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Date Printed: July 25, 2016: 11:54 AM

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This medical policy (medical coverage guideline) is Copyright 2016, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2016 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

01-99500-01

Original Effective Date: 12/31/00

Reviewed: 1/24/13

Revised: 01/01/16

Subject: Home Health Care

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates    
           

DESCRIPTION:

This guideline addresses coverage for the various types of health care services that could be provided in the home, as permitted by the member’s contract.

Home health care is the provision of health care services to an individual in the home by health care professionals (e.g., physicians, nurses, therapists) or paraprofessionals (e.g. home health aides) to achieve and sustain an optimum state of health and independence for that individual.

Home health care services include:

POSITION STATEMENT:

 

Certificate of Medical Necessity

Submit a completed Certificate of Medical Necessity (CMN) along with your request to expedite the medical review process.

1. Click the link Speech Therapy in the Home - Certificate of Medical Necessity (MS Word) to open the form.

2. Complete all fields on the form thoroughly.

3. Print and submit a copy of the form with your request.

Note: Florida Blue regularly updates CMNs. Ensure you are using the most current copy of a CMN before submitting to Florida Blue. For a complete list of available CMNs, visit the Certificates of Medical Necessity page.

NOTE: Home Health Care services are covered according to the member’s/subscriber’s contract benefits. Member’s/subscriber’s contract benefits may have limitations, exclusion, or criteria applicable to certain home health care services.

Home health care services meet the definition of medical necessity when the individual receiving the care meets ALL of the following criteria:

  1. The attending physician documents that the patient is unable to leave his or her home without considerable effort due to one or more of the following conditions:

OR

  1. The patient is able to receive care in the home as an appropriate cost-effective alternative to care in another health care setting (e.g., office visits, clinics, inpatient or outpatient rehabilitation, skilled nursing facility, long term care facility, sub-acute setting, dialysis centers).

AND

  1. Home care is prescribed by the attending physician every 60 days. The needed care is:

Skilled nursing care rendered by a licensed Registered Professional Nurse (RN) OR Licensed Practical Nurse (LPN) in the patient's/client's home, is the provision of health care services consisting of certain tasks, procedures, or interventions which may include one or more of the following services:

Physical therapy in the home may include:

Physical therapy in the home is eligible for coverage when criteria for Home Health Care are met and the services are rendered by a licensed Registered Physical Therapist (RPT) within the scope of the licensed therapist’s practice and require the abilities of a licensed RPT to perform, (i.e., cannot be performed by the patient, family member, or caregiver) AND there is continued patient/client progress toward achieving the expected restoration of a physical function, as documented by professional progress notes.

NOTE: The physical therapy and occupational therapy services are covered according to the member’s/subscriber’s contract benefits. Member’s/subscriber’s contract benefits may have limitations, exclusion, or criteria applicable to physical therapy services. Refer also to MCG 01-97000-01, Physical Therapy (PT) and Occupational Therapy (OT).

Occupational therapy evaluation, initial or re-evaluation are considered visits and is eligible for coverage as home health services when ALL of the following conditions exist:

  1. The previously defined requirements for Home Health Care are met;
  2. The services:
  1. There is continued practical improvement in the patient's/client's functional capability, as documented by professional progress notes.

Occupational therapy evaluation/re-evaluation may include one or more of the following:

Occupational therapy evaluation/re-evaluation includes evaluating the level of functioning through special testing. The testing may include the following components:

Speech therapy provided in the home may include one or more of the following services:

Speech therapy is considered a visit and is eligible for coverage when ALL of the following exist:

  1. The previously defined requirements for Home Health Care are met;
  2. The services:

NOTE: The speech therapy services are covered according to the member’s/subscriber’s contract benefits. Member’s/subscriber’s contract benefits may have limitations, exclusion, or criteria applicable to speech therapy services. Refer also to MCG 01-92506-01, Speech Therapy Services.

NOTE: For coverage of speech therapy rendered by a physician or physician's employee, in the physician's office, see 01-92506-01 Speech Therapy.

Medical Social services/counseling may include one or more of the following:

Medical Social services/counseling is considered a visit and is eligible for coverage when ALL of the following exist:

  1. The previously defined requirements for Home Health Care are met;
  2. The services:
  1. The patient is also receiving covered nursing care, physical therapy, occupational therapy OR speech therapy.

