CMS Pub. 100-02, ch. 7, § 50.2

For home health aide services to be covered:

• The patient must meet the qualifying criteria as specified in §30;

• The services provided by the home health aide must be part-time or intermittent

as discussed in §50.7;

• The services must meet the definition of home health aide services of this section;

and

• The services must be reasonable and necessary to the treatment of the patient's

illness or injury.

NOTE: A home health aide must be certified consistent the competency evaluation

requirements.

The reason for the visits by the home health aide must be to provide hands-on personal

care of the patient or services needed to maintain the patient's health or to facilitate

treatment of the patient's illness or injury.

The physician or allowed practitioner's order should indicate the frequency of the home

health aide services required by the patient. These services may include but are not

limited to:

A. Personal Care

Personal care means:

1. Bathing, dressing, grooming, caring for hair, nail, and oral hygiene which are

needed to facilitate treatment or to prevent deterioration of the patient's health,

changing the bed linens of an incontinent patient, shaving, deodorant application,

skin care with lotions and/or powder, foot care, and ear care; and

2. Feeding, assistance with elimination (including enemas unless the skills of a

licensed nurse are required due to the patient's condition, routine catheter care and

routine colostomy care), assistance with ambulation, changing position in bed,

assistance with transfers.

EXAMPLE 1:

A physician has ordered home health aide visits to assist the patient in personal care

because the patient is recovering from a stroke and continues to have significant right

side weakness that causes the patient to be unable to bathe, dress or perform hair and oral

care. The plan of care established by the HHA nurse sets forth the specific tasks with

which the patient needs assistance. Home health aide visits at an appropriate frequency

would be reasonable and necessary to assist in these tasks.

EXAMPLE 2:

A physician ordered four home health aide visits per week for personal care for a

multiple sclerosis patient who is unable to perform these functions because of increasing

debilitation. The home health aide gave the patient a bath twice per week and washed

hair on the other two visits each week. Only two visits are reasonable and necessary

since the services could have been provided in the course of two visits.

EXAMPLE 3:

A physician ordered seven home health aide visits per week for personal care for a bed-bound, incontinent patient. All visits are reasonable and necessary because the patient

has extensive personal care needs.

EXAMPLE 4:

A patient with a well-established colostomy forgets to change the bag regularly and has

difficulty changing the bag. Home health aide services at an appropriate frequency to

change the bag would be considered reasonable and necessary to the treatment of the

illness or injury.

B. Simple Dressing Changes That Do Not Require the Skills of a Licensed Nurse

EXAMPLE 5:

A patient who is confined to the bed has developed a small reddened area on the

buttocks. The physician has ordered home health aide visits for more frequent

repositioning, bathing and the application of a topical ointment and a gauze 4x4. Home

health aide visits at an appropriate frequency would be reasonable and necessary.

C. Assistance With Medications Which Are Ordinarily Self-Administered and Do

Not Require the Skills of a Licensed Nurse to Be Provided Safely and Effectively

NOTE: Prefilling of insulin syringes is ordinarily performed by the diabetic as part of

the self-administration of the insulin and, unlike the injection of the insulin, does not

require the skill of a licensed nurse to be performed properly. Therefore, if HHA staff

performs the prefilling of insulin syringes, it is considered to be a home health aide

service. However, where State law precludes the provision of this service by other than a

licensed nurse or physician, Medicare will make payment for this service, when covered,

as though it were a skilled nursing service. Where the patient needs only prefilling of

insulin syringes and does not need skilled nursing care on an intermittent basis, physical

therapy, speech-language pathology services, or have a continuing need for occupational

therapy, then Medicare cannot cover any home health services to the patient (even if

State law requires that the insulin syringes be filled by a licensed nurse).

Home health aide services are those services ordered in the plan of care that the aide is

permitted to perform under State law. Medicare coverage of the administration of insulin

by a home health aide will depend on whether or not the agency is in compliance with all

Federal and State laws and regulations related to this task. However, when the task of

insulin administration has been delegated to the home health aide, the task must be

considered and billed as a Medicare home health aide service. By a State allowing the

delegation of insulin administration to home health aides, the State has extended the role

of aides, not equated aide services with the services of a registered nurse.

D. Assistance With Activities which Are Directly Supportive of Skilled Therapy

Services but Do Not Require the Skills of a Therapist to Be Safely and Effectively

Performed Such as Routine Maintenance Exercises and Repetitive Practice of

Functional Communication Skills to Support Speech-Language Pathology Services

E. Provision of Services Incidental to Personal Care Services not Care of Prosthetic

and Orthotic Devices

When a home health aide visits a patient to provide a health related service as discussed

above, the home health aide may also perform some incidental services which do not

meet the definition of a home health aide service (e.g., light cleaning, preparation of a

meal, taking out the trash, shopping, etc.) However, the purpose of a home health aide

visit may not be to provide these incidental services since they are not health related

services, but rather are necessary household tasks that must be performed by anyone to

maintain a home.

EXAMPLE 1:

A home health aide visits a recovering stroke patient whose right side weakness and poor

endurance cause her to be able to leave the bed and chair only with extreme difficulty.

The physician has ordered physical therapy and speech-language pathology services for

the patient and home health aide services three or four times per week for personal care,

assistance with ambulation as mobility increases, and assistance with repetitive speech

exercises as her impaired speech improves. The home health aide also provides

incidental household services such as preparation of meals, light cleaning and taking out

the trash. The patient lives with an elderly frail sister who is disabled and who cannot

perform either the personal care or the incidental tasks. The home health aide visits at a

frequency appropriate to the performance of the health related services would be covered,

notwithstanding the incidental provision of noncovered services (i.e., the household

services) in the course of the visits.

EXAMPLE 2:

A physician orders home health aide visits three times per week. The only services

provided are light housecleaning, meal preparation and trash removal. The home health

aide visits cannot be covered, notwithstanding their importance to the patient, because the

services provided do not meet Medicare's definition of "home health aide services."