Hi Kim,

 

Patients with chronic leg ulcers are difficult to case manage for the reasons you listed below. I would be a little cautious about keeping the patient open to skilled nursing services when she does not have active wounds. It might be appropriate for a very short time after the wounds heal, but I think there would be some risk involved if you were to keep her open for a long period of time.

 

It’s a great question and I would love to hear what others think J

 

 

 

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Situation:

We have a patient who has lymphedema. She has been on and off services for treatment of weeping/ulcers to her legs. When home health is involved, her legs improve and heal. When care is transitioned to her caregiver, her legs quickly deteriorate and need skilled services again as her caregiver is unable to physically perform the wraps correctly. Currently her legs are healed enough to only require a lymphedema pump daily and twice a week ACE wraps. I am looking for guidance and opinions on the interpretation of the Medicare benefit policy manual below regarding our situation. I feel that in this situation, it does require the skill of an RN to assess/evaluate the legs and their response to treatment and start wound care early if it is needed. I am wondering if a HHA 2x week and then RN assessment routinely (every other week) would be compliant?

 

40.1.1 -  General Principles Governing Reasonable and Necessary Skilled Nursing Care(Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)If all other eligibility and coverage requirements under the home health benefit are met, skilled nursing services are covered when an individualized assessment of the patient’s clinical condition demonstrates that the specialized judgment, knowledge, and skills of a registered nurse or, when provided by regulation, a licensed practical (vocational) nurse (“skilled care”) are necessary.  Skilled nursing services are covered where such skilled nursing services are necessary to maintain the patient’s current condition or prevent or slow further deterioration so long as the beneficiary requires skilled care for the services to be safely and effectively provided.  When, however, the individualized assessment does not demonstrate such a necessity for skilled care, including when the services needed do not require skilled nursing care because they could safely and effectively be performed by the patient or unskilled caregivers, such services will not be covered under the home health benefit. Skilled nursing care is necessary only when (a) the particular patient’s special medical complications require the skills of a registered nurse or, when provided by regulation, a licensed practical nurse to perform a type of service that would otherwise be considered non-skilled; or (b) the needed services are of such complexity that the skills of a registered nurse or, when provided by regulation, a licensed practical nurse are required to furnish the services.  To be considered a skilled service, the service must be so inherently complex that it can be safely and effectively performed only by, or under the supervision of, professional or technical personnel as provided by regulation, including 42 C.F.R. 409.32

 

40.1.2.1 -  Observation and Assessment of the Patient's Condition When Only the Specialized Skills of a Medical Professional Can Determine Patient's Status(Rev. 265, Issued: 01-10-20, Effective: 01-01-20, Implementation: 02-11-20)Observation and assessment of the patient's condition by a nurse are reasonable and necessary skilled services where there is a reasonable potential for change in a patient's condition that requires skilled nursing personnel to identify and evaluate the patient's need for possible modification of treatment or initiation of additional medical procedures until the patient's clinical condition and/or treatment regimen has stabilized.  Where a patient was admitted to home health care for skilled observation because there was a reasonable potential of a complication or further acute episode, but did not develop a further acute episode or complication, the skilled observation services are still covered for 3 weeks or so long as there remains a reasonable potential for such a complication or further acute episode. Information from the patient's home health record must document the rationale that demonstrates that there is a reasonable potential for a future complication or acute episode and, therefore, may justify the need for continued skilled observation and assessment beyond the 3-week period.  Such signs and symptoms as abnormal/fluctuating vital signs, weight changes, edema, symptoms of drug toxicity, abnormal/fluctuating lab values, and respiratory changes on auscultation may justify skilled observation and assessment.  Where these signs and symptoms are such that there is a reasonable potential that skilled observation and assessment by a licensed nurse will result in changes to the treatment of the patient, then the services would be covered.  However, observation and assessment by a nurse is not reasonable and necessary for the treatment of the illness or injury where fluctuating signs and symptoms are part of a longstanding pattern of the patient's condition which has not previously required a change in the prescribed treatment.

 

 

Kimberly Fleischfresser, RN, BSN, COS-C

LB Home Care Director

Phone:218.998.1407

Fax: 218.998.1440

Kim.fleischfresser@lbhomes.org

 

LB Homes

Fergus Falls, Minnesota

www.LBHomes.org

 

 

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