Home Health & Hospice

Important Principles Guide Reasonable and Necessary Teaching

Homecare Insider, December 21, 2009

The final rule to update the Prospective Payment System (PPS) payment rate for 2010 addresses teaching.  A new provision in 42 CFR 409.42 notes that teaching services would not be necessary when “it became apparent, after a reasonable period of time, that the patient, family, or caregiver could not or would not be trained.”  If the language sounds familiar, that’s because it is very similar to the coverage criteria in the Medicare Benefit Policy Manual.  However, now that this provision is regulation, it carries more weight in the medical review process.  It will be important to build a strong case for reasonable and necessary teaching.  Begin with these points from CMS Publication 100-2, Chapter 7, §40.1.1.  
•    The skill is in the act of teaching, not the subject taught.  Teaching a patient about an unskilled subject can constitute reasonable and necessary teaching.  Example:  The nurse instructs the diabetic patient about foot care.
•    Teaching activities must be related to the patient’s functional loss, illness, or injury.  Example:  The need to learn foot care by the diabetic patient relates to his illness.
•    There is no requirement that the patient or family member must learn a skill if they choose not to or cannot learn the care.  Example:  The diabetic patient’s wife refuses to learn about insulin administration.  The nurse will instruct the patient.  (Even though patients and family members do not have to learn to provide care, the demands of the PPS can help homecare nurses to becomes more persuasive and creative in their approaches to teaching.)

Building your case begins with identifying the patient’s or caregiver’s knowledge or skill deficit.  Important areas of focus include how to manage the illness, deal with problems or symptoms, and improve or maintain function.  There should be connection between this knowledge or skill deficit and the patient’s illness, injury, or functional loss.  If the connection is not evident, document the deficit specifically.  Examples:  1) The patient is on five new medications for treatment of congestive heart failure.  His plan of care identifies the new medications with the letter “N.”  The connection between this teaching and the patient’s illness is evident.  2) The plan of care does not include any new or changed medications but the nurse plans to teach the patient about medications.  The connection is not evident.  The nurse must document a need for teaching.  In the initial assessment, the nurse writes, “Observed patient setting up medications, made several mistakes in dose calculation. “

Coming next to this Web site, more important points about teaching as a skilled service.  The Beacon Academy offers an e-learning lesson on teaching.  Check it out at — http://www.beaconhealth.org/item--Teaching-and-Training-Activities-Course--MM503.html.