LCD for PRN Orders for Skilled Nursing Facilities (L1426)

 

Contractor Information

Contractor Name 

BlueCross BlueShield of Tennessee (Riverbend Government Benefits Administrator) 

Contractor Number 

00390 

Contractor Type 

FI 

 

LCD Information

LCD ID Number 

L1426 

 

LCD Title 

PRN Orders for Skilled Nursing Facilities 

 

Contractor's Determination Number 

1426 

 

AMA CPT / ADA CDT Copyright Statement 

CPT codes, descriptions and other data only are copyright 2007 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.  

 

CMS National Coverage Policy 

Title XVIII of the Social Security Act, Section 1862 (a)(1)(A). This section excludes coverage of items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Title XVIII of the Social Security Act, Section 1862 (a)(7). This section prohibits Medicare payment for any expenses on items and services incurred for routine physical examinations.

Title XVIII of the Social Security Act, Section 1833 (e). This section prohibits Medicare payment for any claim that lacks the necessary information to process the claim.
 

 

Primary Geographic Jurisdiction 

New Jersey
Tennessee
 

 

Secondary Geographic Jurisdiction 

Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
North Carolina
North Dakota
Nebraska
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
Tennessee
Texas
Utah
Virginia
Vermont
Washington
Wisconsin
West Virginia
Wyoming
 

 

Oversight Region 

Region IV
 

 

 

Original Determination Effective Date 

For services performed on or after 04/01/1998  

 

Original Determination Ending Date 

 

 

Revision Effective Date 

For services performed on or after 12/08/2005  

 

Revision Ending Date 

 

 

Indications and Limitations of Coverage and/or Medical Necessity 

Federal legislation has set forth requirements for skilled nursing facilities (SNF) to participate in the Medicare program, and for nursing facilities NFs) to participate in the Medicaid program. One requirement is that each SNF and NF resident have an initial and a periodic comprehensive assessment, in order to institute a comprehensive care plan that meets the resident’s medical, nursing, mental, and psychological needs. The care plan must be developed and revised by an interdisciplinary team that includes at least the attending physician and a registered nurse with responsibility for the resident. The components of the care plan are then documented on the physician’s order sheet, which is signed by the physician and the nurse.

The physician's order sheet is used to list the medications, diet, activities and hygienic needs of a resident of SNF or NF. However, it has also been used to list various providers specialties which may render services and procedures to the resident, and various screening services which may be routinely performed on the resident. Provider specialties have often included audiology, optometry, podiatry, psychology, psychiatry, physical therapy, speech therapy and occupational therapy. Routine screening services have often included laboratory tests, electrocardiograms and portable chest x-rays. These "PRN" or standing orders for care by other provider specialties and provision of routine screening services have resulted in considerable overutilization, and are being addressed by this policy.

Consultations and services ordered on a PRN basis take away from the physician prerogative to have made a decision after evaluating the patient. The decision cannot be passed on to other individuals who are not practitioners within the scope of Medicare's definition.

This policy applies to a "PRN" or "standing" order for any provider specialty or for any routine screening service (except as otherwise specified in manual instructions, e.g. MCM 2049.4 permits a standing order for pneumococcal pneumonia vaccinations) whether the order is written on the physician's order sheet integral to the resident's comprehensive care plan, or elsewhere in the resident's medical record.

This intermediary will not cover any service or procedure that is performed on a resident of a SNF or NF unless:


1. The resident's attending physician evaluates the resident and authorizes the order for the service or procedure, or for the referral of the resident to another provider specialty, or

2. Unless another physician, whose attendance is requested by the resident's family member or legal guardian, and authorizes the order for the service or procedure.

3. The attending physician must be notified of any change in the resident's physical, mental or psychosocial status, or of the need to alter the resident's treatment significantly.



Thus, Medicare will not cover Evaluation and Management (E&M) services, procedure, testing or other services rendered in a nursing home in response to a PRN standing order. Note that this does not apply to PRN medications. Parameter orders (e.g. "CBC and call MD if temperature is over 101.5") are appropriate only if the physician is then promptly informed and involved in the ongoing plan of care.
 

 

Coverage Topic 

Skilled Nursing Facility Care
 

 

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.

 

 

 

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.

 

99999

Not Applicable

 

 

CPT/HCPCS Codes 

 

XX000

Not Applicable

 

 

ICD-9 Codes that Support Medical Necessity 

ICD-9 codes should reflect the diagnosis, reason for the service, or signs and symptoms, that support performance of the service. All ICD-9 codes must be carried to their highest level of specificity.

XX000

Not Applicable

 

 

Diagnoses that Support Medical Necessity 

 

 

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 

 

 

General Information

Documentation Requirements 

1. The medical necessity for and nature of each service or procedure must be clearly documented by a physician, and this physician’s authorization of the order for the service or procedure or for the referral of the resident to another provider specialty, must be clearly recorded in the resident's medical record.

2. There should be a specific order for services requested from another provider, this may be written by the attending physician or given telephonically and signed later on. Progress notes on that day or in case of telephone calls, the subsequent progress notes should reflect the medical necessity for ordering such services and document the contemplated end point for such services. 

 

Appendices 

LINK TO QUESTIONS AND ANSWERS (COMMENTS) ABOUT THIS
POLICY:

Frequently Asked Questions


 

 

Utilization Guidelines 

 

 

Sources of Information and Basis for Decision 

Section 1862 (a)(l)(A) of the Social Security Act.

CRF Part 483, Subpart B-Requirements for Long Term Care Facilities.

"From the Health Care Financing Administration." An article on physical therapy in skilled nursing facilities. JAMA 271:974,1994.

Kim, David B., and Dan R. Berlowitz. The Limited Value of Routine Laboratory Assessments in Severely Impaired Nursing Home Residents. JAMA 272: 1447-1452, 1994.

Ouslander, Joseph 0., and Dan Osterwell. Physician Evaluation and Management of Nursing Home Residents. Ann.Int. Med. 120:584-592, 1994.

Other Carrier and Intermediary Policies 

 

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 contractor, this policy was developed in cooperation with advisory groups, which includes representatives from appropriate specialties as well as provider (facility) representatives. 

 

Start Date of Comment Period 

01/15/1998 

 

End Date of Comment Period 

 

 

Start Date of Notice Period 

03/01/1998 

 

Revision History Number 

057-98h 

 

Revision History Explanation 

07/24/2002 Formatted

01/02/2001 Added information highlighted in blue, updated CPT codes by 2001 code book

This LCD was converted from an LMRP on 12/7/2005

10/05/2007 - Frequently Asked Questions restored to Appendices. 

 

Reason for Change 

Other
 

Last Reviewed On Date 

10/05/2007 

 

Related Documents 

Article(s)
A37897 - PRN Orders for Skilled Nursing Facilities

 

LCD Attachments 

FAQ - Comment and Response (888 bytes)

 

Other Versions 

Updated on 09/01/2006 with effective dates 12/08/2005 - N/A

Updated on 12/07/2005 with effective dates 12/08/2005 - N/A

Updated on 12/07/2005 with effective dates 07/24/2002 - 12/07/2005

Updated on 03/11/2003 with effective dates 07/24/2002 - N/A

Updated on 10/04/2002 with effective dates 07/24/2002 - N/A