Skilled Nursing Care in the Home

Number 10.01.500*

Effective Date July 24, 2013

Revision Date(s) 07/08/13; 09/11/12; 12/13/11; 02/09/10; 02/10/09; 06/10/08; 07/10/07; 07/11/06; 07/12/05; 07/13/04; 12/10/02; 09/21/00; 07/25; 11/02/99

Replaces None

*Medicare has a policy.


Skilled nursing care in the home setting may be considered medically necessary when applicable MCG™ (formerly Milliman Care Guidelines) and ALL of the following criteria are met:

  • The patient must be confined to the home also called homebound. This means the patient’s physical condition makes it difficult to get in/out of bed without help from one other person. And two people, the driver and another person, are needed to help the patient in/out of a car or other means of transport in order to leave the home.

Note: Homebound status is not determined by the lack of available transportation. Homebound status may be applied to members whose immune status or overall health status is compromised to a degree that reverse isolation precautions are recommended by their providers to limit their exposure to possible infection. (Examples of this are extremely premature infants, members undergoing intensive chemotherapy, or members with a chronic disease that has lowered their immune status and thus resistance to disease).

  • The patient must meet skilled care criteria.
  • Services are required for the patient to regain or partially regain a prior level of function.
  • Services of one discipline or agency may not duplicate those provided by another.
  • The services must be ordered by a physician and directly related to an active treatment plan of care established by the physician.

Related Policies


Physical Medicine and Rehabilitation – Physical Therapy and Medical Massage Therapy


Occupational Therapy


Speech Therapy


Criteria for Acute Inpatient Rehabilitation Care

Policy Guidelines

Skilled Nursing Services in the home

Skilled nursing care is provided in the home setting by a registered nurse (RN) or Licensed Practical Nurse (LPN).

The care must require the technical proficiency, scientific skills, and knowledge of an RN or LPN.

Criteria for skilled nursing visits in the home setting are:

  • The need for skilled nursing is determined by the condition of the patient, the nature of the services required and the complexity or technical aspects of the services provided. Nursing care is not skilled simply because an RN or LPN delivers it or because a physician orders it.
  • The following treatments, procedures, or services require the skills and technical expertise of an RN or LPN and home visits to provide them may be considered medically necessary. The patient must require at least one of the following to qualify for home skilled nursing visits. In conjunction with delivering these services, the nurse is expected to provide teaching and training to the patient, available family members and/or caregiver(s). The goal of this teaching is to facilitate participation in and/or assumption of the patient’s care.
  • Skilled supervision and management: required due to a high probability, as opposed to a possibility, that complications would arise without oversight of the treatment program by a licensed nurse.
  • Skilled observation, assessment, and monitoring of the patient are required due to a complicated condition.
  • Teaching
  • The activity or procedure being taught may or may not be skilled; the teaching is the skilled service.
  • There must be documentation of the reason why the teaching was not completed in the prior treatment setting, if any, and of the patient’s capability of compliance.
  • Visit frequency depends on the complexity of the procedure being taught and the learning ability of the caregiver and/or patient.
  • In general, up to three visits for teaching may be medically necessary. If more than three visits are needed, there must be documentation of learning barriers or unusual circumstances.
  • Once a procedure is mastered by the patient and/or caregiver, further visits to reiterate previous teaching are considered not medically necessary.
  • If a caregiver changes, additional visits may be medically necessary for the purpose of training the new caregiver.
  • Catheter care may be medically necessary for the following services:
  • Insertion of urinary catheters, visit frequency should be every 3-6 weeks unless unusual circumstances are documented.
  • Irrigation of indwelling catheters.
  • Straight catheterization for residual, or to obtain a specimen for a urinary analysis (UA). Ongoing intermittent straight catheterization would be considered non-skilled.
  • Teaching of catheter care
  • Catheter removal
  • Feeding tubes (nasogastric, jejunostomy, gastrostomy) may be medically necessary for the following services:
  • Feeding tube insertion
  • Feeding tube irrigation, depending on the severity of the patient’s condition
  • Teaching feeding tube management and care
  • Non-routine subcutaneous (SQ), intramuscular (IM, or intravenous (IV) medication administration may be medically necessary if the drug is the appropriate treatment for the condition and there is a medical reason for not administering the oral form of the drug if one is available. Teaching subcutaneous administration management should be accomplished in 1 to 3 visits.
  • Complex medication management
  • Home visits may be medically necessary for management of a complex range of newly prescribed medications (including oral) where there is a high probability of adverse reactions and/or a change in the dosage or type of medication. Up to 3 visits may be necessary unless the patient’s condition changes and a new treatment plan must be made.
  • Wound care may be medically necessary when the following criteria are met:
  • Extensive wound care is needed (i.e., packing, debridement, irrigation, using sterile technique)
  • Occasional nursing visits for assessment of wound healing may be necessary in complicated cases (e.g., diabetics). Visits solely for observation in uncomplicated cases that do not include extensive wound care are not considered medically necessary.
  • Stoma dilation for colostomy care
  • Manual removal of a fecal impaction
  • Blood draws if portable lab service is not available
  • Ventilator or continuous positive airway pressure (CPAP) monitoring for respiratory insufficiency in the home is considered medically necessary when all the following criteria are met:
  • For patients on a ventilator up to 24 hours per day for up to three weeks upon initial discharge from an inpatient setting as a transition to home may be medically necessary. Thereafter up to 16 hours of home nursing care per day is considered medically necessary.
  • If 24 hours per day of nursing care is being requested for an indefinite period of time, SNF placement should be considered. If a SNF bed is not available, home nursing care for up to 24 hours may be medically necessary until a SNF bed is available.

