§ 1249.53. Payment conditions for skilled nursing care.
(a) Skilled nursing care is a covered home health service and is reimbursable under the MA Program if the following conditions are met:
(1) The services are ordered by and included in the plan of treatment established by the recipient’s attending physician.
(Editor’s Note: Under section 2(5)(i) of the act of October 28, 2022 (P.L. 1632, No. 98) and to the extent permitted under Federal law, § 1249.53(a)(1) is abrogated to the extent that home health services are only covered and reimbursable under the medical assistance program if a physician orders the services and establishes the plan of treatment.)
(2) The services are performed by a registered nurse or a licensed practical nurse. A home health agency is not reimbursed for personal care services performed by a registered nurse or licensed practical nurse if not provided in conjunction with skilled services.
(3) The services are reasonable and necessary to the treatment of an illness or injury. To be considered reasonable and necessary, the services furnished shall be:
(i) Consistent with the recipient’s particular medical needs as determined by the recipient’s attending physician.
(ii) Consistent with accepted standards of medical practice.
(b) Skilled nursing care includes, but is not limited to, the following:
(1) Observation and evaluation.
(2) Teaching and training the recipient or family members to provide care such as, but not limited to:
(i) Giving an injection.
(ii) Irrigating a catheter.
(iii) Applying dressings to wounds involving prescription medications and aseptic techniques.
(iv) Teaching the proper use of medications.
(3) Insertion and sterile irrigation of catheters.
(4) Bladder training.
(5) Administering injections.
(6) Administering enteral and intravenous total parenteral nutrition.
(7) Treating decubitus ulcers and other skin disorders.
(c) Activities, such as the administration of eye drops, topical ointments, bathing the skin and applying creams do not constitute skilled care.
Authority The provisions of this § 1249.53 amended under sections 403(a) and (b), 443.2(2) and 509 of the Public Welfare Code (62 P. S. § § 403(a) and (b), 443.2(2) and 509).
Source The provisions of this § 1249.53 adopted December 6, 1980, effective December 1, 1980, 10 Pa.B. 4618; amended August 12, 1988, effective September 1, 1988, 18 Pa.B. 3571. Immediately preceding text appears at serial page (117531).
Cross References This section cited in 55 Pa. Code § 1249.51 (relating to general payment policy).
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