Clinical UM Guideline

 

Subject: Home Health
Guideline #:  CG-MED-23 Publish Date:    11/02/2018
Status: Revised Last Review Date:    03/22/2018

Description

This document addresses home health care and the conditions under which it would be considered medically necessary. Home health care refers to intermittent skilled health care related services provided by or through a licensed home health agency to an individual in his or her place of residence. Home health care includes skilled nursing care, as well as other skilled care services including, but not limited to, physical, occupational, and speech therapies.

Note: Please see the following related documents for additional information:

Note: This document does not address home health care for mental health conditions.

Clinical Indications

Medically Necessary:

Home health services are considered medically necessary when all of the following criteria A through D are met:

  1. The individual is confined to the home:
    1. The individual’s overall physical/medical condition poses a serious and significant impediment to receiving intermittent or occasional, skilled, medically necessary services outside the home setting. This includes those who are bedridden and those who are non-bedridden but whose medical condition is such that they meet all other criteria for home health services. In general, the condition of these individuals should be such that there exists a normal inability to leave home and, consequently, leaving home would require a considerable and taxing effort; and
    2. If the individual does in fact leave the home, the absences from the home are infrequent or for periods of relatively short duration, or are attributable to the need to receive health care treatment. The following are examples of acceptable medical and non-medical absences (these examples are not all-inclusive and are provided as a means to illustrate the kinds of infrequent or unique events an individual may attend):
      1. Medical absences to receive health care treatment, including but not limited to:
        1. Ongoing receipt of outpatient kidney dialysis; or
        2. Receipt of outpatient chemotherapy or radiation therapy; or
        3. Participation in psychosocial or medical treatment in an adult day-care program that is licensed or certified by a state, or accredited, to furnish adult day-care services; or
      2. Non-medical absences:
        1. To attend a funeral, religious service, or graduation; or
        2. An occasional trip to the barber, a walk around the block; or
        3. Other infrequent or unique event (for example, a family reunion or other such occurrence);
          Note: Any absence of an individual from the home attributable to the need to receive health care treatment of the types described above shall not disqualify an individual from being considered to be confined to the home. Any other absence from the home shall not so disqualify an individual if the absence is of infrequent or of relatively short duration. It is expected that in most instances, absences from the home that occur will be for the purpose of receiving health care treatment. However, occasional absences from the home for nonmedical purposes, as described above, would not necessitate a finding that one is not homebound if the absences are undertaken on an infrequent basis or are of relatively short duration and do not indicate that the individual has the capacity to obtain the health care provided outside rather than in the home.
          and
  2. The service must be prescribed by the attending physician, health care provider practicing within the scope of license, or the primary care physician in coordination with the attending physician as part of a written plan of care;
    and
  3. The service(s) is so inherently complex that it can be safely and effectively performed only by:
    1. Qualified technical or professional health personnel such as registered nurses, licensed practical (vocational) nurses, physical therapists, licensed social-workers, speech pathologists, or audiologists;
      and
    2. The home health services are provided directly by or under the general supervision of these skilled nursing, skilled rehabilitation, or professional personnel to assure safety and to achieve the desired result;
      and
  4. The primary care physician, health care provider practicing within the scope of license, or attending physician in coordination with the primary care physician should review the treatment plan at least once every 30 days to assess the continued need for skilled intervention.

Certain extended home infusion treatments are considered medically necessary because they are more appropriately performed in the home setting, even if the member is not homebound. The optimal location for these treatments is dependent upon a number of factors including the toxicity of the medication, the individual’s previous response to the treatment, the monitoring required for safe administration, and the individual’s underlying medical condition. Examples of infusion treatments sometimes performed in the home setting include, but are not limited to, the following:

  1. Intravenous gamma globulin; or
  2. Intravenous hydration for a variety of conditions; or
  3. Infusions for pain control; or
  4. Some chemotherapy regimens.

Other conditions for which intermittent intravenous infusions of medications provided in the home setting are considered medically necessary either because of the complexity of the underlying condition, or the infusion itself include, but are not limited to, the following:

  1. Infections requiring a prolonged treatment course; or
  2. Coagulation disorders; or
  3. Enzyme deficiency states; or
  4. Pain management.

Not Medically Necessary:

Home health services are considered not medically necessary when:

  1. The treatment plan provided by the primary care physician does not demonstrate the continued need for skilled intervention; or
  2. Goals have been achieved per plan of care.
Duration

Duration: Dependent upon the individual needs of the person receiving home health services.

