Topic of the Month - Home Health Management and Evaluation of a Patient Care Plan
Topic of the Month
During several Palmetto GBA home health workshops this year, questions were asked concerning when and how to use the Medicare Home Health Management and Evaluation Benefit. The purpose of this article is to review this benefit and give examples of when it would be appropriate.
It is important to distinguish between observation and assessment and management and evaluation as Medicare benefits. Where observation and assessment is a problem with the beneficiary's medical condition, management and evaluation is a problem with the implementation of the beneficiary's care plan. Observation and assessment of the beneficiary's medial condition and management and evaluation of the beneficiary's care plan may be provided at the same time.
When underlying medical conditions or complications require that only a registered nurse can ensure that essential nonskilled care is achieving its purpose, management and evaluation may be considered reasonable and necessary services.
The complexity of unskilled services must require the involvement of skilled nursing personnel to promote the beneficiary's recovery and medical safety in view of the overall complexity of the beneficiary's medical situation.
Orders for management and evaluation should indicate that the services being provided are for management and evaluation. The clinical documentation should reflect the specific management and evaluation services rendered and billed.
Management and evaluation is not intended to serve as a primary mechanism for providing long-term care or qualify a beneficiary for home health services when the services needed are custodial care.
- Example: Skilled nursing visits for the sole purpose of setting up a medication planner would not be considered management and evaluation of the care plan.
- Example: Continuing recertification to observe and assess a beneficiary whose acute episode of illness has subsided and the nurse visits are to ensure the beneficiary is taking their medication and eating correctly or to observe and assess the aide services would not be considered management and evaluation of the care plan.
Services included under the management and evaluation benefit must be directed at complications that are safety and high-risk concerns.
- Example: A beneficiary needs relatively uncomplicated medical treatment but has multiple, unskilled caregivers providing support service. This situation may be considered unsafe until all the caregivers fully understand their caregiver responsibilities. The goal of the skilled intervention is coordination and stabilization of the activities of the caregivers. These skills are necessary to coordinate the unskilled nursing services and avoid harm to the beneficiary.
- Example: A beneficiary with dementia has multiple unskilled medical needs and lives in a home environment that is unsafe. The situation has prompted the home health agency to contact Adult Protective Services. The home health agency would need to monitor administration of the beneficiary's care plan until other arrangements are made by Adult Protective Services.
- Example: A beneficiary has multiple uncomplicated medical problems, multiple medications, nutritional and hydration problems, restrictive functional limitations, and mental status problems. Having a caregiver who sets up and administers medications, ensures that the beneficiary has adequate nutritional and hydration intake, assists with ADLs and monitoring the overall wellbeing of the beneficiary would not require the skills of a registered nurse. However, a skilled nursing visit may be needed to ensure the caregiver realizes the impact of the coordination of these skills on the beneficiary and how all the necessary needs must be met to ensure the recovery and safety of the beneficiary.
In conclusion, skilled visits for management and evaluation of a beneficiary's care plan may be reasonable and necessary when:
- There are underlying medical conditions or complications,
- Only a skilled person can ensure that essential nonskilled care is achieving its purpose, and
- The complexities of the unskilled services require the involvement of skilled nursing personnel to promote the beneficiary's recovery and medical safety.
Reference: CMS Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 7, Section 40.1.2.2