HI 00601.370 Psychiatric Nursing

Whether a particular service constitues a skilled nursing service is ordinarily determined on a case-to-case basis. As a general rule, however, the counselling and evaluation services required by an elderly patient suffering from a diagnosed psychiatric disorder that required active treatment in a psychiatric institution requires the skills of a psychiatrically trained nurse. (A psychiatrically trained nurse is a nurse who has special training and/or experience beyond the standard curriculum required for the R.N.) The special training of such nurses enables them to interpret the underlying meaning in the patient"s actions and to evaluate the need for the psychiatrist to change the plan of treatment or to reschedule visits to the psychiatrist"s office. Conversely, if the visiting nurse has not been trained in psychiatric care, that nurse's visits would not be reimbursable since they are not deemed “reasonable” to the treatment of the patient"s illness, unless the entire plan of treatment consists solely of injections of fluphenazine, a behavior modifier, which can be furnished by a nurse, that has not been “psychiatrically” trained. It is expected that an individual whose psychiatric disorder is severe enough to require the special skills of a psychiatric nurse will be under the care of a psychiatrist and that the plan of treatment calling for the services of a psychiatric nurse will be established and reviewed by the psychiatrist.

In effect the law precludes an HHA which is primarily for the care and treatment of mental diseases from participating in the program. However, this exclusion does not preclude payment where psychiatric nursing is furnished by an agency which is not primarily for the care and treatment of mental diseases. Should the intermediary find that the number of bills submitted for individuals with mental disorders is significant enough to raise the possibility that an HHA is primarily for the care and treatment of mental diseases, it notifies the CMS RO.