LCD L34562

Coverage Guidance

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

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

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.

42 CFR §409.40-409.49, Subpart E Home Health Services

42 CFR §424.22 Requirements for Home Health Services

CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 7, §40.1.1 General Principles Governing Reasonable and Necessary Skilled Nursing Care and §40.1.2.3 Teaching and Training Activities

CMS Internet-Only Manual, Pub. 100-08, Medicare Program Integrity Manual, Chapter 6, §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

This Local Coverage Determination (LCD) addresses a specific category of skilled nursing care currently available to Medicare home health (HH) beneficiaries with Alzheimer’s disease (AD) and behavioral disturbances – the category of skilled nursing care is called “teaching and training activities.” Teaching and training activities are defined in the Centers for Medicare and Medicaid Services (CMS) Internet-Only Manual (see citation under CMS National Coverage Policy section of this policy) and in the case of the beneficiary population with AD and behavioral disturbances, could be part of a unique beneficiary-centered care plan directed at teaching the family or caregiver how to manage the behavioral disturbances.

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

Behavioral disturbances often complicate the medical management of beneficiaries with AD. At baseline many individuals with AD manifest activity limitations in such domains as communication and self-care. The occurrence of behavioral disturbances, if not addressed in a comprehensive and systematic manner, may further compromise the activity limitations present at baseline resulting in sub-optimal clinical outcomes.

Each behavioral disturbance should be fully characterized and answers to the following questions should be documented in the patient’s medical records:

What is the specific behavioral disturbance being addressed?

What is the frequency of the behavior?

Are there specific situations or activities that “trigger” the behavior?

When does it occur?

Where does it occur?

Who is involved?

Are there other possible explanations for the behavior (e.g., pain, infection, change in medication, disruption in schedule, swallowing difficulties, catastrophic reaction induced by environment or personal interaction)?

What are the consequences of the behavior?

What interventions have been successful in addressing this behavior in the past?

What other techniques or interventions can be used to address the behavior?

Teaching and training interventions should be based on the answers to the above questions, the specific impairment(s) and activity limitation(s) identified for each beneficiary, as well as the ability of the family or caregiver to learn and implement the proposed interventions. Environmental factors impacting the identified behavior(s) and the resultant care plan must also be considered.

The CMS Internet-Only Manual, Pub. 100-02, 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.

In the HH setting, skilled education services are no longer needed if it becomes apparent, after a reasonable period of time, that the patient, family, or caregiver could not or would not be trained. Further teaching and training would cease to be reasonable and necessary in this case and would cease to be considered a skilled service. Notwithstanding that the teaching or training was unsuccessful, the services for teaching and training would be considered to be reasonable and necessary prior to the point that it became apparent that the teaching or training was unsuccessful, as long as such services were appropriate to the patient's illness, functional loss, or injury.

Summary of Evidence

N/A

Analysis of Evidence

N/A

Associated Information

Documentation Requirements

Skilled nursing care is necessary only when (a) the particular patient’s special medical complications require the skills of a registered nurse (RN) or, when provided by regulation, a licensed practical nurse (LPN) to perform a type of service that would otherwise be considered non-skilled; or (b) the needed services are of such complexity that the skills of a RN or, when provided by regulation, a LPN are required to furnish the services. To be considered a skilled service, the service must be so inherently complex that it can be safely and effectively performed only by, or under the supervision of, professional or technical personnel as provided by regulation.

For each HH visit there should be documentation of the need for skilled nursing for teaching and training and the clinical notes should document the patient/caregiver response to any interventions provided. This documentation supporting medical necessity should be legible, maintained in the patient’s medical record, and must be made available to the A/B HHH MAC upon request.

Therefore, the HH clinician must document as appropriate the following:

• 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, including the characterization of target behavior(s) as described under the Coverage Indications, Limitations and/or Medical Necessity section of this LCD

• The patient/caregiver's response to the skilled services provided, and if a family member/caregiver is involved in the patient’s care, the documentation must include both the patient and caregiver’s response to the skilled services provided

• 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

• Any other pertinent characteristics of the beneficiary or home

• A clinical note must be written for each visit.

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 plan of care (POC).

The documentation should describe the goal of the skilled nursing intervention, and at each visit the services provided should support the goal.

Objective measurements of physical outcomes of treatment should be provided and/or a clear description of the changed behaviors due to education programs should be recorded in order that all concerned can follow the results of the applied services.

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. For unsuccessful teaching and training services, the reason(s) why the training was unsuccessful should be documented in the clinical record.

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 recertification are met. Recertifications are needed at least every 60 days when there is a need for continuing home care.

Bibliography

1. Gray KF. Managing agitation and difficult behavior in dementia. Clin in Geriat Med.2004;20(1):69-82.

2. Schaber P. Occupational therapy practice guidelines for adults with Alzheimer's disease and related disorders. 2nd ed. The American Occupational Therapy Association; 2010.