Home Health Aide (HHA) services are considered a visit and are eligible for coverage when ALL of the following are met:

  1. The previously defined requirements for Home Health Care are met;
  2. The patient is also receiving covered skilled nursing care, physical therapy, occupational therapy, OR speech therapy.
  3. The home health aide services support the skilled nursing services rendered.
  4. The services:

HHA services that include the following custodial care services do not meet the definition of medical necessity and are generally considered contract exclusions:

Nutrition Guidance may include:

Respiratory therapy may include one or more of the following:

Respiratory therapy is considered a visit and is eligible for coverage when the following exist:

  1. The previously defined requirements for Home Health Care are met;
  2. The services:
  1. There is continued progress by the patient/family member/caregiver toward achieving independence in the performance of respiratory therapy/care, as documented by professional progress notes.

For coverage of respiratory therapy rendered by a physician, see 01-94010-07 Outpatient Pulmonary Rehabilitation Services.

Medical supplies are items designed only to serve a medical purpose and include items such as, but not limited to:

Drugs and biologicals administered by a health care professional in the home are eligible for coverage when:

  1. The previously defined requirements for Home Health Care are met;
  2. The drug OR biological is administered by subcutaneous/intramuscular injection OR intravenous injection/infusion; AND
  3. The services:

Visits provided by health care professionals of differing specialties or by a paraprofessional on the same day, are considered separate visits and are covered services subject to the coverage guidelines outlined above.

Skilled nursing services, physical therapy services, occupational therapy, speech therapy, medical social services are eligible for coverage subject to the previously outlined coverage guidelines when provided:

Home health aid services, nutritional guidance, and respiratory therapy are eligible for coverage subject to the coverage guidelines outlined above and only when provided by a licensed home health agency that employs or contracts with nutritionists/dietitians, HHA's and RRT's.

NOTE: All custodial care and respite care are non-covered as these services are generally contract exclusions.

BILLING/CODING INFORMATION:

The following codes may be used to describe home health care services:

CPT Codes:

92507

Treatment of speech, language, voice communication, and/or auditory processing disorder; individual

99500

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

99501

Home visit for postnatal assessment and follow-up care

99502

Home visit for newborn care and assessment

99503

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

99504

Home visit for mechanical ventilation care

99505

Home visit for stoma care and maintenance including colostomy and cystostomy

99506

Home visit for intramuscular injections

99507

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

99509

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

99510

Home visit for individual, family, or marriage counseling (non-covered)

99511

Home visit for fecal impaction management and enema administration

99512

Home visit for hemodialysis

99601

Home infusion/specialty drug administration, per visit (up to 2 hours)

99602

Home infusion/specialty drug administration, per visit (up to 2 hours); each additional hour (List separately in addition to code for primary procedure)

97001 - 97799

Physical therapy modalities, therapeutic procedures, wound care, tests and measurements, orthotic management, and prosthetic management

HCPCS Codes:

A0160

Non-emergency transportation: per mile - case worker or social worker (non-covered)

G0151 - G0155

Services of physical therapist, occupational therapist, speech and language pathologist, skilled nurse, or clinical social worker in home health setting, each 15 minutes

G0155

Services of Clinical Social Worker in Home Health Care Setting, Each 15 Minutes

G0162

Skilled services by a registered nurse (RN) in the delivery of management & evaluation of the plan of care; each 15 minutes (the patient's underlying condition or complication requires an RN to ensure that essential non-skilled care achieve its purpose in the home health or hospice setting)

G0163

Skilled services of a licensed nurse (LPN or RN) in the delivery of observation & assessment of the patient's condition, each 15 minutes (when the likelihood of change in the patient's condition requires skilled nursing personnel to identify and evaluate the patient's need for possible modification of treatment in the home health or hospice setting)

G0164

Skilled services of a licensed nurse, in the training and/or education of a patient or family member, in the home health or hospice setting, each 15 minutes

G0299

Direct skilled nursing services of a registered nurse (rn) in the home health or hospice setting, each 15 minutes

G0300

Direct skilled nursing services of a license practical nurse (lpn) in the home health or hospice setting, each 15 minutes

G0409

Social Work And Psychological Services, Directly Relating To And/Or Furthering The Patient's Rehabilitation Goals, Each 15 Minutes, Face-To-Face; Individual (Services Provided By A Corf-Qualified Social Worker Or Psychologist In A Corf)

