LCD L34561

Coverage Guidance

Title XVIII of the Social Security Act, §1862(a)(1)(A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Title XVIII of the Social Security Act, §1814(a)(2)(C) Requirements of requests and certifications

Title XVIII of the Social Security Act, §1835(a)(2)(A) Procedure for payment of claims of providers of services

42 CFR §409.42 Beneficiary qualifications for coverage of services

42 CFR §409.43 Plan of care requirements

42 CFR §424.22 Requirements for Home Health Services

CMS Internet-Only Manual, Pub. 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 4, §30.1 Content of the Physician Certification

CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 7, §30.5.1.1 Face-to-Face Encounter, §40.1.1 General Principles Governing Reasonable and Necessary Skilled Nursing Care, §40.1.2.3 Teaching and Training Activities, §40.1.2.15 Psychiatric Evaluation, Therapy, and Teaching, §40.1.3 Intermittent Skilled Nursing Care, §40.2.1 General Principles Governing Reasonable and Necessary Physical Therapy, Speech-Language Pathology Services, and Occupational Therapy, and §50.3 Medical Social Services

CMS Internet-Only Manual, Pub. 100-08, Medicare Program Integrity Manual, Chapter 6, §6.2 Medical Review of Home Health Services, §6.2.1 Physician Certification of Patient Eligibility for the Medicare Home Health Benefit, §6.2.1.1 Certification Requirements, §6.2.2 Physician Recertification, §6.2.2.1 Recertification Elements, §6.2.3 The Use of the Patient's Medical Record Documentation to Support the Home Health Certification, §6.2.5 Medical Necessity of Services Provided, and §6.2.6 Examples of Sufficient Documentation Incorporated Into a Physician's Medical Record

Indications and Limitations of Coverage

Skilled nursing services must be based on the patient's medical condition as described in the Centers for Medicare and Medicaid Services (CMS) Internet-Only Manual (IOM), Medicare Benefit Policy Manual, Pub. 100-02, Chapter 7, §40.1.1.

The evaluation, psychotherapy and teaching activities needed by patients suffering from a diagnosed psychiatric disorder requiring active treatment by a psychiatrically trained nurse may be covered as skilled nursing services. Patients may also require medical social services, occupational therapy (OT), home health aide visits or other home health (HH) services related to the treatment of their psychiatric diagnosis.

If all other eligibility and coverage requirements under the HH benefit are met, skilled nursing services are covered when an individualized assessment of the patient’s clinical condition demonstrates that the specialized judgment, knowledge, and skills of a registered nurse (RN) are necessary.

HH clinical notes must document as appropriate the following:

1. The patient must be confined to the home.

The condition of these patients should be such that there exists a normal inability to leave home and, consequently, leaving the home would require a considerable and taxing effort.

A patient with a psychiatric disorder is considered to be homebound "... if his/her illness is manifested in part by a refusal to leave the home, or is of such a nature that it would not be considered safe for him/her to leave home unattended even if he/she has no physical limitations."

The following conditions support the homebound determination:

• Agoraphobia, paranoia or panic disorder

• Disorders of thought processes wherein the severity of delusions, hallucinations, agitation and/or impairment of thoughts/cognition grossly affect the patient’s judgment and decision making, and therefore the patient’s safety

• Acute depression with severe vegetative symptom

• Psychiatric problems associated with medical problems that render the patient homebound.

If a patient does in fact leave the home, the patient may, nevertheless, be considered homebound if the absences from the home are infrequent or for relatively short duration, or are attributable to the need to receive medical treatment.

2. Services must be provided under a HH Plan of Care (POC) approved and signed by the treating physician.

3. Nursing services provided must meet the part-time or intermittent requirements for HH services. "In most instances, this definition will be met if a patient requires a skilled nursing service at least every 60 days."

4. Services must be reasonable and necessary for treating the patient's psychiatric diagnosis and/or symptoms.

5. The services of a skilled psychiatric nurse must be required to provide the necessary care, i.e., observation/assessment, teaching/training activities, management and evaluation of a patient care plan, or direct patient care of a diagnosed psychiatric condition which may include behavioral/cognitive interventions.

6. Further guidance on required documentation may be found in the CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 7, §40.1.2.15.