An essential factor in consideration of home care is the availability of family members or other sources of support for the patient who is both willing and able to participate in the care. If family or other sources of care are not available or are not willing to assume significant care duties after a reasonable period of training, home care should not be considered for the member. In these cases the member or family should be directed to appropriate facilities for the level of care needed.

Non-Skilled Services

The following are examples of non-skilled services unless there is documentation of extraordinary comorbidities and complications which require individual consideration.

  • Administration and/or set up of oral medications
  • Administration of oxygen, IPPB treatements and nebulizer treatments
  • Administration of suppositories and/or enema
  • Application of eye drops or ointments or topical medications
  • Custodial care: activities of daily living that can be provided by non-medical people for example help in bathing, eating, dressing, and preventing a person from self-harm
  • Heat treatments: whirlpool, paraffin baths and heat lamps
  • Home health aides and supervisory visits for observation of home health aides
  • Ongoing intermittent straight catheterization for chronic conditions
  • Preparation of plans, records, or programs involved in care is considered an administrative function and not direct patient care.
  • Routine administration of maintenance medications including insulin. This applies to oral, SQ, IM, and IV medications
  • Routine colostomy care
  • Routine enteral feedings
  • Routine foot and nail care
  • Routine services directed toward the prevention of injury or illness
  • Simple dressing changes
  • Suctioning of the nasopharynx
  • Visits for administrative purposes such as recertification assessments


Skilled nursing services in the home setting may be medically necessary for the treatment of an illness, disease, or bodily for restoration of function and health. The services are intermittent and provided in place of a hospital or nursing home confinement or leaving the home for the skilled care. Coverage for skilled nursing care in the home is based on the member’s health plan contract benefits and medical necessity.

Facility based treatment may be shortened and the transition to home made more safe and effective by providing medically necessary care in the home when it has been determined that the condition is medically stable but specific interventions are required to maintain that status and support continued improvement. This is short term, episodic care.

Examples of cases in this category are post-surgical delay or complication of wound healing, newly instituted regimes of care that require self-injected medications, new conditions that require training for self-care such as management of colostomy or ileostomy care, transition to home for members with motor impairments such as stroke or fractures that limit mobility or more severe limitation situations.

Some medical conditions create the need for observation with possible need for intervention if self-care is compromised by inability to perform critical functions. This may be long term care and benefits may not be available depending on the individual patient’s clinical needs.

Some examples of this category are:

  • Communication is severely impaired or non-existent
  • Management of secretions is severely impaired or non-existent
  • Nutritional needs must be managed by alternative methods
  • Voluntary movement is severely impaired or non-existent

Skilled Home Care is provided in two ways:

  1. Home Health Services are agency based services that include registered nurse (RN), licensed practical nurse (LPN), home health aide (HHA), and certified nursing assistant (CNA) services as well as physical therapist (PT), occupational therapist (OT), speech therapist (ST), and medical social work (MSW) services.
  2. Private Duty Nursing for hourly care may be contracted for individually or through an agency and includes RN and LPN services only. Not all member contracts provide benefits for private duty nursing.

NOTE: Services other than nursing services are addressed in separate medical policies. (See Related Policies).


