Local Coverage Determination (LCD)

Home Health Skilled Nursing Care-Teaching and Training: Alzheimer's Disease and Behavioral Disturbances

L34562

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Contractor Information

Contractor Name	Contract Type	Contract Number	Jurisdiction	States
Palmetto GBA	A and B and HHH MAC	11004 - HHH MAC	J - M	Alabama Arkansas Florida Georgia Illinois Indiana Kentucky Louisiana Mississippi New Mexico North Carolina Ohio Oklahoma South Carolina Tennessee Texas

LCD Information

Document Information

LCD ID
L34562

LCD Title
Home Health Skilled Nursing Care-Teaching and Training: Alzheimer's Disease and Behavioral Disturbances

Proposed LCD in Comment Period
N/A

Source Proposed LCD
N/A

Original Effective Date
For services performed on or after 10/01/2015

Revision Effective Date
For services performed on or after 03/14/2024

Revision Ending Date
N/A

Retirement Date
N/A

Notice Period Start Date
N/A

Notice Period End Date
N/A

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Issue

Issue Description

This LCD outlines limited coverage for this service with specific details under Coverage Indications, Limitations and/or Medical Necessity.

CMS National Coverage Policy

Title XVIII of the Social Security Act, §1814(a)(2)(C) addresses requirements of requests and certifications.

Title XVIII of the Social Security Act, §1835(a)(2)(A) addresses the procedure for payment of claims of providers of services.

Title XVIII of the Social Security Act §1862(a)(1)(A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

42 CFR §409.40-409.49, Subpart E Home Health Services

42 CFR §424.22 Requirements for Home Health Services

CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 7, §40.1.1 General Principles Governing Reasonable and Necessary Skilled
Nursing Care and §40.1.2.3 Teaching and Training Activities

CMS Internet-Only Manual, Pub. 100-08, Medicare Program Integrity Manual, Chapter 6, §6.2.3 The Use of the Patient’s Medical Record Documentation to
Support the Home Health Certification, §6.2.5 Medical Necessity of Services Provided and §6.2.6 Examples of Sufficient Documentation Incorporated Into a
Physician’s Medical Record

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

This Local Coverage Determination (LCD) addresses a specific category of skilled nursing care currently available to Medicare home health (HH) beneficiaries with Alzheimer’s disease (AD) and behavioral disturbances – the category of skilled nursing care is called “teaching and training activities.” Teaching and training activities are defined in the Centers for Medicare and Medicaid Services (CMS) Internet-Only Manual (see citation under CMS National Coverage Policy section of this policy) and in the case of the beneficiary population with AD and behavioral disturbances, could be part of a unique beneficiary-centered care plan directed at teaching the family or caregiver how to manage the behavioral disturbances.

Skilled nursing services must be based on the patient's medical condition as described in the CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual Chapter 7 §40.1.1.

Behavioral disturbances often complicate the medical management of beneficiaries with AD. At baseline many individuals with AD manifest activity limitations in such domains as communication and self-care. The occurrence of behavioral disturbances, if not addressed in a comprehensive and systematic manner, may further compromise the activity limitations present at baseline resulting in sub-optimal clinical outcomes.

Each behavioral disturbance should be fully characterized and answers to the following questions should be documented in the patient’s medical records:

What is the specific behavioral disturbance being addressed?
What is the frequency of the behavior?
Are there specific situations or activities that “trigger” the behavior?
When does it occur?
Where does it occur?
Who is involved?
Are there other possible explanations for the behavior (e.g., pain, infection, change in medication, disruption in schedule, swallowing difficulties, catastrophic reaction induced by environment or personal interaction)?
What are the consequences of the behavior?
What interventions have been successful in addressing this behavior in the past?
What other techniques or interventions can be used to address the behavior?

Teaching and training interventions should be based on the answers to the above questions, the specific impairment(s) and activity limitation(s) identified for each beneficiary, as well as the ability of the family or caregiver to learn and implement the proposed interventions. Environmental factors impacting the identified behavior(s) and the resultant care plan must also be considered.