Note: Psychiatric nursing must be furnished by an agency that does not primarily provide care and treatment of mental disorders. These agencies are precluded from participating as Medicare HH agencies.

QUALIFICATIONS FOR PSYCHIATRICALLY TRAINED NURSES PROVIDING PSYCHIATRIC EVALUATION AND THERAPY IN THE HOME

1. Psychiatrically trained nurses are nurses who have special training and/or experience beyond the standard curriculum required for a RN. The services of the psychiatric nurse are to be provided under a POC established and reviewed by a physician.

2. This A/B HHH MAC would consider the special training and/or experience requirements to be met, if the RN meets 1 of the following criteria:

• A RN with a Master’s degree with a specialty in psychiatric or mental health nursing and licensed in the state where practicing would qualify. The RN must have nursing experience (recommended within the last 3 years) in an acute treatment unit in a psychiatric hospital, psychiatric home care, psychiatric partial hospitalization program or other outpatient psychiatric services.

• A RN with a Bachelor’s degree in nursing and licensed in the state where practicing would qualify. The RN must have 1 year of recent nursing experience (recommended within the last 3 years) in an acute treatment unit in a psychiatric hospital, psychiatric home care, psychiatric partial hospitalization program or other outpatient psychiatric services.

• A RN with a Diploma or Associate degree in nursing and licensed in the state where practicing would qualify. The RN must have 2 years of recent nursing experience (recommended within the last 3 years) in an acute treatment unit in a psychiatric hospital, psychiatric home care, psychiatric partial hospitalization program or other outpatient psychiatric services.

3. It is highly recommended that psychiatric RNs also have medical/surgical nursing experience, because many psychiatric patients meet homebound criteria due to a physical illness.

4. Nurses with these qualifications would meet the requirements necessary to provide psychiatric evaluation and therapy to Medicare HH patients. The services of a psychiatric nurse are to be provided under a POC established and reviewed by the treating physician.

5. For additional information, see the Article Text subsection BILLING WHEN SEPARATE VISITS WERE MADE FOR MEDICAL AND PSYCHIATRIC NURSING CARE section of the Billing and Coding: Home Health - Psychiatric Care A56756 article.

Diagnostic Criteria

1. The patient must be under the care of a physician who is qualified to sign the physician’s certification and recertify the POC at least every 60 days (2 months). The physician's evaluation and subsequent recertifications must become part of the patient's medical record.

2. If the skills of a psychiatric RN are required, the service must be reasonable and necessary and intermittent.

3. Reasonable goals must be established, and there must be a reasonable expectation that the goals will be achieved. Decreasing and/or shortening inpatient and emergency room care may be a goal for the psychiatric patient's POC.

Home Health POC

The POC for a psychiatric patient must be completed. Emphasis must be placed on documentation of mental status and those skills necessary to treat the psychiatric diagnosis.

Psychiatric Interdisciplinary Team's Role

Physician

1. Certifies/Recertifies the patient’s homebound status.

2. Approves HH POC, which must be signed and dated prior to the HH agency billing for services.

3. Prescribes medications as necessary.

4. Provides supplemental orders when medically necessary.

Skilled Nursing Care

Registered Psychiatric Nurse

1. Makes initial assessment visit utilizing observation/assessment skills.

2. Manages medical illness per POC; performs psycho-biological interventions.

3. Evaluates, teaches and reviews medications and compliance; administers intramuscular (IM) or intravenous (IV) medication.

4. Manages situational or other crises; performs assessments of potential self-harm or harm to others and refers to the treating physicians as necessary.

5. Teaching and training activities that require skilled nursing personnel to teach a patient, the patient's family, or caregivers how to manage the treatment regimen would constitute skilled nursing services.

• Teaches self-care, mental and physical well-being, promotes independence and patient’s rights.

The CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 7, §40.1.2.3 provides guidance in determining the reasonableness and necessity of the number of training visits and the appropriateness of re-teaching and re-training.

6. Promotes and encourages patient/caregiver to maintain a therapeutic environment.

7. Provides supportive counseling psychotherapy and psycho-therapeutic interventions according to education and licensure. Provides psychoeducation, such as teaching/training with disease process, symptom and safety management, coping skills and problem solving.

8. Provides evaluation and management of the patient's care plan.

9. Counseling services may be rendered by either a trained psychiatric nurse or a social worker. These services should not be duplicative. Concurrent counseling or psychotherapy services by multiple providers are not medically necessary.

