Skilled Need — The Coverage Test

Homebound status gets the patient in the door. Skilled need is what keeps the episode covered. Every visit you bill has to stand on its own for both.

The rule

A service that, by its nature, requires the skills of a nurse to be provided safely and effectively continues to be a skilled service even if it is taught to the patient, the patient's family, or another caregiver.

And the mirror image:

If a service can be safely and effectively performed — or self-administered — by an unskilled person without the direct supervision of a nurse, the service cannot be regarded as skilled even though a nurse actually provides it.

That second rule catches people out. The availability of a competent person to do a non-skilled task does not make the task skilled just because no such person happens to be there. Importance to the patient is not the test. The nature of the service is the test.

Why home health, and why now?

This is the question every admission and every visit note has to answer. The usual valid answers:

• New diagnosis
• Exacerbation of a chronic illness
• Recent hospitalization
• New or changed medications or treatments
• Current infection requiring antibiotics
• A wound requiring skilled wound care
• Decline in function
• Decline in ability to perform ADLs
• Change in speech or swallowing

If you cannot answer "why now" in a sentence, stop and work out whether there is a skilled need at all.

Skilled versus non-skilled

Note the last one on the right: venipuncture for the sole purpose of obtaining a blood sample is specifically excluded from qualifying skilled nursing. It can be provided, but it cannot be the reason the patient is on service.

Observation and assessment

Observation and assessment is skilled when there is a reasonable potential for change requiring a nurse's judgment. What justifies extending the frequency:

• Abnormal or fluctuating vital signs
• Weight changes
• Edema
• Symptoms of drug toxicity
• Abnormal or fluctuating lab values
• Respiratory changes on auscultation

Practical limits our agency works to:

• A maximum of 3 weeks for observation, assessment, and education
• Preferred frequency for observation/assessment/education patients is 3w1, 2w2
• One visit a week is not medically necessary on its own
• Front-loading is required to prevent hospitalization — an RN should be in the home within the first week of the start of care

Teaching and training

Teaching is skilled while it is still teaching. It stops being skilled when the patient or caregiver has learned it. So the note has to show movement:

• What was taught, in specifics — not "educated on diet"
• Why it is needed now — abnormal findings, noncompliance, a new or changed diagnosis
• How the patient responded — teach-back, return demonstration, what they got wrong
• What is left to teach, and the plan for the next visit

Repeating the same teaching week after week with no change in the patient's understanding is the pattern reviewers look for. If teaching is not progressing, either change the approach and say why, or move toward discharge.

Hands-on care

If you are performing a procedure, the note needs to show why it takes a nurse:

• Detail the steps of the procedure
• Say why it requires a nurse to perform it
• Say whether a caregiver could be taught — and if not, why not

The three questions to ask yourself before you leave the home

1. What was my skill on this visit? Assessment, education, or hands-on care — name it.
2. Does the patient still meet homebound criteria, and does my own assessment support the reasons I wrote?
3. Why does this patient need another visit? If you cannot answer, plan the discharge.

If there is no skill, or the patient is not homebound, you cannot complete and bill the visit.

Reference

CMS Medicare Benefit Policy Manual, Chapter 7 — Home Health Services. bp102c07.pdf