The CMS Internet-Only Manual, Pub. 100-02, Chapter 7 §40.1.2.3 provides guidance in determining the reasonableness and necessity of the number of training visits and the appropriateness of re-teaching and re-training.

In the HH setting, skilled education services are no longer needed if it becomes apparent, after a reasonable period of time, that the patient, family, or caregiver could not or would not be trained. Further teaching and training would cease to be reasonable and necessary in this case and would cease to be considered a skilled service. Notwithstanding that the teaching or training was unsuccessful, the services for teaching and training would be considered to be reasonable and necessary prior to the point that it became apparent that the teaching or training was unsuccessful, as long as such services were appropriate to the patient's illness, functional loss, or injury.

Summary of Evidence

N/A

Analysis of Evidence (Rationale for Determination)

N/A

Proposed Process Information

Synopsis of Changes

Changes	Fields Changed
	N/A

Associated Information

Sources of Information

Bibliography

Open Meetings

Contractor Advisory Committee (CAC) Meetings

MAC Meeting Information URLs

Proposed LCD Posting Date

Comment Period Start Date

Comment Period End Date

Reason for Proposed LCD

Requestor Name	Requestor Letter
	View Letter

Requestor Information

Contact for Comments on Proposed LCD

Coding Information

Bill Type Codes

Code	Description
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Revenue Codes

Code	Description
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ICD-10-CM Codes that Support Medical Necessity

ICD-10-CM Codes that DO NOT Support Medical Necessity

Additional ICD-10 Information

General Information

Associated Information

Documentation Requirements

Skilled nursing care is necessary only when (a) the particular patient’s special medical complications require the skills of a registered nurse (RN) or, when provided by regulation, a licensed practical nurse (LPN) 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 RN or, when provided by regulation, a LPN 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.

For each HH visit there should be documentation of the need for skilled nursing for teaching and training and the clinical notes should document the patient/caregiver response to any interventions provided. This documentation supporting medical necessity should be legible, maintained in the patient’s medical record, and must be made available to the A/B HHH MAC upon request.

Therefore, the HH clinician must document as appropriate the following:

The history and physical exam pertinent to the day’s visit, (including the response or changes in behavior to previously administered skilled services) and the skilled services applied on the current visit, including the characterization of target behavior(s) as described under the Coverage Indications, Limitations and/or Medical Necessity section of this LCD
The patient/caregiver's response to the skilled services provided, and if a family member/caregiver is involved in the patient’s care, the documentation must include both the patient and caregiver’s response to the skilled services provided
The plan for the next visit based on the rationale of prior results
A detailed rationale that explains the need for the skilled service in light of the patient’s overall medical condition and experiences
The complexity of the service to be performed
Any other pertinent characteristics of the beneficiary or home
A clinical note must be written for each visit.

Clinical notes should be written so that they adequately describe the reaction of a patient to his/her skilled care. Clinical notes should also provide a clear picture of the treatment, as well as “next steps” to be taken. Vague or subjective descriptions of the patient’s care should not be used. For example, terminology such as the following would not adequately describe the need for skilled care:

Patient tolerated treatment well
Caregiver instructed in medication management
Continue with plan of care (POC).

The documentation should describe the goal of the skilled nursing intervention, and at each visit the services provided should support the goal.

Objective measurements of physical outcomes of treatment should be provided and/or a clear description of the changed behaviors due to education programs should be recorded in order that all concerned can follow the results of the applied services.

Where it becomes apparent after a reasonable period of time that the patient, family, or caregiver will not or is not able to be trained, then further teaching and training would cease to be reasonable and necessary. For unsuccessful teaching and training services, the reason(s) why the training was unsuccessful should be documented in the clinical record.

In order for HH patients to be eligible to receive services under the Medicare HH benefit the following must be documented for certification/re-certification:

a) Patient is under a physician's care
b) Homebound status-with documentation of confinement to home in medical records
c) Established POC must be signed and dated by the certifying physician
d) Face-to-Face no more than 90 days prior or 30 days after start of HH care
e) Skilled need services must be medically necessary, and documentation of the skilled need should be in the patient's medical records.

