LCD/NCD Portal

NCD170.1

 

INSTITUTIONAL AND HOME CARE PATIENT EDUCATION PROGRAMS

 

Effective Date of this Version

• This is a longstanding national coverage determination.

• The effective date of this version has not been posted.

 

Benefit Category

• Extended Care Services.

• Home Health Services.

• Inpatient Hospital Services.

• Outpatient Hospital Services Incident to a Physician's Service.

• Outpatient Occupational Therapy Services.

• Outpatient Physical Therapy Services.

• Note: This may not be an exhaustive list of all applicable Medicare benefit categories for this item or service.

 

Indications and Limitations of Coverage

• While the Act does not specifically identify patient education programs as covered services, reimbursement may be made under Medicare for such programs furnished by providers of services (i.e., hospitals, SNFs, HHAs, and OPT providers) to the extent that the programs are appropriate, integral parts in the rendition of covered services which are reasonable and necessary for the treatment of the individual's illness or injury.

o For example, educational activities carried out by nurses such as teaching patients to give themselves injections, follow prescribed diets, administer colostomy care, administer medical gases, and carry out other inpatient care activities may be reimbursable as a part of covered routine nursing care.

o Also, the teaching by an occupational therapist of compensatory techniques to improve a patient's level of independence in the activities of daily living may be reimbursed as a part of covered occupational therapy.

o Similarly, the instruction of a patient in the carrying out of a maintenance program designed for him/her by a physical therapist may be reimbursed as part of covered physical therapy.

• However, when the educational activities are not closely related to the care and treatment of the patient, such as programs directed toward instructing patients or the public generally in preventive health care activities, reimbursement cannot be made since the Act limits Medicare payment to covered care which is reasonable and necessary for the treatment of an illness or injury.

o For example, programs designed to prevent illness by instructing the general public in the importance of good nutritional habits, exercise regimens, and good hygiene are not reimbursable under Medicare.

 

Medicare NCD Link