L31532-LCD

Automated World Health

Local Coverage Determination (LCD) for Home Health Skilled Nursing

Care-Teaching and Training: Alzheimer's Disease and Behavioral Disturbances (L31532)

Contractor Information

Contractor Name Palmetto GBA

Contractor Number 11004

Contractor Type HHH MAC

LCD Information

Document Information

LCD ID Number L31532

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

Contractor's Determination Number J11HH-11-003-L

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Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.

Primary Geographic Jurisdiction opens in new window Alabama

Arkansas Florida Georgia Illinois Indiana Kentucky Louisiana Mississippi

North Carolina New Mexico Ohio Oklahoma

South Carolina Tennessee Texas

Oversight Region Region IV

Original Determination Effective Date

For services performed on or after 01/24/2011 Original Determination Ending Date

Revision Effective Date

For services performed on or after 11/16/2012

Revision Ending Date

CMS National Coverage Policy

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.

CMS Manual System, Pub. 100-02 Medicare Benefit Policy Manual, Chapter 7 – Home Health Services, §40.1.2.3 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.

Federal Register Final Rule/Vol. 74, No 216, dated November 10, 2009, pp 58111-58112. (42 CFR 409.42 (c)(1)(ii))

Indications and Limitations of Coverage and/or Medical Necessity

This policy addresses a specific category of skilled nursing care currently available to Medicare home health beneficiaries with Alzheimer’s disease and behavioral disturbances – the category of skilled nursing care is called “teaching and training activities”. Teaching and training activities are defined in the CMS Manual System (see citation under CMS National Coverage Policy section of this policy) and in the case of the beneficiary population with Alzheimer’s disease 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.

Behavioral disturbances often complicate the medical management of beneficiaries with Alzheimer’s disease. At baseline many individuals with Alzheimer’s disease 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, and 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. Use of the World Health Organization’s International Classification of Functioning Disability and Health (ICF) would facilitate the identification and documentation of specific impairments, activity limitations, and environmental factors.

In the home health 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.

Coding Information

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

032x Home Health - Inpatient (plan of treatment under Part B only)

033x Home Health - Outpatient (plan of treatment under Part A, including DME under Part A)

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

0550 Skilled Nursing - General Classification

CPT/HCPCS Codes

G0154 DIRECT SKILLED NURSING SERVICES OF A LICENSED NURSE (LPN OR RN) IN THE HOME HEALTH OR HOSPICE SETTING, EACH 15 MINUTES

ICD-9 Codes that Support Medical Necessity

294.11 DEMENTIA IN CONDITIONS CLASSIFIED ELSEWHERE WITH BEHAVIORAL DISTURBANCE

294.21 DEMENTIA, UNSPECIFIED, WITH BEHAVIORAL DISTURBANCE

331.0 ALZHEIMER'S DISEASE

Diagnoses that Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity N/A

General Information

Documentations Requirements

Documentation supporting the medical necessity should be legible, maintained in the patient’s medical record, and must be made available to the A/B MAC upon request.

Documentation should include:

Characterization of target behavior(s) as described under the Indications and Limitations of Coverage and/or Medical Necessity section of this LCD.

The specific impairment(s) and activity limitation(s) identified for each beneficiary.

An evaluation of the ability of the family or caregiver to learn and implement the proposed interventions. If the family or caregiver could not or would not be trained, further teaching and training would cease to be reasonable and necessary. At that point the teaching and training would cease to be considered a skilled service.

Environmental factors impacting the identified behavior(s) and the resultant care plan.

For unsuccessful teaching and training services, the reason(s) why the training was unsuccessful should be documented in the record.

Appendices N/A

Utilization Guidelines N/A

Sources of Information and Basis for Decision

Gray KF Managing agitation and difficult behavior in dementia. Clinics in Geriatric Medicine Volume 20, Number 1, February 2004.

World Health Organization International Classification of Functioning, Disability, and Health: ICF World Health Organization, Geneva 2001.

Occupational Therapy Practice Guidelines for Adults With Alzheimer’s Disease. The AOTA Practice Guidelines Series; AOTA. (2001) Advisory Committee Meeting Notes This policy does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the Intermediary, this policy was

developed in cooperation with advisory groups, which include representatives from Home Health Providers.

Advisory Committee Meeting date:

Start Date of Comment Period

End Date of Comment Period

Start Date of Notice Period 12/09/2010

Revision History Number Revision #2, 11/16/2012

Revision History Explanation Revision #2, 11/16/2012

Under Documentation Requirements changed the word "Intermediary" to "A/B MAC." Annual review completed. This revision becomes effective on 11/16/2012.

Revision #1, 10/01/2011

Under ICD-9 Codes That Support Medical Necessity ICD-9 code 294.21 was added. This revision becomes effective 10/01/2011.

01/24/2011 - In accordance with Section 911 of the Medicare Modernization Act of 2003, Palmetto GBA Title 18 RHHI (00380) was removed from this LCD and implemented to Palmetto GBA J11 HH and H MAC (11004). Effective date of this Implementation is January 24, 2011.

Reason for Change Maintenance (annual review with new changes, formatting, etc.)