Medical policies are systematically developed guidelines that serve as a resource for Company staff when determining coverage for specific medical procedures, drugs or devices. Coverage for medical services is subject to the limits and conditions of the member benefit plan. Members and their providers should consult the member benefit booklet or contact a customer service representative to determine whether there are any benefit limitations.

Benefit Application

Most contracts have benefits for Home Health Care, which includes skilled nursing services when criteria are met.

Private Duty Nursing is available in a limited number of contracts but may be used as an alternative to institutional care under the provisions of some member contracts.

The goal of skilled home care is help the member/family reach a level of independence with medical treatments/therapy or home exercise programs so the skilled home visits can decrease then stop. When a member is assessed for home care services, a plan of care needs to be developed that clearly defines the anticipated time to achieve goals for improving functional ability either by the patient, or the caregiver and when home nursing care will cease.

The level of care is one element in the determination of availability of contract benefits. Member contract criteria for Rehabilitation and Home Care need to be reviewed when making determinations regarding coverage. All member contracts describe Skilled Care as the level of care that is needed for benefits to be available. In addition to that requirement, it may be necessary to meet other criteria in order for benefits to be available.




  1. Centers for Medicare and Medicaid Services (CMS). Medicare Benefit Policy Manual. Chapter 7 Home Health Services – Section 40.1.1 Skilled Nursing Care [electronic version]. Available online at: Last accessed June 21, 2013.
  2. Milliman Care Guidelines: 17th Edition, Home Care. (Optimal Recovery Guidelines [ORG] vary by condition/surgery). Available online at: Last accessed June 21, 2013.







Home visit for prenatal monitoring and assessment to include fetal heart rate, non-stress test, uterine monitoring, and gestational diabetes monitoring



Home visit for postnatal assessment and follow-up care



Home visit for newborn care and assessment



Home visit for respiratory therapy care (e.g., bronchodilator, oxygen therapy, respiratory assessment, apnea evaluation)



Home visit for mechanical ventilation care



Home visit for stoma care and maintenance including colostomy and cystostomy



Home visit for intramuscular injections



Home visit for care and maintenance of catheter(s) (e.g., urinary, drainage, and enteral)



Home visit for assistance with activities of daily living and personal care



Home visit for individual, family, or marriage counseling



Home visit for fecal impaction management and enema administration



Home visit for hemodialysis



Unlisted home visit service or procedure

ICD-9 Procedure


ICD-9 Diagnosis




Nursing care, in the home; by registered nurse, per hour (use for general nursing care only, not to be used when CPT codes 99500-99602 can be used)



by licensed practical nurse, per hour

Type of Service

Skilled Nursing


Place of Service









Add to Administrative Section - New Policy


Replace Policy - Proposed Care Management Guidelines/Medical Care Guidelines document addressing Hourly Skilled Nursing Care


Replace Policy - Additional clarification to wording provided by CTCA. No criteria changes.


Replace Policy - Scheduled review; no criteria changes.


Replace Policy - Scheduled review; no criteria changes; new review date only.


Replace Policy - Policy Renumbered from PR.10.01.500. No date changes.


Replace Policy - Policy re-written for ease of understanding. Title changed from Skilled Care, Expanded Nursing Care, Non-Skilled Care, and Custodial Care.


Replace Policy - Policy reviewed; no change to policy statement; Scope and Disclaimer updated.


Replace Policy - Policy updated with literature review; no change in policy statement.


Cross References Updated - No other changes.


Cross References Updated - No other changes.


Replace Policy - Policy updated with literature search; no change in policy statement.


Cross Reference Update - No other changes.


Replace Policy - Policy updated with literature search. Policy statement updated, minor edits did not change the intent of statement.


Code update - All CPT codes added, no other changes.


Replace Policy - Policy updated with literature search; no change in policy statement.


Replace Policy – Policy updated. Removed reference to Interqual criteria.


Replace policy. Policy updated with literature search; no change in policy statement.


Update Related Policies – Add 11.01.501.


Replace policy. Policy statement clarified to state that coverage determination is based on applicable MCG & additional criteria in the policy. Minor edits & format changes for readability. Policy statement unchanged.

Disclaimer: This medical policy is a guide in evaluating the medical necessity of a particular service or treatment. The Company adopts policies after careful review of published peer-reviewed scientific literature, national guidelines and local standards of practice. Since medical technology is constantly changing, the Company reserves the right to review and update policies as appropriate. Member contracts differ in their benefits. Always consult the member benefit booklet or contact a member service representative to determine coverage for a specific medical service or supply. CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA).
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