Services Covered by Medicare

Skilled Nursing

In order for Medicare to pay for home nursing services, care must be provided by or under the supervision of the Registered Nurse and be safe and effective. Care must be reasonable and necessary to the diagnosis and treatment of client's injury or illness. The need for care should be based on the client's unique condition and individual needs. Care must be skilled and intermittent (not a long-term, highly intensive service). If all of the above criteria are met, including those general requirements described earlier, nursing services may be provided.

Quick Links: Skilled Nursing Therapy Services (Physical, Speech and Occupational) Medical Social Work Services Home Health Aides Nutritionists Practitioner's Guide to Home Care

Observation and Assessment

1. A skilled nurse is required to identify and assess need for modification of treatment or initiation of medical treatment.
2. There is a reasonable potential for complications or progression to an acute episode.

Teaching and Training Activities
Teaching and training include activities or treatments that require the nurse to teach the client or caregiver how to manage the treatment regimen. If it is determined that the patient/caregiver will not or cannot learn to provide the care, coverage will cease.

Activities that may be taught include, but are not limited to:

1. When the complexity of the wound, overall condition of client or the ability of the caregiver makes teaching necessary.
2. Administration of gastrostomy and enteral feedings, medications, or complex range of medications, gaseous medications, including side effects and avoidance of interaction with other medications and food.
3. Care and application of any specialized dressing or skin treatment.
4. Transfer techniques, i.e. wheelchair to bed.
5. Maintenance of therapeutic diet.
6. Ostomy, or reinforcement of ostomy care, when bowel or bladder dysfunction exists.
7. Maintenance of peripheral and central venous lines and IV medication administration through these lines.
8. Activities of daily living when assistive devices and or special techniques are required.

Skilled Treatments

1. Injections
2. Wound Care
3. Intravenous medication administration
4. In-dwelling catheter insertion
5. Nasogastric tube insertion

Maternal/Child Services
In order for a patient to qualify for Sparrow's Maternal-Child services the patient must meet the guidelines of participating insurance carriers. In general, the patient must:

1. be under a physician's care,
2. require skilled nursing care, and
3. require part-time intermittent care.

Services provided by our maternal child program includes:

1. Observation and Evaluation
1. Where the patient's condition may change.
2. Where the physical assessment skills of a RN are required to evaluate assess and report significant findings to the physician.
2. Teaching, training and treatment - The patients, family members, and others may be taught to perform certain procedures or treatments.
1. Treatment of open and or infected wounds, surgical incisions, burns, weight loss.
2. Poor feed prognosis and failure to thrive.
3. Administration of injections, intravenous therapy, and medications requiring supervision.
4. Reinforcement of teaching related to peripheral and central line care.
5. Monitoring vital signs, oxygen therapy, and respiratory treatments.
6. Home environmental evaluation/assessment for patients frequently admitted to the hospital.
7. Asthma management.
8. Apnea monitor teaching, follow-up, and assessment.
9. Jaundice treatment with photo-therapy in home.
10. Inserting and or replacing drainage tubes, catheters, and nasal/oral gastric tubes.
11. Pre-natal assessment for high-risk mothers.
12. Breast feeding assistance.
13. Assessment of mother-baby and premature/high risk infants after delivery/discharge.
14. Observation and teaching regarding special duties or gavage feedings.

Therapy Services

In order for Medicare to cover Therapy services the service must:

1. Require that it be performed by or under the supervision of licensed therapist.
2. A therapist's skills are needed to manage and periodically re-evaluate the appropriateness of a maintenance program due to intensified danger to the client.
3. Medical complications require supervision and/or observation of the client.
4. There is an expectation that services will result in improvement in a reasonable and predictable time period or are necessary to establish a safe and effective maintenance program.
5. Services must be specific and effective treatment for a client's condition.
6. Must be consistent with the nature and severity of the illness or injury.

If all of the above criteria are met, including those general requirements described earlier, the patient may be eligible for therapy services.

The following is a list of covered therapy services with a non-inclusive list of examples of the types of service that may be provided.

Physical Therapy Services

1. Assessment of rehab needs and potential
2. Therapeutic exercises
3. Gait training, range of motion, ultrasound
4. Short-wave and microwave therapy
5. Hot packs
6. Home maintenance programs
7. Therapy and potential assessment

Speech Pathology

1. Processing of speech
2. Language communication
3. Swallowing ability

Occupational Therapy
(Must be provided in conjunction with Nursing, PT or ST)

1. Rehab potential assessment
2. Services to restore physical function
3. Services to restore sensory integrative function
4. Services to improve independence in ADLs
5. Fitting of orthotic devices

Social Services

(Must be provided in conjunction with Nursing, PT, OT or ST)

1. Services designed to resolve problems that are expected to impede improvement in the client's medical condition.
2. Referrals to and from community resources.
3. Assistance to develop a plan for long term care.

Home Health Aide Services

(Must be provided in conjunction with Nursing, PT, OT or ST)
Maintenance of treatment and care (NOTE: The reason for the visit must be related to the diagnosis and treatment plan. The visit cannot be for ancillary services only, such as light housekeeping, linen changes, etc.)

1. Hair and nail care
2. Non-sterile dressing changes
3. Personal Hygiene

Nutritionists

Consultation with clinical staff regarding client's dietary and nutritional needs.