10. Although intervention with family members may be appropriate on occasion, services by a trained psychiatric nurse to family members are not covered as a HH benefit, even if the patient will benefit.

Medical Social Services

Medical social services provided by a qualified medical social worker (MSW) or a social work assistant under the supervision of a qualified MSW, may be covered as HH services when all of the following apply:

• The patient meets the qualifying criteria for coverage of HH services.

• The services of these professionals are necessary to resolve social or emotional problems which are, or are expected to be, an impediment to the effective treatment of the patient's psychiatric condition or his/her rate of recovery.

• The POC clearly indicates that the skills of a qualified MSW (or a social worker assistant under the supervision of a qualified MSW) are required to safely and effectively provide the needed care.

When the above requirements are met, coverage for social worker visits may include, but are not limited to the following:

• Assessment of the need for care related to the social and emotional factors associated with the patient's illness, the actual need for care, adjustment to the care and the response to the treatment along with the assessment of the patient's financial resources, home situation, and the availability of community resources.

• Counseling services that are required by the patient for the treatment of their psychiatric condition (Psychotherapy services, constituting active treatment of the psychiatric condition, may be provided by MSWs).

• Brief counseling (2 or 3 visits) of the patient's family or caregiver(s) when they are reasonable and necessary to resolve problems that are a clear and direct impediment to the treatment of the patient's illness or injury or rate of recovery.

• Appropriate action to obtain available community resources to assist in resolving the patient's problem.

Note: Medicare does not cover the services of a MSW to assist in filing the application for Medicaid or follow up on the application. Federal regulation requires the state to provide assistance in completing the application to anyone who chooses to apply for Medicaid.

Note: A patient may require separate and distinct services provided by a skilled psychiatric nurse and a MSW. However, care must be used to avoid duplication of services that could be provided by both of these disciplines, e.g., counseling of the patient.

Home Health Aide (HHA)

HHAs may perform personal care or other covered HHA services.

Occupational Therapist (OT)

1. The skills of an OT may be required to decrease or eliminate limitations in functional activity imposed by psychiatric illness or disability. OTs may address factors which interfere with the performance of specific functional activities due to cognitive, sensory, psychosocial or perceptual deficits.

Additional guidance on these services and the accepted standards may be found in the CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 7, §40.2.1.

2. The skills of an OT to assess and reassess a patient’s rehabilitation needs and potential, or to develop and/or implement an OT plan are covered when they are reasonable and necessary because of the patient’s condition.

3. The planning, implementing and supervision of therapeutic programs (including, but not limited to those listed below) are skilled OT services. As such, these services are covered, if they are reasonable and necessary for the treatment of the patient's illness or injury.

a. Selecting and teaching task oriented, therapeutic activities designed to restore and increase cognitive abilities and functional participation in activities of daily living (ADLs) and advanced ADLs

b. Planning, implementing and supervising therapeutic tasks and activities designed to restore sensory-integrative function

c. Planning, implementing and supervising of individualized therapeutic activity programs (as well as, adapting to the environment) as part of an overall “active treatment” program for a patient with a diagnosed psychiatric illness

d. Assessing and planning for improved home safety.

Maintenance Program

Coverage of therapy services, including OT services, for a maintenance program is based on the individual's need for skilled care in that maintenance program as described in the CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 7, §40.2.1.

Concurrent Admission to HH and Partial Hospitalization Program (PHP)

Because partial hospitalization services are intended to meet all of the patient's psychiatric care needs, patients admitted to a PHP are not generally considered appropriate for psychiatric HH services. Medical necessity must be substantiated on a case-by-case basis. If there are concurrent admissions, the HH claims will be reviewed to verify the medical necessity of the service(s) provided and that the homebound criterion is met.

Discharge Criteria

Patients should cease receiving psychiatric HH services when:

1. Physician orders discharge

2. Patient discontinues/refuses service with physician or nurse

3. Patient is not compliant with the treatment plan, despite appropriate provider interventions

4. Patient/family requests discharge

5. The treatment objectives and stated functional outcome goals have been attained or are no longer attainable

6. The patient is no longer homebound

7. Other appropriate discharge protocols, e.g., the patient moves or is transferring to another agency, etc.

8. A maintenance program is established, if appropriate.

Psychiatric Nursing in Group Setting

Group interventions for psychiatric HH patients are not covered under the HH benefit. The POC and treatment must be individualized.