Q5001

Hospice Or Home Health Care Provided In Patient's Home/Residence

Q5002

Hospice Or home Health Care Provided In Assisted Living Facility

Q5009

Hospice Or Home Health Care Provided In Place Not Otherwise Specified (NOS)

S0255

Hospice Referral Visit (Advising Patient And Family Of Care Options) Performed By Nurse, Social Worker, Or Other Designated Staff

S0320

Telephone calls by a registered nurse to a disease management program member for monitoring purposes, per month (non-covered)

S5108

Home care training to home care client; per 15 minutes (non-covered)

S5109

Home care training to home care client; per session (non-covered)

S5110

Home care training, family; per 15 minutes (non-covered)

S5111

Home care training, family; per session (non-covered)

S5115

Home care training, nonfamily; per 15 minutes (non-covered)

S5116

Home care training, nonfamily; per session (non-covered)

S5498 – S5502

Home infusion therapy

S5517 – S5523

Home infusion therapy

S9098

Home visit, phototherapy services (e.g., Bili-lite) including equipment rental, nursing services, blood draw, supplies, and other services, per diem

S9122

Home health aide or certified nurse assistant, providing care in the home; per hour

S9123

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 are used)

S9124

Nursing care, in the home; by licensed practical nurse, per hour

S9127

Social Work Visit, In The Home, Per Diem

S9128 - S9131

Speech therapy, occupational therapy, or physical therapy, in the home, per diem

S9208 - S9214

Home management

S9325 - S9379

Home infusion therapy

S9474

Enterostomal therapy by a registered nurse certified in enterostomal therapy, per diem

S9490 - S9538

Home infusion therapy

S9542 – S9562

Home injectable therapy

S9810

Home therapy; professional pharmacy services for provision of infusion, specialty drug administration and/or disease state management, not otherwise classified, per hour (do not use this code with any per diem code)

LOINC Codes:

The following information may be required documentation to support medical necessity: e.g., attending physician history and physical, attending physician visit notes, other pertinent information such as nursing home records, home health agency records, and records from other healthcare professionals.

Documentation Table

LOINC Codes

LOINC Time Frame Modifier Code

LOINC Time Frame Modifier Codes Narrative

Attending physician visit note

18733-6

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Physician initial assessment

18736-9

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Physical therapy initial assessment

18735-1

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Treatment plan, plan of treatment

18776-5

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Physician history and physical

28626-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Physician history and physical

28626-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Clinical notes and chart section (i.e., nursing home records, home health agency records, and other health care professional

28650-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

REIMBURSEMENT INFORMATION:

Reimbursement for skilled nursing care in the home is limited to no more than 12 hours per day, 7 days per week unless otherwise limited by the contract language.

Reimbursement for Physical Therapy evaluation/re-evaluation: Refer to member’s/subscriber’s contract benefits. Member’s/subscriber’s contract benefits may have limitations, exclusion, or criteria applicable to physical therapy services. Services may be subject to medical review of documentation (e.g., physician history and physical, physician progress notes, plan of treatment [narrative], physical therapy treatment plan, progress notes and attainment of goals, reason to continue and justification) for determination of medical necessity.

Reimbursement for Occupational Therapy evaluation or Occupational Therapy re-evaluation in the home is limited to one (1) service per day and 8 visits within a 60-day period unless documented as to medical necessity for Medical Review.

Additionally, reimbursement for initial OT evaluations is limited to one in 6 months.

Reimbursement for a Speech Therapy session is limited to one (1) visit per day unless documented as to medical necessity for Medical Review.

Reimbursement for Respiratory Therapy in the home is limited to one visit per day for one month, unless documented as to medical necessity for Medical Review.

Reimbursement for Medical Social services/counseling is limited to one (1), one-hour visit per day, unless documented as to medical necessity for Medical Review.

Reimbursement for Home Health Aide services provided when the member is also receiving skilled care, PT, OT, or ST and the HHA services support skilled nursing care being rendered, is limited to one visit per day unless documented as to medical necessity.

Reimbursement for Nutritional Guidance provided by a dietitian, nutritionist, LPN or RN is included in the basic allowance of the nursing visit.

Reimbursement for visits provided by health care professionals of differing specialties is limited to one per day for each different professional. Additional visits are subject to medical review of medical necessity.

NOTE: The industry standard definition of a home health “visit” is a visit up to 2 consecutive hours of treatment.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage Products:

The following National Coverage Determination (NCD) was reviewed on the last guideline reviewed date: Home Health Visits to a Blind Diabetic (290.1) located at cms.gov.

