Section 9: Skilled Nursing Medicare Criteria for Skilled Nurse Coverage Medicare reimburses home health agencies for specific nursing services. These include Observation and Assessment, Teaching and Training, and specific Direct Care that requires the skills of a nurse, as well as Management and Evaluation of the Care Plan when nursing skills are required to oversee unskilled care. Specific descriptions and examples can be found in the CMS Medicare Benefit Policy Manual, Chapter 7, Home Health Services Section 40.1. 1. Observation and Assessment “Observation and assessment of the patient’s/client’s condition by a nurse are reasonable and necessary skilled services where there is a reasonable potential for change in a patient’s/client’s condition that requires skilled nursing personnel to identify and evaluate the patient’s/client’s need for possible modification of treatment or initiation of additional medical procedures until the patient’s/client’s clinical condition and/or treatment regimen has stabilized. Where a patient/client was admitted to home health care for skilled observation because there was a reasonable potential of a complication or further acute episode but did not develop a further acute episode or complication, the skilled observation services are still covered for 3 weeks or so long as there remains a reasonable potential for such a complication or further acute episode. Information from the patient’s/client’s home health record must document the rationale that demonstrates that there is a reasonable potential for a future complication or acute episode and, therefore, may justify the need for continued skilled observation and assessment beyond the 3-week period. Such signs and symptoms as abnormal/fluctuating vital signs, weight changes, edema, symptoms of drug toxicity, abnormal/fluctuating lab values, and respiratory changes on auscultation may justify skilled observation and assessment. Where these signs and symptoms are such that there is a reasonable potential that skilled observation and assessment by a licensed nurse will result in changes to the treatment of the patient/client, then the services would be covered. However, observation and assessment by a nurse is not reasonable and necessary for the treatment of the illness or injury where fluctuating signs and symptoms are part of a longstanding pattern of the patient’s/client’s condition which has not previously required a change in the prescribed treatment.” – Medicare Benefit Policy Manual 40.1.2.1 2. Management and Evaluation of a Patient’s/Client’s Care Plan “Skilled nursing visits for management and evaluation of the patient’s/client’s care plan are also reasonable and necessary where underlying conditions or complications require that only a registered nurse can ensure that essential unskilled care is achieving its purpose. For skilled nursing care to be reasonable and necessary for management and evaluation of the patient’s/client’s plan of care, the complexity of the necessary unskilled services that are a necessary part of the medical treatment must require the involvement of skilled nursing personnel to promote the patient’s/client’s recovery and medical safety in view of the patient’s/client’s overall condition.” – Medicare Benefit Policy Manual 40.1.2.2
