G0151 SERVICES PERFORMED BY A QUALIFIED PHYSICAL THERAPIST IN THE HOME HEALTH OR HOSPICE SETTING, EACH 15 MINUTES
G0152 SERVICES PERFORMED BY A QUALIFIED OCCUPATIONAL THERAPIST IN THE HOME HEALTH OR HOSPICE SETTING, EACH 15 MINUTES
G0299 DIRECT SKILLED NURSING SERVICES OF A REGISTERED NURSE (RN) IN THE HOME HEALTH OR HOSPICE SETTING, EACH 15 MINUTES
G0300 DIRECT SKILLED NURSING SERVICES OF A LICENSE PRACTICAL NURSE (LPN) IN THE HOME HEALTH OR HOSPICE SETTING, EACH 15 MINUTES
Coverage Indications, Limitations, and/or Medical Necessity
The process of falls evaluation and intervention is a complex task for which there exists evidence-based procedures. The translation of these evidence-based procedures into clinical care, however, has been limited by an incomplete understanding of Medicare coverage rules. While no Medicare benefit category exists for a specific suite of “falls evaluation and intervention” services, some evidence-based falls evaluation and intervention procedures utilize home-based components that may be covered by Medicare with the appropriate documentation. The goal of this policy is to provide the framework for covered skilled nursing, physical therapy, and occupational therapy evaluations and interventions in the population of Medicare beneficiaries with a history of falls.
The complexity of both the evidence-based fall evaluations and interventions and the applicable Medicare coverage instructions, require that documentation be as patient-centered as possible (i.e., reflect the unique needs and circumstances of the patient and the available therapeutic options). The coverage of component, skilled services requires that beneficiaries first be eligible for an existing Medicare defined benefit and then under a physician’s order receive covered services that are “reasonable and necessary” with regard to amount, type, frequency and duration.
Home Health Benefit (Bill type 32X):
Once eligibility for the Medicare Home Health Benefit has been established, physicians may request that Medicare-certified Home Health Agency (HHA) evaluate the circumstances of fall events and establish a plan of care to intervene by identifying and modifying known risk factors for fall events. The skilled nursing service and/or a therapist 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. To be considered reasonable and necessary for the diagnosis or treatment of the patient’s illness or injury, the services must be consistent with the nature and severity of the illness or injury, the patient’s particular medical needs, and accepted standards of medical and nursing practice. The determination of whether the services are reasonable and necessary should be made in consideration that a physician has determined that the services ordered are reasonable and necessary. The services must, therefore, be viewed from the perspective of the condition of the patient when the services were ordered and what was, at that time, reasonably expected to be appropriate treatment for the illness or injury throughout the certification period. A patient’s overall medical condition, without regard to whether the illness or injury is acute, chronic, terminal, or expected to extend over a long period of time, should be considered in deciding whether skilled services are needed. A patient’s diagnosis should never be the sole factor in deciding that a service the patient needs is either skilled or not skilled. Skilled care may, depending on the unique condition of the patient, continue to be necessary for patients whose condition is stable. The documentation of each component service must substantiate the need for the skilled services, be specified in the care plan and not be duplicative. 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. Beneficiary-appropriate goals and objectives, with measurable outcomes must be included in the documentation. Documentation must also show that the skills of a nurse or therapists are required. 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. If the measurement results do not reveal progress toward therapy goals and/or do not indicate that therapy is effective, but therapy continues, the qualified therapist(s) must document why the physician and therapist have determined therapy should be continued.
Coverage of skilled nursing care does not turn on the presence or absence of a patient’s potential for improvement from the nursing care, but rather on the patient’s need for skilled care.
Skilled nursing and/or therapy services may be necessary to improve a patient’s current condition, to maintain the patient’s current condition, or to prevent or slow further deterioration of the patient’s condition.
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.
In determining the reasonable and necessary number of teaching and training visits, consideration must be given to whether the teaching and training provided constitutes reinforcement of teaching provided previously in an institutional setting or in the home or whether it represents initial instruction. Where the teaching represents initial instruction, the complexity of the activity to be taught and the unique abilities of the patient are to be considered. Where the teaching constitutes reinforcement, an analysis of the patient’s retained knowledge and anticipated learning progress is necessary to determine the appropriate number of visits. Skills taught in a controlled institutional setting often need to be reinforced when the patient returns home. Where the patient needs reinforcement of the institutional teaching, additional teaching visits in the home are covered.
Re-teaching or retraining for an appropriate period may be considered reasonable and necessary where there is a change in the procedure or the patient’s condition that requires re-teaching, or where the patient, family, or caregiver is not properly carrying out the task. The medical record should document the reason that the re-teaching or retraining is required and the patient/caregiver response to the education.
Part B Outpatient Therapy Benefit (Bill type 34X):
Medicare beneficiaries not meeting the eligibility criteria for the Home Health Benefit, but otherwise in need of Medicare-covered, home-based therapy services for the evaluation and intervention of falls, may be eligible for the component physical and occupational therapy services available through the Part B outpatient Medicare benefit. Assuming all other eligibility and coverage criteria have been met, the skilled therapy services must be reasonable and necessary to the treatment of the patient’s illness or injury within the context of the patient’s unique medical condition.
To be considered reasonable and necessary for the treatment of the illness or injury:
a. The services must be consistent with the nature and severity of the illness or injury, the patient’s particular medical needs, including the requirement that the amount, frequency, and duration of the services must be reasonable; and
b. The services must be considered, under accepted standards of medical practice, to be specific, safe, and effective treatment for the patient’s condition, meeting the standards” listed in Publication 100-02, Chapter 7, Section 40.2.1. The home health record must specify the purpose of the skilled service provided.
if it becomes apparent at some point that the goal set for the patient is no longer a reasonable one, then the treatment goal itself should be promptly and appropriately modified to reflect this, and the patient should then be reassessed to determine whether the treatment goal as revised continues to require the provision of skilled services.
Coverage of therapy services (not an assistant) to perform a maintenance program is not determined solely on the presence or absence of a beneficiary’s potential for improvement from the therapy, but rather on the beneficiary’s need for skilled care. Assuming all other eligibility and coverage requirements are met, skilled therapy services are covered when an individualized assessment of the patient’s clinical condition demonstrates that the specialized judgment, knowledge, and skills of a qualified therapist (“skilled care”) are necessary for the performance of a safe and effective maintenance program. Such a maintenance program to maintain the patient’s current condition or to prevent or slow further deterioration is covered so long as the beneficiary requires skilled care for the safe and effective performance of the program. When, however, the individualized assessment does not demonstrate such a necessity for skilled care, including when the performance of a maintenance program does not require the skills of a therapist because it could safely and effectively be accomplished by the patient or with the assistance of non-therapists, including unskilled caregivers, such maintenance services will not be covered.
Palmetto GBA recommends use of the concepts contained within the World Health Organization’s (WHO’s) International Classification of Functioning, Disability, and Health (ICF) to organize the necessary data and communicate the patient-centered information describing the unique health status of each beneficiary. Such communication is critical to both documenting and delivering reasonable and necessary home-based Medicare services to the heterogeneous population of Medicare beneficiaries experiencing fall events.
The component Home Health skilled nursing services (e.g., “observation and assessment”) and the corresponding skilled therapy services must adhere to the coverage criteria outlined in the CMS Manual System, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 7 – Home Health Services, Sections 40.1 and 40.2 respectively. The component Outpatient skilled physical and occupational therapy services must adhere to the CMS Manual System, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §§220-230.2. For unsuccessful interventions the reason(s) why the intervention(s) were unsuccessful should be documented in the record.