If the requirements for certification are not met then claims for subsequent episodes of care, which require a re-certification, will not be covered, even if the requirements for recertification are met. Recertifications are needed at least every 60 days when there is a need for continuing home care.

Sources of Information
N/A

Bibliography

Gray KF. Managing agitation and difficult behavior in dementia. Clin in Geriat Med.2004;20(1):69-82.

Schaber P. Occupational Therapy Practice Guidelines for Adults with Alzheimer's Disease and Related Disorders. Bethesda MD: 2nd edition. The American Occupational Therapy Association; 2010.

Revision History Information

Revision History Date	Revision History Number	Revision History Explanation	Reasons for Change
03/14/2024	R13	Under *CMS National Coverage policy* updated section headings. Under *Coverage Indications Limitations and/or Medical Necessity* removed verbiage “Use of the International Classification of Functioning, Disability and Health (ICF) would facilitate the identification and documentation of specific impairments, activity limitations, and environmental factors” as it is no longer accessible. Under *Bibliography* removed source: International classification of functioning, disability and health: ICF. Geneva: World Health Organization, 2001, as it is no longer accessible. Formatting, punctuation, and typographical errors were corrected throughout.	Provider Education/Guidance
10/24/2019	R12	This LCD is being revised in order to adhere to CMS requirements per Chapter 13, Section 13.5.1 of the Program Integrity Manual, to remove all coding from LCDs. There has been no change in coverage with this LCD revision. Regulations regarding billing and coding were removed from the *CMS National Coverage Policy* section of this LCD and placed in the related Billing and Coding: Home Health Skilled Nursing Care-Teaching and Training: Alzheimer’s Disease and Behavioral Disturbances A56641 Article. At this time 21^stCentury Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.	Provider Education/Guidance
07/04/2019	R11	All coding located in the *Coding Information* section has been moved into the related Billing and Coding: Home Health Skilled Nursing Care- Teaching and Training: Alzheimer’s Disease and Behavioral Disturbances A56641 article and removed from the LCD. Under *Bibliography* changes were made to citations to reflect AMA citation guidelines. Formatting, punctuation and typographical errors were corrected throughout the LCD. At this time 21^stCentury Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.	Provider Education/Guidance
05/02/2019	R10	Under *Coverage Indications, Limitations and/or Medical Necessity* removed all quoted Internet-Only Manual (IOM) text in the second and third paragraphs and replaced with “Skilled nursing services must be based on the patient's medical condition as described in the CMS Internet-Only Manual, Pub 100-02, Medicare Benefit Policy Manual Chapter 7 §40.1.1.” All quoted Internet-Only Manual (IOM) text in the seventh and eighth paragraphs was removed and replaced with “The CMS Internet-Only Manual, Pub. 100-02, Chapter 7 §40.1.2.3 provides guidance in determining the reasonableness and necessity of the number of training visits and the appropriateness of re-teaching and re-training.” Formatting, typographical errors and punctuation were corrected throughout the LCD. Acronyms were inserted and defined where appropriate throughout the LCD. At this time 21^stCentury Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.	Provider Education/Guidance
05/03/2018	R9	Under *CMS National Coverage Policy* added 42 CFR §424.22 Requirements for Home Health. Under *Bibliography* revisions were made to the sources to reflect AMA citation guidelines. At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.	Provider Education/Guidance
01/01/2017	R8	Under *CPT/HCPCS Codes* the description was revised for HCPCS code G0300. This revision is due to the 2017 Annual CPT/HCPCS Code Update and becomes effective 1/1/17.	Provider Education/Guidance Revisions Due To CPT/HCPCS Code Changes
10/01/2016	R7	Under *ICD-10 Codes That Support Medical Necessity* added ICD-10 codes F03.90, G31.01, G31.1 and G31.85. This revision is due to the Annual ICD-10 Code Update and becomes effective 10/01/16.	Provider Education/Guidance Revisions Due To ICD-10-CM Code Changes
