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Management and Evaluation

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.

 

Even though it has been a reimbursable service since 1989, Management and Evaluation (Code G-0162) remains a complex and confusing service, with a history of denials.

The History of Management and Evaluation 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.

To read the coverage criteria, refer to the Medicare Benefit Policy Manual (MBPM)- Chapter 7, Home Health Services §40.1.2.2:

“Management and Evaluation of a Patient Care Plan (Rev. 179, Issued: 01-14-14, Effective: 01-07-14, Implementation: 01-07-14) A3-3118.1.B.2, HHA-205.1.B.2 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 unskilled care is achieving its purpose. For skilled nursing care to be reasonable and necessary for management and evaluation of the patient’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 recovery and medical safety in view of the patient’s overall condition.”

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.

The Plan Must be Complex, Unskilled, Requiring RN Oversight

Complex care means there are many facets involved in the patient’s care. 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. 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.”

G-0162Skilled services by a licensed nurse (RN only) for management and evaluation of the plan of care, each 15 minutes (the patient’s underlying condition or complication requires an RN to ensure that essential non-skilled care achieves its purpose in the home health or hospice setting).

Sources

Frequently Asked Questions

What are some examples of Management and Evaluation Scenarios?

EXAMPLE 1

An aged patient with a history of diabetes mellitus 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. Although a properly instructed person could perform any of the required services, that person would not have the capability to understand the relationship among the services and their effect on each other. Since the combination of the patient’s condition, age, and immobility create a high potential for serious complications, such an understanding is essential to ensure the patient’s recovery and safety. The management of this plan of care requires skilled nursing personnel until nursing visits are not needed to observe and assess the effects of the non-skilled services being provided to treat the illness or injury until the patient recovers. Where nursing visits are not needed to observe and assess the effects of the non-skilled services being provided to treat the illness or injury, skilled nursing care would not be considered reasonable and necessary, and the management and evaluation of the care plan would not be considered a skilled service.

EXAMPLE 2

An aged patient with a history of mild dementia is recovering from pneumonia which has been treated at home. The patient has had an increase in disorientation, has residual chest congestion, decreased appetite, and has remained in bed, immobile, throughout the episode with pneumonia. While the residual chest congestion and recovery from pneumonia alone would not represent a high risk factor, the patient’s immobility and increase in confusion could create a high probability of a relapse. In this situation, skilled oversight of the unskilled 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. For this determination to be made, the home health documentation must describe the complexity of the unskilled services that are a necessary part of the medical treatment and which require the involvement of a registered nurse in order to ensure that essential unskilled care is achieving its purpose. Where visits by a licensed nurse are not needed to observe and assess the effects of the unskilled services being provided to treat the illness or injury, skilled nursing care would not be considered reasonable and necessary to treat the illness or injury.

EXAMPLE 3

A physician orders one skilled nursing visit every 2 weeks and three home health aide visits each week for bathing and washing hair for a patient whose recovery from a CVA has left him with residual weakness on the left side. The cardiovascular condition is stable and the patient has reached the maximum restoration potential. There are no underlying conditions that would necessitate the skilled supervision of a licensed nurse in assisting with bathing or hair washing. The skilled nursing visits are not necessary to manage and supervise the home health aide services and would not be covered.

What are does supporting documentation need to 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.

Helpful Tip


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.

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