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 §220.127.116.11, to identify specific concepts and examples of management and evaluation, including the following:
- Underlying conditions or potential exacerbation of complications.
- Complexity of the necessary unskilled services (Places the patient at risk for hospitalization or health problem exacerbation).
- Essential non-skilled care (The plan is complex but, unskilled).
- Is part of a Medical Plan of Care?
- Only an RN can assure that the care is followed (No LVN care is permitted).
- Promote patient’s recovery and medical safety (There is an unstable caregiving situation).
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
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:
- Multiple medical diagnoses, co-morbidities, or cultural, physical, or mental health problems
- Limitations in activities of daily living, mental status, etc.
- The examples identified by CMS include “an aged patient with a history of DM and angina pectoris is recovering from an open reduction of the neck of the femur. He requires, among other services, careful skin care, appropriate oral medications, a diabetic diet, a therapeutic exercise program to preserve muscle tone and body condition, and observation to notice signs of deterioration in his condition or complications resulting from his restricted, but increasing mobility.”
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 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 non-skilled 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 care plan oversight?
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 non-skilled care is achieving its purpose.”
- Management and evaluation is a qualifying skilled service provided by an RN only.
- Management and evaluation focuses on safe and effective implementation of a complex, unskilled care plan for a patient who is at increased risk for problem exacerbation or hospitalization.
- Management and evaluation services can be provided along with other skills such as assessment and teaching of patients (beneficiaries), education of caregivers, and direct procedures.
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.