The following National Coverage Determination (NCD) was reviewed on the last guideline reviewed date: Home Health Nurses' Visits to Patients Requiring Heparin Injection (290.2) located at cms.gov.

DEFINITIONS:

Biologicals: medicinal preparations (i.e., serums, vaccines, antigens, and antitoxins).

Drugs: chemical compounds used for medicinal purposes.

Custodial care: care that serves to assist an individual in the activities of daily living, such a assistance in walking, getting in and out of bed, bathing, dressing, feeding, and using the toilet, preparation of special diets, and supervision of medication that usually can be self administered. Custodial care essentially is personal care that does not require the continuing attention of trained medical or paramedical personnel. In determining whether a person is receiving custodial care, consideration is given to the level of care and medical supervision required and furnished. A determination that care received is custodial is not based on the patient’s diagnosis, type of condition, degree of functional limitation, or rehabilitation potential.

Homebound: when there is a condition due to illness or injury that restricts the ability to leave the place of residence except with the aid of supportive devices, or special transportation, or assistance of another person, or a condition exists that leaving home is medically contraindicated. This does not include the aged person who does not leave home because of feebleness and insecurity due to advanced age unless the above conditions exist. “Homebound” is not synonymous with “bedridden”.

Respite care: care that provides relief to a primary caregiver who is maintaining and supporting a chronically dependent individual in their home, but who, for a variety of reasons, is temporarily unable to perform that role.

Visit: the industry standard definition of a home health “visit” is a visit up to 2 consecutive hours of treatment.

RELATED GUIDELINES:

Durable Medical Equipment (DME), 09-E0000-01
Home Dialysis Services, Supplies, Equipment, and Accessories, 01-90918-01

Hospice Care, 01-99500-03

Hyperalimentation, 09-A4000-04

Orthotics, 09-L0000-03

Outpatient Pulmonary Rehabilitation Services, 01-94010-07

Physical Therapy (Physical Medicine), 01-97000-01

Speech Therapy, 01-92506-01

OTHER:

None applicable.

REFERENCES:

  1. Agency for Health Care Administration (AHCA), Consumer Awareness Brochure, Home Health Care in Florida (September 2012).
  2. American Academy of Family Physicians, Policy on Home Health Care, 2004, accessed 08/01/07.
  3. Centers for Medicare and Medicaid Services (CMS) National Coverage Determination (NCD) for Home Health Nurses' Visits to Patients Requiring Heparin Injection (290.2). Accessed 01/07/13.
  4. Centers for Medicare and Medicaid Services (CMS) National Coverage Determination (NCD) for Home Health Visits to a Blind Diabetic (290.1); 10/02/06
  5. Centers for Medicare and Medicaid Services (CMS) Medicare Benefit Policy Manual. Chapter 7 - Home Health Services (05/06/11)
  6. Florida Statutes, Chapter 400, Part III, "Home Health Services Act", ss. 400.461-400.518.
  7. HCFA (Medicare) Manuals – Home Health Agency Manual (HHA 204) (03/02).

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 01/24/13.

GUIDELINE UPDATE INFORMATION:

04/08/99

Medical Coverage Guideline Reformatted.

04/15/02

Reviewed, revised to correct typographical and formatting errors; limitations for skilled nursing care changed.

10/01/02

Local codes removed (HIPPA-AS).

11/15/03

Add coverage statement regarding home health care services for non-home bound individuals

10/15/05

Scheduled review (consensus review); no change in guideline.

04/15/06

Revision consisting of adding clarification of reimbursement limitation for skilled nursing care in the home.

12/15/06

Revision consisting of adding Program Exception information for Medicare Advantage products.

09/15/07

Review, coverage statements maintained, guideline reformatted, references updated.

11/15/09

Revision of reimbursement statement regarding physical therapy evaluation/re-evaluation.

08/15/11

Revision of Billing and Coding section to include CPT and HCPCS codes; formatting changes.

06/15/12

Revision of Position Statement, changing recertification period to 60-days.

02/15/13

Review and revisions of Position Statement to clarify coverage criteria; formatting changes; references updated.

07/01/13

3rd Quarter HCPCS coding update: Added Q5001, Q5002, and Q5009; Program Exceptions section updated.

01/01/16

Annual HCPCS code update. Deleted G0154. Added G0299 and G0300.

Date Printed: July 25, 2016: 11:54 AM