Download clinical training - AT HOME HEALTH, Inc.

COVERAGE OF SERVICES
“SKILLED NURSING”
Provided by:

Registered Nurses

Licensed Practical Nurse (under the Supervisor of a Registered Nurse)
Covered Services:
1.
Intravenous and intra-muscular injections
2.
Insertion of catheter
3.
Providing an enema if a patient is an irritable bowel syndrome patient recovering
from rectal surgery.
4.
Changing colostomy bags
5.
Open wounds requiring dressing changes
6.
Insulin injections (blind, cripple, crazy)
7.
Teaching catheter malfunction
8.
Terminally ill patient with malignant melanoma requiring skilled observation,
assessment, teaching and treatment.
9.
MS patient with exacerbation needs skilled nursing to teach meds and measures to
overcome urinary retention.
10.
Evaluating the NEED to modify a treatment program or initiation of an additional
medical procedure (skilled observation coverage = 3 weeks - qualify)
COVERAGE OF SERVICES
EXAMPLES OF SKILLED OBSERVATIONS:
A.
1.
Fluctuating Vital Signs
2.
Weight Changes
3.
Edema
4.
Drug Toxicity
5.
Fluctuating Lab Values
6.
Respiratory changes on auseulaxation
NOTE:
Observation MUST result in changes in treatment.
Not covered for long standing pattern and there is no attempt to change treatment.
B. Monitoring nutrition for a pneumonia patient because patient will not eat or eats poorly –
monitoring intake of fluid and need for tube feeding.
Must observe:
-Oral intake
-Output and Hydration
C. HTN patient who requires skilled observation and monitoring of BP who has suffered
dizziness. Physician has discharged meds due to decreased BP. Nurse observes to be
sure the patient is stable and BP is in desired range.
D. Patient with glaucoma and who has a cardiac condition needs skilled nursing to monitor
interaction between eye drops for glaucoma condition and cataracts and the betablocker for the cardiac condition (patient is at risk for arrhythmic).
E. PVD (including by-pass) – Skilled Nursing needs to monitor the vascular supply to the
legs and the incision site.
F. Heart Attack Patient - Skilled Nursing needs to monitor whether exertion will
exacerbate the heart disease.
G. CHF patient requires the Skilled Nurse to observe for signs of adverse effects of
medication. Skilled Nursing needs to determine whether drug regimen should be
modified.
H. Patient with low DM and Angina recovering from open reduction of the neck and _____
needs Skilled Nursing for careful skin care, oral meds, diabetic diet and exercise
COVERAGE OF SERVICES
SKILLED NURSING
TEACHING / TRAINING

If a patient has a long-standing inability to self-administer insulin it is NOT reasonable to
try to teach patient, unless patient has had a recent change in mental status or another
problem. (i.e. Patient has recently lost the use of his dominant hand.)

If patient teaching is unsuccessful you must document the reason training and teaching
were unsuccessful.

The medical record must always include why re-teaching / retraining is necessary.

Must specify whether this teaching is initial instruction and why teaching at this time is
necessary.
NOTE:
All teaching POST hospitalization is covered.
COVERAGE OF SERVICES
Teaching and training activities that
REQUIRE the skills of a licensed nurse include, but are not limited to, the following:
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Teaching the self-administration of injectable medications or a complex range of
medications;
Teaching a newly-diagnosed diabetic or caregiver all aspects of diabetes management,
including how to prepare and administer insulin injections, prepare and follow a diabetic
diet, observe foot-care precautions, and observe for and understand signs of
hyperglycemia and hypoglycemia;
Teaching self-administration of medical gases;
Teaching wound care where the complexity of the wound, the overall condition of the
patient, or the ability of the caregiver makes teaching necessary.
Teaching care for a recent ostomy or where reinforcement of ostomy care is needed;
Teaching self-catheterization;
Teaching self-administration of gastrostomy or enteral feedings;
Teaching care for and maintenance of peripheral and central venous lines and
administration of intravenous medications through such lines;
Teaching bowel or bladder training when bowel or bladder dysfunction exists;
Teaching how to perform the activities of daily living when the patient or caregiver must
use special techniques and adaptive devices due to a loss of function;
Teaching transfer techniques, e.g., from bed to chair, that are needed for safe transfer;
Teaching proper body alignment and positioning, and turning techniques of a bedbound patient;
Teaching ambulation with prescribed assistive devices (such as crutches, walker, cane,
etc.) that are needed due to a recent functional loss;
Teaching prosthesis care and gait training;
Teaching the use and care of braces, splints and orthotics, and associated skin care;
Teaching the proper care and application of any specialized dressings or skin
treatments (for example, dressings or treatments needed by patients with severe or
widespread fungal infections, active and severe psoriasis or eczema, or due to skin
deterioration from radiation treatments);
Teaching the preparation and maintenance of a therapeutic diet; and
Teaching proper administration of oral medications, including signs of side effects and
avoidance of interaction with other medications and food.
COVERAGE OF SERVICES
Administration of Medications
Although drugs and biologicals are specifically excluded from coverage by the statute
(§1861(m)(5) of the Social Security Act), the services of a licensed nurse that are required to
administer medications safely and effectively may be covered if they are reasonable and
necessary to the treatment of the illness or injury.
Intravenous, intra-muscular, or subcutaneous injections and infusions, and hypodermoclysis or
intravenous feedings require the skills of a nurse to be performed (or taught) safely and
effectively. Where these services are reasonable and necessary to treat the illness or injury,
they may be covered. For these services to be reasonable and necessary, the medication
being administered must be accepted as safe and effective treatment of the patient's illness or
injury, and there must be a medical reason that the medication cannot be taken orally.
Moreover, the frequency and duration of the administration of the medication must be within
accepted standards of medical practice or there must be a valid explanation regarding the
extenuating circumstances to justify the need for the additional injections.
COVERAGE OF SERVICES
SKILLED NURSING - COVERED SERVICES
1.
Vit Biz injections for specified anemias, pernicious anemia, megaloblastic anemias,
macrocytic anemias, fish tapenomy anemia – certain neuropathy.
Covered
2.
Pre-filling syringes for insulin (unless it is state law that a nurse is required to pre-fill),
usually
NOT Covered
3.
Eye Drops / Ointments
4.
Tube feedings
Covered
5.
Nasopharengal and tracheostomy aspiration
Covered
6.
Foley Catheter
usually
Covered
skilled once every 30
days
7.
Silicone Catheter
usually
Covered
once every 60-90 days
8.
Wounds
(See pages)
9.
Heat Treatments
Specifically ordered by the MD
10.
Administration of Medical Gases and Skilled Observation for reaction to gases
Covered
11.
Veripuncture -(in isolation)
NOT Covered
but where the collection of a specimen is necessary to the diagnosis and treatment of
the patient’s illness is covered.
NOT Covered
For Example:
To monitor:
 Catapril as med to monitor WB Cell count (every 3 months)
 Dilantin levels to check toxicity
 FBS levels
 Monitor stable non-insulin dependent diabetics every 2-3 months.
 Prothrombin levels where the documentation shows that the dosage is being
adjusted – once stable, monthly monitoring would be appropriate.
Student Nurse Visits
-
See #11