Skilled Nursing Visits


	UM Guidelines

Skilled Nursing Visits - Education

Home Health

BlueCross BlueShield of Tennessee developed this guideline to supplement the Milliman Care Guidelines®

BCBST modification effective June 26, 2008*

Added:

Exceptions may be required to comply with EPSDT and TennCare regulations.

Description - Homebound status does not apply to these services.

Skilled nursing visits should be covered for teaching and training activities that require skilled nursing personnel to teach a patient, the patient’s family or caregivers to manage the treatment regimen for a patient’s functional loss, illness or injury. Keep in mind that the test of whether a service is skilled relates to the skill required to teach and not to the nature of what is being taught. Therefore, the skilled nursing visit may be covered if it takes the skills of a nurse to teach the unskilled service.

When it becomes apparent after a reasonable period of time that the patient, family or caregiver will not or is not able to be trained, then further teaching and training would cease to be reasonable and necessary. The reason why the training was unsuccessful should be documented in the record.

Care Planning - Number of visits to approve:

3 visits can be approved initially for teaching and training purposes.

A maximum of 14 visits may be approved upon referral of the case to the Case Manager or Regional or Utilization Management Medical Director, citing:

Service that member is being taught

Problem that is being experienced by member, family and/or caregiver

Recommendation of how many more visits may be needed.

Teaching and training activities:

Teaching and training activities that require the skills of a licensed nurse include, but are not limited to the following:

Teaching the self-administration of injectable medications, or a complex range of medications

Teaching a newly diagnosed or noncompliant diabetic or caregiver all aspects of diabetes management, including how to prepare and to administer insulin injections, to prepare and follow a diabetic diet, to observe foot-care precautions, and to observe for and understand signs of hyperglycemia and hypoglycemia

Teaching wound care where the complexity of the wound, the overall condition of the patient or the ability of the caregiver makes teaching necessary

Teaching care for a recent ostomy or where reinforcement of ostomy care is needed

Teaching self catheterization

Teaching self-administration of gastrostomy or enteral feedings

Teaching care for and maintenance of peripheral and central venous lines and administration of intravenous medications through such lines;

Teaching the proper care and application of any special dressings or skin treatments (for example, dressings or treatments needed by patients with severe or widespread fungal infections, or due to skin deterioration due to radiation treatments)

Teaching home care of recently discharged neonates with special needs (e.g. premature neonates, neonates with apnea monitors, neonates requiring bilirubin lights)

Sources

BlueCross BlueShield of Tennessee network physicians. April - June 2008.

Center of Medicare & Medicaid Services. (2003, October). Medicare Benefit Policy Manual: Home Health Services, Chapter 7, (40.1.2.3, 40.1.2.4 - 40.1.2.9, 40.1.2.1 - 40.1.2.2, 40.2.1 - 40.2.2, 40.2.4, 40.2.3, 50.3). Retrieved March 29, 2004 from http://www.cms.hhs.gov/manuals/Downloads/bp102c07.pdf.

* These guideline(s) have been revised from the Milliman USA Milliman Care Guidelines. The portions of the guideline(s) which have been revised are identified through the use of [insert: italic, boldface, underlined, etc. as appropriate] text, and Milliman USA has neither reviewed nor approved the modified material. Any statement to the contrary or association of the modified material with Milliman USA is strictly prohibited. This document has been classified as public information.

The above information only contains the modified portion of the Milliman Care Guideline. If you wish to view the complete Milliman Care Guideline, please contact Milliman USA.

	Added:


	*Exceptions may be required to comply with EPSDT and TennCare regulations.* Description - Homebound status does not apply to these services. Skilled nursing visits should be covered for teaching and training activities that require skilled nursing personnel to teach a patient, the patient’s family or caregivers to manage the treatment regimen for a patient’s functional loss, illness or injury. Keep in mind that the test of whether a service is skilled relates to the skill required to teach and not to the nature of what is being taught. Therefore, the skilled nursing visit may be covered if it takes the skills of a nurse to teach the unskilled service. When it becomes apparent after a reasonable period of time that the patient, family or caregiver will not or is not able to be trained, then further teaching and training would cease to be reasonable and necessary. The reason why the training was unsuccessful should be documented in the record. Care Planning - Number of visits to approve: 3 visits can be approved initially for teaching and training purposes. A maximum of 14 visits may be approved upon referral of the case to the Case Manager or Regional or Utilization Management Medical Director, citing: Service that member is being taught Problem that is being experienced by member, family and/or caregiver Recommendation of how many more visits may be needed. Teaching and training activities: Teaching and training activities that require the skills of a licensed nurse include, but are not limited to the following: Teaching the self-administration of injectable medications, or a complex range of medications Teaching a newly diagnosed or noncompliant diabetic or caregiver all aspects of diabetes management, including how to prepare and to administer insulin injections, to prepare and follow a diabetic diet, to observe foot-care precautions, and to observe for and understand signs of hyperglycemia and hypoglycemia Teaching wound care where the complexity of the wound, the overall condition of the patient or the ability of the caregiver makes teaching necessary Teaching care for a recent ostomy or where reinforcement of ostomy care is needed Teaching self catheterization Teaching self-administration of gastrostomy or enteral feedings Teaching care for and maintenance of peripheral and central venous lines and administration of intravenous medications through such lines; Teaching the proper care and application of any special dressings or skin treatments (for example, dressings or treatments needed by patients with severe or widespread fungal infections, or due to skin deterioration due to radiation treatments) Teaching home care of recently discharged neonates with special needs (e.g. premature neonates, neonates with apnea monitors, neonates requiring bilirubin lights) Sources BlueCross BlueShield of Tennessee network physicians. April - June 2008. Center of Medicare & Medicaid Services. (2003, October). Medicare Benefit Policy Manual: Home Health Services, Chapter 7, (40.1.2.3, 40.1.2.4 - 40.1.2.9, 40.1.2.1 - 40.1.2.2, 40.2.1 - 40.2.2, 40.2.4, 40.2.3, 50.3). Retrieved March 29, 2004 from http://www.cms.hhs.gov/manuals/Downloads/bp102c07.pdf.