ArticlesToolsNewslettersVideosLinks

What is Management and Evaluation?

Since the new G-Codes have been implemented, G-162 has raised questions once again.

Management and evaluation is the Medicare covered qualifying skilled nursing service, introduced in 1989.  Even though it has been around for over two decades, it remains a complex and confusing service, with a history of denials.

In the mid 1990s, during Operation Restore Trust (ORT), many agencies suffered costly denials when the ORT surveyors determined that the service was not properly documented with inadequate reflection of a beneficiary need that was reasonable and necessary. The Recovery Audit Contractors (RAC) are now honing in on medical necessity interventions provided by homecare agencies. Once again there is risk.

To read the coverage criteria, refer to the Medicare Benefit Policy Manual (MBPM)- Chapter 7, Home Health Services §40.1.2.2, to identify specific concepts and examples of management and evaluation, including the following:

Management and evaluation focuses on the implementation, by an RN, of a complex, unskilled care plan for a patient who is at risk because of underlying conditions or complications. that may be manifested in multiple medical diagnoses, limitations physically or mentally, or with other risk factors including safety and environmental.

Underlying complications, at risk of hospitalization

1. The patient must have underlying conditions or complications that place them  at risk for hospitalization or exacerbation of a health problem if the plan is not implemented properly.

Documentation should include:

No example in the manual shows a patient with a single primary diagnosis, thus, HTN or COPD alone does not seem to fit the requirements for this service.

The plan of care MUST be COMPLEX and UNSKILLED.

2. The plan must be complex, unskilled, requiring RN oversight.

Complex care means there are many facets involved in the patient’s care, which is unskilled. There may be many medications, treatments, or pieces of equipment that do not require the skills of a nurse to deliver if each is taught individually but, with another condition that adds risk, an RN is vital to coordinate and oversee a plan to minimize risk for hospitalization.

An example given in the MBPM includes a patient with mild dementia recovering from pneumonia, suffering from an increase in disorientation “has residual chest congestion, decreased appetite, and has remained in bed, immobile, throughout the episode with pneumonia.” In this situation, “skilled oversight of the nonskilled services would be reasonable and necessary pending the elimination of the chest congestion and resolution of the persistent disorientation to ensure the patient’s medical safety.”

The assessing RN must ask herself,  what would happen if the RN was not involved in the careplan oversight?

There is an unstable caregiving situation

3. The caregiving situation is unstable.

An unstable caregiving situation can result from ongoing changes in the plan, the involvement of many services or caregivers, or an unsafe environment that does not provide adequate support. The RN will anticipate caregiver needs or identify potential factors in the  environment that could complicate the patient’s safety or care.  Because of complex situations, multiple diagnoses, and several caregivers, it is frequently the patient’s caregivers who cause or exacerbate the instability. In order to adequately provide the unskilled care, caregivers are needed. They are frequently not readily available or capable of managing a complex plan of care.

It takes the skills of the RN to manage the multiple complex diagnoses or factors and ensure that caregivers implement the complex, unskilled plan properly. Per the Medicare Benefits Policy Manual, “skilled nursing visits for management and evaluation of the patient’s care plan are also reasonable and necessary where underlying conditions or complications require that only a registered nurse can ensure that essential nonskilled care is achieving its purpose.”

Summary:

Remember, in the 1990s this skilled qualifying service was scrutinized heavily. There is reason to believe that this could occur again under MAC or RAC review.

Tags: , , , , ,

8 Responses to “What is Management and Evaluation?”

  1. mary says:

    What is documented on each visit note by the RN? Please send samples for a patient with re-hospitalizations due to pneumonia.

  2. Donna Rose RN says:

    could you send sample plan of care and nurse documentation of patient with poor vision unable to manage medications safely, bil partial amputations to feet, pacemaker, diabetes, CHF, PVD. Private paid sitter to assist with IADLs. Would this patient be a possible candidate for nursing management and evaluation?

  3. carlos zuniga, RN says:

    can a home health aide be used in M&E

  4. su brown says:

    please send visit note samples

  5. staci seddon says:

    How does a home care agency qualify for providing this service?

  6. Chris Perry says:

    While I agree with M&E requiring a RN, what source are you quoting saying that RN’s must do the visits? I have been asked this. When looking at the Medicare Manual it does not state this. Thanks

  7. Janice Matherne says:

    Can an home health aid be provided during and management and evaluation episode?

  8. MARY RUNICE says:

    SEND UPDATED INFORMATION ON REQUIREMENTS FOR M&E ALSO EXAMPLES OF ACCEPTABLE CHARTING/DOCUMENTATION

Leave a Reply

Articles Categories

Educational Articles

Articles this month: Post Hospital Syndrome (Updated): Is Home Health Prepared to Intervene? While... Read more...
View All Select Data's Educational Articles