The Centers for Medicare and Medicaid Services (CMS) places specific restrictions on coverage for psychiatric home health services and not all psychiatric home services are approved for Medicare reimbursement. CMS places limitations on the quantity of approved home health visits and requires specific training and education for services delivered by home-care providers.

Who Qualifies for Psychiatric Nursing?

Potential patients must meet one or more of the following criteria:

• Be under the care of a psychiatrist or medical doctor and have been diagnosed with psychiatric illness or symptom
• Have auditory or visual hallucinations causing abnormal behavior
• Have uncontrolled anger outbursts
• Have inability to cope because of extreme anxienty
• Have paranoid ideations causing abnormal behavior
• Have agorphobia (fear of leaving his/her home)
• Have a short-term memory deficit requiring supervision to leave home
• Have mental confusion
• Have profound lethargy (inability to maintain continued activity)
• Be unable to self-direct (requires intermittent or constant supervision)
• Have poor judgement (negative social interaction occurs when patient ventures out without supervision)

Diagnosis

• Medicare requires that psychiatric home health recipients have a pre-existing psychiatric diagnosis in order to receive financial reimbursement for services rendered. CMS excludes coverage for the delivery of psychiatric home health services for individuals who are non-compliant, forgetful or difficult to manage.

Treatment

• Patients who receive psychiatric home health services must receive active treatment from a qualified physician who identifies the patient with acute psychiatric symptoms. The patient must be under the care and direction of a physician when he receives home health services. Patients who take psychoactive drugs for non-psychiatric diagnoses, or who have stabilized psychiatric symptoms, do not qualify for Medicare home health services reimbursement.

Referring Physician

• In addition to psychiatrists, any physician may refer patients for psychiatric home health services when warranted, and if the patient is under active treatment. The patient is not required to have a medical diagnosis to be eligible for Medicare reimbursement for psychiatric home health services; however, she must be home-bound to meet the requirements of CMS.

Services

• Psychiatric home health services may include skilled assessment, evaluation, psychotherapy, teaching and counseling by a qualified psychiatric nursing professional, and the services must be under the direction and in collaboration with a physician. Nurses must have specialized psychiatric nurse training and experience that extends beyond standard registered nursing requirements. The nurse and doctor must work together to create an effective care plan based on the patient's condition.

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