CMS Pub. 100-02, ch. 7, § 40.1.2.2

Skilled nursing visits for management and evaluation of the patient's care plan are also

reasonable and necessary where underlying conditions or complications require that only

a registered nurse can ensure that essential unskilled care is achieving its purpose. For

skilled nursing care to be reasonable and necessary for management and evaluation of the

patient's plan of care, the complexity of the necessary unskilled services that are a

necessary part of the medical treatment must require the involvement of skilled nursing

personnel to promote the patient's recovery and medical safety in view of the patient's

overall condition.

EXAMPLE 1:

An aged patient with a history of diabetes mellitus and angina pectoris is recovering from

an open reduction of the neck of the femur. He requires, among other services, careful

skin care, appropriate oral medications, a diabetic diet, a therapeutic exercise program to

preserve muscle tone and body condition, and observation to notice signs of deterioration

in his condition or complications resulting from his restricted, but increasing mobility.

Although a properly instructed person could perform any of the required services, that

person would not have the capability to understand the relationship among the services

and their effect on each other. Since the combination of the patient's condition, age, and

immobility create a high potential for serious complications, such an understanding is

essential to ensure the patient's recovery and safety. The management of this plan of care

requires skilled nursing personnel until nursing visits are not needed to observe and

assess the effects of the non-skilled services being provided to treat the illness or injury

until the patient recovers. Where nursing visits are not needed to observe and assess the

effects of the non-skilled services being provided to treat the illness or injury, skilled

nursing care would not be considered reasonable and necessary, and the management and

evaluation of the care plan would not be considered a skilled service.

EXAMPLE 2:

An aged patient with a history of mild dementia is recovering from pneumonia which has

been treated at home. The patient has had an increase in disorientation, has residual chest

congestion, decreased appetite, and has remained in bed, immobile, throughout the period

with pneumonia. While the residual chest congestion and recovery from pneumonia

alone would not represent a high risk factor, the patient's immobility and increase in

confusion could create a high probability of a relapse. In this situation, skilled oversight

of the unskilled services would be reasonable and necessary pending the elimination of

the chest congestion and resolution of the persistent disorientation to ensure the patient's

medical safety. For this determination to be made, the home health documentation must

describe the complexity of the unskilled services that are a necessary part of the medical

treatment and which require the involvement of a registered nurse in order to ensure that

essential unskilled care is achieving its purpose. Where visits by a licensed nurse are not

needed to observe and assess the effects of the unskilled services being provided to treat

the illness or injury, skilled nursing care would not be considered reasonable and

necessary to treat the illness or injury.

EXAMPLE 3:

A physician orders one skilled nursing visit every 2 weeks and three home health aide

visits each week for bathing and washing hair for a patient whose recovery from a CVA

has left him with residual weakness on the left side. The cardiovascular condition is

stable and the patient has reached the maximum restoration potential. There are no

underlying conditions that would necessitate the skilled supervision of a licensed nurse in

assisting with bathing or hair washing. The skilled nursing visits are not necessary to

manage and supervise the home health aide services and would not be covered.