Skilled Nursing Visits


	UM Guidelines

Skilled Nursing Visits - Invasive

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 - Members should be homebound for these services unless otherwise noted.

Those services requiring the skills of a registered nurse or a licensed practical nurse under the supervision of a registered nurse. The skilled nursing services 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.

Examples of Invasive Services are:

Intravenous or Intramuscular Medications – medication being administered must be accepted as safe and effective treatment of the patient’s illness or injury, and there must be a medical reason that the medication cannot be taken orally. The frequency and duration of the administration of the medication must be within accepted standards of medical practice, or there must be a valid explanation regarding the extenuating circumstances to justify the need for the additional dosage. (These members may or may not be homebound with intravenous (IV) and/or intramuscular (IM) medications).

Tube Feedings – for replacement or adjustment of the feeding tube, as well as training family to give the feeding.

Catheters – insertion and sterile irrigation and replacement of catheters, care of a suprapubic catheter and/or urethral catheter. Foley catheters generally require skilled care once every 60-90 days and this frequency of service would be considered reasonable and necessary. Where there are complications, more frequent visits may be required.

Wound Care – Care of wounds when the skills of a licensed nurse are needed to provide safely and effectively the services necessary to treat the illness or injury is considered to be a skilled service (see Wound Care UM Guidelines for Home Health & Outpatient). In order for skilled care to be reasonable and necessary to treat a wound, the size, depth, nature of drainage (color, odor, consistency, and quantity), and condition and appearance of the skin surrounding the wound must be documented in the clinical findings so that an assessment of the need for skilled nursing can be made. The plan of care must contain the specific instructions for the treatment of the wound. The following wound characteristics are usually reasonable and necessary:

Open wounds which are draining purulent or colored exudates or have a foul odor present or for which the patient is receiving IV antibiotic therapy;

Wounds with a drain or T-tube which requires shortening or movement of such drain;

Wounds which require irrigation or instillation of a sterile cleansing or medicated solution into several layers of tissue and skin and/or packing with sterile gauze;

Recently débrided ulcers;

Pressure sores (decubitus ulcers) with the following characteristics:

Partial tissue loss with signs of infection such as foul odor or purulent drainage;

There is full thickness tissue loss that involves exposure of fat or invasion of other tissue such as muscle or bone;

Wounds with exposed internal vessels or a mass that may have a proclivity for hemorrhage when a dressing is changed (e.g. post radical neck surgery, cancer of the vulva);

Skin conditions that require application of nitrogen mustard or other chemotherapeutic medication that present a significant risk to the patient;

Other open or complex wounds that require treatment that can only be provided safely and effectively by a licensed nurse;

Post-operative wounds where there are complications such as infection.

IV line maintenance if family and/or caregiver is not available or is unwilling to perform.

NOTE: Wounds or ulcers that show redness, edema, and induration, at times with epidermal blistering or desquamation do not ordinarily require skilled nursing care.

Venipunctures should be associated with the specific symptom or diagnosis, or the documentation should clarify the need for the test when it is not diagnosis/illness specific. The treatment must be recognized as being reasonable and necessary to the treatment of the illness or injury. The member needs to be homebound in order to get these services.

Example: Venipunctures for Prothrombin times following Total Hips. Total hip surgeries leave the member as homebound for a period of 2 weeks. The prothrombin level needs to be checked 4 times during this 2-week period. If requested after this period of time, there needs to be adequate documentation regarding homebound status.

Total Knee replacements are not considered homebound for venipunctures.

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 - Members should be homebound for these services unless otherwise noted. Those services requiring the skills of a registered nurse or a licensed practical nurse under the supervision of a registered nurse. The skilled nursing services 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. Examples of Invasive Services are: Intravenous or Intramuscular Medications – medication being administered must be accepted as safe and effective treatment of the patient’s illness or injury, and there must be a medical reason that the medication cannot be taken orally. The frequency and duration of the administration of the medication must be within accepted standards of medical practice, or there must be a valid explanation regarding the extenuating circumstances to justify the need for the additional dosage. (These members may or may not be homebound with intravenous (IV) and/or intramuscular (IM) medications). Tube Feedings – for replacement or adjustment of the feeding tube, as well as training family to give the feeding. Catheters – insertion and sterile irrigation and replacement of catheters, care of a suprapubic catheter and/or urethral catheter. Foley catheters generally require skilled care once every 60-90 days and this frequency of service would be considered reasonable and necessary. Where there are complications, more frequent visits may be required. Wound Care – Care of wounds when the skills of a licensed nurse are needed to provide safely and effectively the services necessary to treat the illness or injury is considered to be a skilled service (see Wound Care UM Guidelines for Home Health & Outpatient). In order for skilled care to be reasonable and necessary to treat a wound, the size, depth, nature of drainage (color, odor, consistency, and quantity), and condition and appearance of the skin surrounding the wound must be documented in the clinical findings so that an assessment of the need for skilled nursing can be made. The plan of care must contain the specific instructions for the treatment of the wound. The following wound characteristics are usually reasonable and necessary: Open wounds which are draining purulent or colored exudates or have a foul odor present or for which the patient is receiving IV antibiotic therapy; Wounds with a drain or T-tube which requires shortening or movement of such drain; Wounds which require irrigation or instillation of a sterile cleansing or medicated solution into several layers of tissue and skin and/or packing with sterile gauze; Recently débrided ulcers; Pressure sores (decubitus ulcers) with the following characteristics: Partial tissue loss with signs of infection such as foul odor or purulent drainage; There is full thickness tissue loss that involves exposure of fat or invasion of other tissue such as muscle or bone; Wounds with exposed internal vessels or a mass that may have a proclivity for hemorrhage when a dressing is changed (e.g. post radical neck surgery, cancer of the vulva); Skin conditions that require application of nitrogen mustard or other chemotherapeutic medication that present a significant risk to the patient; Other open or complex wounds that require treatment that can only be provided safely and effectively by a licensed nurse; Post-operative wounds where there are complications such as infection. IV line maintenance if family and/or caregiver is not available or is unwilling to perform. NOTE: Wounds or ulcers that show redness, edema, and induration, at times with epidermal blistering or desquamation do not ordinarily require skilled nursing care. Venipunctures should be associated with the specific symptom or diagnosis, or the documentation should clarify the need for the test when it is not diagnosis/illness specific. The treatment must be recognized as being reasonable and necessary to the treatment of the illness or injury. The member needs to be homebound in order to get these services. Example: Venipunctures for Prothrombin times following Total Hips. Total hip surgeries leave the member as homebound for a period of 2 weeks. The prothrombin level needs to be checked 4 times during this 2-week period. If requested after this period of time, there needs to be adequate documentation regarding homebound status. Total Knee replacements are not considered homebound for venipunctures. 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.