Summary of Evidence

N/A

Analysis of Evidence

N/A

Associated Information

Documentation Requirements

A clinical note must be written for each HH visit. The HH clinical notes must document as appropriate:

• the history and physical exam pertinent to the day’s visit, (including the response or changes in behavior to previously administered skilled services) and the skilled services applied on the current visit, and

• the patient/caregiver’s response to the skilled services provided

If a family member/caregiver is involved in the patient’s care, the documentation must also include this, and

• the plan for the next visit based on the rationale of prior results,

• a detailed rationale that explains the need for the skilled service in light of the patient’s overall medical condition and experiences,

• the complexity of the service to be performed, and

• any other pertinent characteristics of the beneficiary or home

Clinical notes should be written so that they adequately describe the reaction of a patient to his/her skilled care. Clinical notes should also provide a clear picture of the treatment, as well as “next steps” to be taken. Vague or subjective descriptions of the patient’s care should not be used. For example, terminology such as the following would not adequately describe the need for skilled care:

• Patient tolerated treatment well

• Caregiver instructed in medication management

• Continue with POC

In order for HH patients to be eligible to receive services under the Medicare HH benefit, the following must be documented for certification/recertification:

a) Patient is under a physician's care

b) Homebound status-with documentation of confinement to home in medical records

c) Established POC-must be signed and dated by the certifying physician

d) Face-to-Face-no more than 90 days prior or 30 days after start of HH care

e) Skilled need-services must be medically necessary, and documentation of the skilled need should be in the patient's medical records

If the requirements for certification are not met, then claims for subsequent episodes of care, which require a recertification, will not be covered- even if the requirements for recertifications are met. Recertifications are needed at least every 60 days, when there is a need for continuing home care.

1. Documentation must be legible, relevant and sufficient to justify the services billed. In general, services must be covered therapy services provided according to Medicare requirements.

2. Legible documentation should be brief and factual. Use descriptive charting: be problem specific.

3. Legible documentation should clearly support the medical necessity for services.

4. Each visit note should include legible documentation of any psychiatric or medical assessment, an evaluation of the patient’s mental status, level of function and progress toward goals. Document objectively when describing behaviors and/or findings.

5. Legibly document changes in the patient’s condition and the actions taken, e.g., notification of the physician.

6. Legibly document the assessment of home milieu and supportive environment.

7. Teaching has to be directed at improving function. Document identified teaching needs in response to psychiatric symptoms. Document all patient/family education, the reason for education, what was taught, and the patient’s response. If repetitive teaching is required, documentation must clearly show the medical necessity of that teaching. Where it becomes apparent after a reasonable period of time that the patient, family, or caregiver will not or is not able to be trained, then further teaching and training would cease to be reasonable and necessary. The reason why the training was unsuccessful should be documented in the record.

8. Document the patient’s understanding and compliance of the medication regimen and treatment plan, and how verified.

9. Document the administration of IM and/or IV medications, their effectiveness, and any side effects of the patient's medication regime.

10. Document patient safety issues.

11. Documentation should show that periodic venipuncture for blood levels for psychiatric medications, such as Lithium, Tegretol®, Clozaril® and others, and other related laboratory work, are performed when necessary and pertinent reports of results are in the medical record. This ensures patient compliance and appropriate therapeutic levels. The frequency of testing should be consistent with acceptable standards of medical practice for continued monitoring of a diagnosis, medical problem, or treatment regimen. The HH record must document the rationale for the blood draw as well as the results of the test(s).

12. The person rendering the service must sign each visit note. If psychiatric services were rendered it must have been performed by a psychiatric RN.

Utilization Guidelines

1. For patients with Alzheimer’s disease, please refer to the Local Coverage Determination (LCD) Home Health Skilled Nursing Care-Teaching and Training: Alzheimer’s Disease and Behavioral Disturbances L34562.

2. The POC and/or Outcome and Assessment Information Set (OASIS) should include whether the therapy is rehabilitative/restorative or maintenance.

Bibliography

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Health Disorders, 5th Edition, DSM-5™. Arlington, VA: American Psychiatric Association;2013.