CMS Pub. 100-02, ch. 13, § 190.1

A visiting nurse provides skilled nursing services. The determination of whether a

service requires the skills of a nurse is based on the complexity of the service (e.g.,

intravenous and intramuscular injections or insertion of catheters), the condition of the

patient (e.g., a non-skilled service that, because of the patient’s condition, can only be

safely and effectively provided by a nurse), and accepted standards of medical and

nursing practice. All services must be reasonable and necessary to the diagnosis and

treatment of the patient’s illness or injury within the context of the patient’s unique

medical condition.

A service that can be safely and effectively self-administered or performed by a

nonmedical person without the direct supervision of a nurse, is not considered a skilled

nursing service, even if provided by a nurse.

A service which, by its nature, requires the skills of a nurse to be provided safely and

effectively continues to be a skilled service even if it is taught to the patient, the patient’s

family, or other caregivers. If a patient needs skilled nursing care and there is no one

trained or able and willing to provide it, the services of a nurse would be reasonable and

necessary to the treatment of the illness or injury.

The determination of whether visiting nurse services are reasonable and necessary is

made by the physician based on the condition of the patient when the services were

ordered and what is reasonably expected to be appropriate treatment for the illness or

injury throughout the certification period.