05/12/2016	R6	Under *CMS National Coverage Policy* added “services” to 42 CFR §424.22, deleted Change Requests 9189 and 9369 and included the cited manual references for these deleted Change Requests. Under *Coverage Indications, Limitations and/or Medical Necessity* in the first paragraph revised CMS Manual System to now read CMS Internet- Only Manual. Under *Associated Information – Documentation Requirements* in the second paragraph added verbiage to the first sentence and deleted “the” from the second sentence. Throughout the LCD punctuation was corrected. Under *Sources of Information and Basis for Decision* journal and book titles were italicized and updated the last cited reference.	Provider Education/Guidance Typographical Error
01/01/2016	R5	Under CMS National Coverage Policy added reference to CMS Internet-Only Manual, Pub 100-04 Medicare Claims Processing Manual, Change Request 9369, Transmittal 3378 dated October 16, 2015. Under CPT/HCPCS Codes section removed G0154 and added HCPCS codes G0299 & G0300.	Provider Education/Guidance Public Education/Guidance Revisions Due To CPT/HCPCS Code Changes
10/01/2015	R4	Under *CMS National Coverage Policy* added the following: 42 CFR §424.22-Requirements for Home Health, 42 CFR §409.42-Beneficiary qualifications for coverage of services, §409.43 Plan of care requirements, Title XVIII of the Social Security Act, §1835 (a)(2)(A) Procedure for payment of claims of providers of services, Title XVIII of the Social Security Act, §1814 (a)(2)(C) Requirements of requests and certifications and CMS Internet-Only Manual, Pub 100-08, Medicare Program Integrity Manual, Transmittal 603, dated July 21, 2015, Change Request 9189. Under *Associated Information-Documentation Requirements* added the requirements for certification/recertification.	Provider Education/Guidance Other (Change Request 9189, Transmittal 603)
10/01/2015	R3	Per CMS Internet-Only Manual, Pub 100-08, Medicare Program Integrity Manual, Chapter 13, §13.1.3 LCDs consist of only “reasonable and necessary” information. All bill type and revenue codes have been removed.	Other (Bill type and revenue code removal)
10/01/2015	R2	Under CMS National Coverage Policy removed “Hospice Care” from citation on 42 CFR and added Home Health Services Subpart E. Under Coverage Indications, Limitations and/or Medical Necessity made a few grammatical and punctuation corrections. Under Bill Type Codes removed 033x per Change Request 8244. Under Associated Information made a few punctuation and formatting corrections, corrected italicized manual reference, under second bullet added “caregiver’s” response to the skilled services provided. Under Sources or Information and Basis for Decision corrected citations to comply to AMA formatting.	Provider Education/Guidance Other (Annual Validation)
10/01/2015	R1	In CMS National Coverage Policy under Pub. 100-02 removed “-Home Health services- Covered Services under a Qualifying Home Health Plan of Care- Skilled Nursing Care- Application of the Principles to Skilled Nursing services-Teaching and Training Activities.” Separated Federal Register Final rule Vol. 74 and 42 CFR into individual citations. In Associated Information under Documentation Requirements corrected a few grammatical and punctuation errors, reworded the sentence “therefore the home health clinical notes must document as appropriate” to read “Therefore the home health clinician must document as appropriate the following:” Reworded the second bullet to read “the patient’s response to the skilled services provided”, reworded the third bullet to read “if a family member/caregiver is involved in the patient’s care, the documentation must include both the patient and caregiver’s response to the skilled services provided.” In Sources of Information and Basis for Decision corrected citations to conform to AMA formatting.	Other (Maintenance- Annual Validation)

Associated Documents

Attachments
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Related Local Coverage Documents
Articles
A56641 - Billing and Coding: Home Health Skilled Nursing Care-Teaching and Training: Alzheimer's Disease and Behavioral Disturbances

Updated On	Effective Dates	Status
03/07/2024	03/14/2024 - N/A	Currently in Effect	You are here
10/18/2019	10/24/2019 - 03/13/2024	Superseded	View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

Home Health
Alzheimer's Disease
Skilled Care Training

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Home Health Skilled Nursing Care-Teaching and Training: Alzheimer's Disease and Behavioral Disturbances

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