Information Bulletin 03-2
Medicare Certified Home Health Agencies Definition of Skilled Services For Medicare and Non-Medicare Patients
The purpose of this information bulletin is to inform Medicare Certified Home Health Agencies (HHAs) of clarification the Minnesota Department of Health (MDH) has received from The Centers for Medicare and Medicaid Services (CMS) regarding the definition of Skilled Services for non-Medicare Patients.
CMS Definition of Skilled Services for non-Medicare and Medicare Patients
The CMS definition of skilled services for non-Medicare and Medicare patients is stated in the CMS HM-11 (The Home Health Agency Manual), Sections 205.1 and 205.2. MDH strongly recommends that sections 205.1 and 205.2 of the HM-11 be read in their entirety for complete understanding of the definition of skilled services. The HM -11 states in part:
Skilled Nursing Service
A. General Principles Governing Reasonable and Necessary Skilled Nursing Care.
1. A skilled nursing service is a service that must be provided by a registered nurse, or a licensed practical (vocational) nurse under the supervision of a registered nurse, to be safe and effective. In determining whether a service requires the skills of a nurse, consider both the inherent complexity of the service, the condition of the patient and accepted standards of medical and nursing practice. Some services may be classified as a skilled nursing service on the basis of complexity alone, e.g., intravenous and intramuscular injections or insertion of catheters, and if reasonable and necessary to the treatment of the patient's illness or injury, would be covered on that basis. However, in some cases the condition of the patient may cause a service that would ordinarily be considered unskilled to be considered a skilled nursing service. This would occur when the patient's condition is such that the service can be safely and effectively provided only by a nurse.
Skilled Therapy Service
A. General Principles Governing Reasonable and Necessary Physical Therapy Speech-Language Pathology Service and Occupational Therapy.
1. The service of a physical, speech-language pathologist or occupational therapist is a skilled therapy service if the inherent complexity of the service is such that it can be performed safely and/or effectively only by or under the general supervision of a skilled therapist. To be covered, the skilled services must also be reasonable and necessary to the treatment of the patient's illness or injury or to the restoration of maintenance of function affected by the patient's illness or injury. It is necessary to determine whether individual therapy services are skilled and whether, in view of the patient's overall condition, skilled management of the services provided is needed although many or all of the specific services needed to treat the illness or injury do not require the skills of a therapist.
2. The development, implementation management and evaluation of a patient care plan based on the physician's orders constitute skilled therapy services when, because of the patient's condition, those activities require the involvement of a skilled therapist to meet the patient's needs, promote recovery and ensure medical safety. Where the skills of a therapist are needed to manage and periodically reevaluate the appropriateness of a maintenance program because of an identified danger to the patient, such services would be covered even if the skills of a therapist are not needed to carry out the activities performed as part of the maintenance program.
3. While a patient's particular medical condition is a valid factor in deciding if skilled therapy services are needed, the diagnosis or prognosis should never be the sole factor in deciding that a service is or is not skilled. The key issue is whether the skills of a therapist are needed to treat the illness or injury, or whether the services can be carried out by nonskilled personnel.
4. A service that is ordinarily considered nonskilled could be considered a skilled therapy service in cases in which there is clear documentation that, because of special medical complications, skilled rehabilitation personnel are required to perform or supervise the service or to observe the patient. However, the importance of a particular service to a patient or the frequency with which it must be performed does not, by itself, make a nonskilled service into a skilled service.
When is This Change Effective?
This change is effective February 1, 2003. MDH surveyors will no longer use HCFA Transmittal 99-2.
How Do I Access CMS's Definition of 'Skilled Services'?
You can access this definition by going to CMS' OASIS Home Page at http://www.cms.hhs.gov/oasis/
In the box on the left of the screen, click on Haven. Scroll down and click on Home Health Agency System User’s Guide. Click yes on the Security Alert screen. Scroll down to the OASIS Q & A’s 6/2005. Click on the down arrow next to Choose the Section and scroll down to category 1, Applicability. Scroll down and see question #9. "Can you explain the term skilled service?" Answer: “Skilled services covered by the Medicare home health benefit are discussed in the Home Health Manual, CMS Publication 11, Chapter II - Coverage of Home Health Services in section 205. (see updated website link below)
You may also access information by clicking on Regulations (on the CMS OASIS Home Page), scroll down to Downloads and click on the Patient Classification Table.
How Do I Directly Access the HM-11 for Definitions of Skilled Nursing Care and Skilled Therapy Services?
How Do I Directly Access the HM-11 for Definitions of Skilled Nursing Care and Skilled Therapy Services? The HM-11, Chapter II, Coverage of Services can be accessed at the following website: http://www.cms.hhs.gov/Manuals/PBM/list.asp
Select Publication 11 – The Home Health Agency Manual (next screen click the same) open 200.2 and scroll down to Section 205.1, Coverage of Services. Paragraph A. is captioned, General Principles Governing Reasonable and Necessary Skilled Nursing Care. Under paragraph A. is item 1 which provides a definition of Skilled Nursing Care.
For the definition of Skilled Therapy Services, scroll down to Section 205.2. Paragraph A, is captioned, General Principles Governing Reasonable and Necessary Physical Therapy, Speech-Language Pathology Services and Occupational Therapy. Item 1, under paragraph A., provides a definition for these services.
If you have any questions regarding this Information Bulletin, please contact in writing:
Minnesota Department of Health
Compliance Monitoring Division
Licensing and Certification Program
85 East Seventh Place, Suite 300
PO Box 64900
St. Paul, Minnesota 55164-0900
Telephone: (651) 201-4101