The skilled nursing service 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 theservices 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.
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, home health aide visits or other home health services related to the treatment of their psychiatric diagnosis.
If all other eligibility and coverage requirements under the home health 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 are necessary.
- G0152: Services performed by a qualified occupational therapist in the home health or hospice setting, each 15 minutes.
- G0154: Direct skilled nursing services of a licensed nurse (LPN or RN) in the home health or hospice setting, each 15 minutes.
- G0155: Services of clinical social worker in the home health or hospice setting, each 15 minutes.
- G0156: Services of hom health/hospice aide in the home health or hospice setting, each 15 minutes.
Local Coverage Determination (LCD): Home Health – Psychiatric Care (L31531)
Frequently Asked Questions
- 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 symptoms
- 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.
The Plan of Care 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. Services must be provided under a Home Health Plan of Care approved and signed by the treating physician.
Documentation must be completed by the physician and not the home health agency.
Nursing services provided must meet the part-time or intermittent requirements for home health services. “In most instances, this definition will be met if a patient requires a skilled nursing service at least every 60 days.”
Services must be reasonable and necessary for treating the patient’s psychiatric diagnosis and/or symptoms.
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.
The home health record at each visit should document the need for psychiatric skilled nursing services and treatment. The home health record must also reflect the patient/caregiver response to any intervention provided.
What are the Qualification Requirements for Psychiatrically Trainied Nurses Providing Psychiatric Evaluation and Therapy in the Home?
Palmetto GBA would consider the special training and/or experience requirements to be met, if the registered nurse (RN) meets one of the following criteria:
- An 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 three years) in an acute treatment unit in a psychiatric hospital, psychiatric home care, psychiatric partial hospitalization program or other outpatient psychiatric services.
- An RN with a Bachelor’s degree in nursing and licensed in the state where practicing would qualify. The RN must have one year of recent nursing experience (recommended within the last three years) in an acute treatment unit in a psychiatric hospital, psychiatric home care, psychiatric partial hospitalization program or other outpatient psychiatric services.
- An RN with a Diploma or Associate degree in nursing and licensed in the state where practicing would qualify. The RN must have two years of recent nursing experience (recommended within the last three years) in an acute treatment unit in a psychiatric hospital, psychiatric home care, psychiatric partial hospitalization program or other outpatient psychiatric services.
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.
Nurses with these qualifications would meet the requirements necessary to provide psychiatric evaluation and therapy to
Medicare home health patients. The services of a psychiatric nurse are to be provided under a plan of care established and reviewed by the treating physician.
- A Patient must have an diagnosis as defined in the Diagnostic and Statistical Manual of Mental Health Disorders, 5th Edition, DSM5™. This diagnosis must match the diagnosis that the ordering physician is treating and/or for which the patient was hospitalized. This diagnosis must be fully documented and available in the medical record.
- The DSM5 ™ has combined Axis III with Axes I and II. Clinicians should continue to list medical conditions that are important to the understanding or management of an individual’s mental disorder as opposed to personality disorders, mental retardation, general medical conditions, psychosocial and environmental problems and global assessment of functioning.
- The patient must be under the care of a physician who is qualified to sign the physician’s certification and recertify the plan of care at least every 60 days (two months). The physician’s evaluation and subsequent recertifications must become part of the patient’s medical record.
- If the skills of a psychiatric RN are required, the service must be reasonable and necessary and intermittent.
- 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 plan of care.
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 home health agencies.