as the professional services rendered by the physician are reasonable and necessary for the care of the patient, such services are reimbursable under the medical insurance program.
b. Principles for evaluating a period of active treatment
The period of time covered by the physician's certification is referred to as a “period of active treatment.” This period includes all days on which the inpatient psychiatric hospital services were provided because of the individual's need for active treatment—not just the days on which specific therapeutic or diagnostic services were rendered. For example, a patient's program of treatment may necessitate the discontinuance of therapy for a period of time or it may include a period of observation, while only maintenance or protective services are furnished. If such periods were essential to the overall treatment plan, they are regarded as part of the period of active treatment.