Nursing services are covered on an intermittent (separated intervals of time) basis when provided by, or under the direct supervision of, a registered nurse (RN).
A nursing visit may include, but is not limited to, one or more of the following nursing services:
* Administering prescribed medications that cannot be self-administered.
* Changing an indwelling catheter.
* Applying dressings that require prescribed medications and aseptic techniques.
* Teaching the beneficiary, available family member, willing friend or neighbor, or caregiver (paid or unpaid) to carry out all or some of the services, as detailed below.
* Observation and evaluation, as detailed below.
Intermittent (separated intervals of time) nurse visits are intended for beneficiaries who generally require nursing services on a short-term basis (typically 60 days or less) for the treatment of an acute illness, injury, or disability and who cannot receive these services in an outpatient setting. Intermittent nursing visits may last from 15 minutes to one or two hours and are reimbursed at a flat rate (i.e., Medicaid feescreen for a visit) regardless of the length of the visit.
Intensive care (for cases that require five or more visits per week or beyond 60 days) may be reviewed by MDHHS during post-payment audit to determine if home care was medically appropriate and a cost effective alternative to institutional care.
Intermittent nurse visits are not covered for a beneficiary receiving Private Duty Nursing Services.
COVERED NURSING SERVICES
The following nursing services are covered home health care services. Limitations, conditions and special considerations are noted when applicable. (Refer to the Billing & Reimbursement for Institutional Providers Chapter of this manual for billing information.)
When use of a catheter is temporary, visits made by the nurse to change the catheter must also include instruction to the beneficiary in bladder training methods. The actual bladder training (e.g., forcing fluids or other measures) does not require the skills of a nurse. After the catheter is removed, a limited number of visits (maximum two visits per month) are allowed to observe and evaluate the effectiveness with which the bladder training has been accomplished (e.g., the degree to which the bladder is emptying).
BLOOD LEAD POISONING NURSING ASSESSMENTS/INVESTIGATION VISITS
A physician’s order is required for a HHA to make home visits regarding blood lead poisoning. Medicaid reimburses up to two nurse visits per child, regardless of the number of children in the home diagnosed with blood lead poisoning.
HHAs who suspect beneficiaries may have evidence of blood lead poisoning or blood lead levels above accepted state levels in the home should refer the beneficiary to the local health department (LHD).
Giving enemas usually does not require the skills of a nurse, and Medicaid does not cover such visits unless the physician has ordered that a nurse give the enema because of clinical indications.
EYE DROPS AND TOPICAL OINTMENTS
Two nurse visits are allowed to teach the administration of eye drops and topical ointments. Nurse visits solely to perform these services are not covered.
If the beneficiary is in need of intravenous infusion and an infusion clinic or ancillary Medicaid provider (who has no nurse) does not cover the service, or family member/care giver will not accept this task, the HHA may perform this service and bill accordingly.
Medicaid will reimburse claims for professional services (e.g., nursing services) associated with the administration of Medicare Part D drug(s) to dually eligible Medicaid/Medicare beneficiaries.
Nurse visits related to neonatal jaundice require supporting documentation in the beneficiary's medical record that the nurse visits are required for a specific medical condition. Supporting documentation should include pertinent laboratory values.
If the attending physician determines that the beneficiary’s condition is unstable and that significant changes may occur, Medicaid covers nurse visits for observation/evaluation. Once the beneficiary’s condition has stabilized and there has been no significant change (e.g., no change in medication or vital signs, no recent exacerbation in the beneficiary’s condition) for a period of three weeks, and no other necessary nursing services are being furnished, nursing visits solely for observation/evaluation are no longer covered. Visits for observation/evaluation to ensure stability of a beneficiary who has an established disability or frail condition are covered by Medicaid if circumstances, conditions, or situations exist that prevent the beneficiary from obtaining services from a physician’s office or outpatient clinic as described in the Home Setting Section of this chapter. Such visits are limited to two visits per month.
Nurse visits for observation/evaluation to insure stability of a beneficiary’s condition cannot be billed within a 30-day period of an initial/subsequent postpartum/newborn follow-up nurse visit, suspected abuse nurse visit or aide visit.
Administration of oral medications does not usually require the skills of a nurse in the home setting. Visits are covered only if the complexity of the beneficiary’s condition and/or the number of drugs prescribed require the skill or judgment of a nurse to detect and evaluate side effects (adverse reactions) and/or provide necessary teaching and instruction.
Placing medication in envelopes/cups, giving reminders, etc., to assist the beneficiary in remembering to take them does not constitute a nursing service.
POSTPARTUM/NEWBORN FOLLOW-UP NURSE VISIT
Home visits for assessment, evaluation and teaching are covered for women and newborns following delivery when a physician has determined the mother or newborn may be at risk. The goals of these services include:
* Fostering a positive outcome for the mother and newborn by detecting medical complications manifested during the
* Instructing the mother in newborn care; and
* Identifying situations that may require intervention with medical and community resources.
The HHA must assess and document, in writing, that the beneficiary is receiving services by a Maternal Infant Health Program (MIHP) provider. If the HHA is also an enrolled MIHP provider, services for the mother and newborn cannot be billed as home health care but must be billed as MIHP services. If the beneficiary is receiving MIHP services from another provider and the HHA is also providing services, the POC must clearl identify why home health services are needed in addition to MIHP and that the two providers do not duplicate services.
Medicaid allows one initial postpartum visit, one initial newborn visit, and one subsequent visit to mother and newborn for a total of three visits per pregnancy.
* The initial postpartum visit must be billed using the mother’s Medicaid ID number.
* The initial newborn visit must be billed using the newborn’s Medicaid ID number.
* The subsequent visit may be billed under either the mother’s ID number or newborn’s ID number, based on the most time spent with each beneficiary.
PRENATAL NURSE VISIT
Medicaid covers home visits for a specific pregnancy related medical condition provided by a HHA.
Home visits provided for preventive health services which address psychosocial issues, provide education, provide transportation, etc. and that do not provide treatment for an illness or injury are a covered service of the MIHP, not Home Health.
ROUTINE PROPHYLACTIC AND PALLIATIVE SKIN CARE
The recognized stages of decubitus ulcers are classified as:
* Stage I - Inflammation or redness of the skin;
* Stage II - Superficial skin break with erythema of surrounding area;
* Stage III - Skin break with deep tissue involvement; and
* Stage IV - Skin break with deep tissue involvement with necrotic tissue present.
The existence of Stage III or IV decubiti or other widespread skin disorders may necessitate the skills of a nurse. The physician’s orders for treating the skin determine the need for this service.
The presence of Stage I or II decubiti, rash, or other relatively minor skin irritations do not indicate a need for nursing care unless ordered by a physician. Bathing the skin, applying creams, etc. are not covered nursing services.