CMS Pub. 100-02, ch. 7, § 40.1.2.15

The evaluation, psychotherapy, and teaching needed by a patient suffering from a

diagnosed psychiatric disorder that requires active treatment by a psychiatrically trained

nurse and the costs of the psychiatric nurse's services may be covered as a skilled nursing

service. Psychiatrically trained nurses are nurses who have special training and/or

experience beyond the standard curriculum required for a registered nurse. The services

of the psychiatric nurse are to be provided under a plan of care established and reviewed

by a physician or allowed practitioner.

Because the law precludes agencies that primarily provide care and treatment of mental

diseases from participating as HHAs, psychiatric nursing must be furnished by an agency

that does not primarily provide care and treatment of mental diseases. If a substantial

number of an HHA's patients attend partial hospitalization or intensive outpatient

programs or receive other outpatient mental health services, the Medicare contractor will

verify whether the patients meet the eligibility requirements specified in §30 and whether

the HHA is primarily engaged in care and treatment of mental disease.

Services of a psychiatric nurse would not be considered reasonable and necessary to

assess or monitor use of psychoactive drugs that are being used for non-psychiatric

diagnoses or to monitor the condition of a patient with a known psychiatric illness who is

on treatment but is considered stable. A person on treatment would be considered stable

if their symptoms were absent or minimal or if symptoms were present but were

relatively stable and did not create a significant disruption in the patient's normal living

situation.

EXAMPLE 1:

A patient is homebound for medical conditions, but has a psychiatric condition for which

he has been receiving medication. The patient's psychiatric condition has not required a

change in medication or hospitalization for over 2 years. During a visit by the nurse, the

patient's spouse indicates that the patient is awake and pacing most of the night and has

begun ruminating about perceived failures in life. The nurse observes that the patient

does not exhibit an appropriate level of hygiene and is dressed inappropriately for the

season. The nurse comments to the patient about her observations and tries to solicit

information about the patient's general medical condition and mental status. The nurse

advises the physician about the patient's general medical condition and the new

symptoms and changes in the patient's behavior. The physician orders the nurse to check

blood levels of medication used to treat the patient's medical and psychiatric conditions.

The physician then orders the psychiatric nursing service to evaluate the patient's mental

health and communicate with the physician about whether additional intervention to deal

with the patient's symptoms and behaviors is warranted. The home health record at each

visit should document the need for the psychiatric skilled nursing services and treatment.

The home health record must also reflect the patient/caregiver response to any

interventions provided.

EXAMPLE 2:

A patient is homebound after discharge following hip replacement surgery and is

receiving skilled therapy services for range of motion exercise and gait training. In the

past, the patient had been diagnosed with clinical depression and was successfully

stabilized on medication. There has been no change in her symptoms. The fact that the

patient is taking an antidepressant does not indicate a need for psychiatric nursing

services.

EXAMPLE 3:

A patient was discharged after 2 weeks in a psychiatric hospital with a new diagnosis of

major depression. The patient remains withdrawn; in bed most of the day, and refusing

to leave home. The patient has a depressed affect and continues to have thoughts of

suicide, but is not considered to be suicidal. Psychiatric skilled nursing services are

necessary for supportive interventions until antidepressant blood levels are reached and

the suicidal thoughts are diminished further, to monitor suicide ideation, ensure

medication compliance and patient safety, perform suicidal assessment, and teach crisis

management and symptom management to family members. The home health record at

each visit should document the need for the psychiatric skilled nursing services and

treatment. The home health record must also reflect the patient/caregiver response to any

interventions provided.