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

CPT

 

99500

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

99503

Home visit for respiratory therapy care (eg, 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) (eg, urinary, drainage, and enteral)

99509

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

99511

Home visit for fecal impaction management and enema administration

99512

Home visit for hemodialysis

99600

Unlisted home visit service or procedure

99601

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

99602

Home infusion/specialty drug administration, per visit , each additional hour

 

 

HCPCS

 

G0151

Services performed by a qualified physical therapist in the home health or hospice setting, each 15 minutes

G0152

Services performed by a qualified occupational therapist in the home health or hospice setting, each 15 minutes

G0153

Services performed by a qualified speech-language pathologist in the home health or hospice setting, each 15 minutes

G0155

Services of clinical social worker in home health or hospice settings, each 15 minutes

G0156

Services of home health/hospice aide in home health or hospice settings, each 15 minutes

G0157

Services performed by a qualified physical therapist assistant in the home health or hospice setting, each 15 minutes

G0158

Services performed by a qualified occupational therapist assistant in the home health or hospice setting, each 15 minutes

G0159

Services performed by a qualified physical therapist, in the home health setting, in the establishment or delivery of a safe and effective physical therapy maintenance program, each 15 minutes

G0160

Services performed by a qualified occupational therapist, in the home health setting, in the establishment or delivery of a safe and effective occupational therapy maintenance program, each 15 minutes

G0161

Services performed by a qualified speech-language pathologist, in the home health setting, in the establishment or delivery of a safe and effective speech-language pathology maintenance program, each 15 minutes

G0162

Skilled services by a registered nurse (RN) for management and 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 achieves its purpose in the home health or hospice setting)

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 licensed practical nurse (LPN) in the home health or hospice setting, each 15 minutes

G0493

Skilled services of a registered nurse (RN) for the observation and assessment of the patient's condition, each 15 minutes (the 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)

G0494

Skilled services of a licensed practical nurse (LPN) for the observation and assessment of the patient's condition, each 15 minutes (the 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)

G0495

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

G0496

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

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)

S5035

Home infusion, therapy, routine service of infusion device (e.g., pump maintenance)

S5036

Home infusion therapy, repair of infusion device (e.g., pump repair)

S5108

Home care training to home care client; per 15 minutes

S5109

Home care training to home care client; per session

S5110-S5111

Home care training, family

S5115-S5116

Home care training, non-family

S5180-S5181

Home health respiratory therapy

S5497-S5523

Home infusion therapy, catheter care maintenance and supplies (includes codes S5497, S5498, S5501, S5502, S5517, S5518, S5520, S5521, S5522, S5523)

S9061

Home administration of aerosolized drug therapy (e.g., pentamidine); per diem

S9097

Home visit for wound care

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.

S9124

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

S9127

Social work visit, in the home, per diem

S9128

Speech therapy, in the home, per diem

S9129

Occupational therapy, in the home, per diem

S9131

Physical therapy, in the home, per diem

S9209-S9214

Home management of complications of pregnancy (includes codes S9209, S9211, S9212, S9213, S9214)

S9325-S9328

Home infusion therapy, pain management infusion, per diem (includes codes S9325, S9326, S9327, S9328)

S9329-S9331

Home infusion therapy, chemotherapy infusion, per diem (includes codes S9329, S9330, S9331)

S9336

Home infusion therapy, continuous anticoagulant infusion therapy (e.g., Heparin); per diem

S9338

Home infusion therapy, immunotherapy; per diem

S9345

Home infusion therapy, anti-hemophilic agent infusion therapy (e.g., factor VIII); per diem

S9346

Home infusion therapy, alpha-1-proteinase inhibitor (e.g., Prolastin); per diem

S9348

Home infusion therapy, sympathomimetic/inotropic agent infusion therapy (e.g., Dobutamine); per diem

S9351

Home infusion therapy, continuous antiemetic infusion therapy; per diem

S9353

Home infusion therapy, continuous insulin infusion therapy; per diem

S9357

Home infusion therapy, enzyme replacement intravenous therapy (e.g., Imiglucerase); per diem

S9361

Home infusion therapy, diuretic intravenous therapy; per diem

S9363

Home infusion therapy, antispasmotic therapy; per diem

S9364-S9368

Home infusion therapy, total parenteral nutrition (TPN); per diem (includes codes S9364, S9365, S9366, S9367, S9368)

S9370

Home therapy, intermittent antiemetic injection therapy; per diem

S9372

Home therapy, intermittent anticoagulant injection therapy (e.g., Heparin), per diem

S9373-S9377

Home infusion therapy, hydration therapy; per diem (includes codes S9373, S9374, S9375, S9376, S9377)

S9379

Home infusion therapy, infusion therapy not otherwise classified; per diem

S9490

Home infusion therapy, corticosteroid infusion; per diem

S9494-S9504

Home infusion therapy, antibiotic, antiviral, or antifungal therapy; per diem (includes codes S9494, S9497, S9500, S9501, S9502, S9503, S9504)

S9538

Home transfusion of blood product(s); per diem

S9542

Home injectable therapy, not otherwise classified; per diem

S9560

Home injectable therapy, hormonal therapy (e.g., leuprolide, goserelin); per diem

S9590

Home therapy, irrigation therapy (e.g., sterile irrigation of an organ or anatomical cavity); per diem

S9810

Home therapy, professional pharmacy services, per hour

T1001

Nursing assessment/evaluation

T1002

RN services, up to 15 minutes

T1003

LPN/LVN services, up to 15 minutes

T1004

Services of a qualified nursing aide, up to 15 minutes

T1021

Home health aide or certified nurse assistant, per visit

T1022

Contracted home health agency services, all services provided under contract, per day

T1030

Nursing care, in the home, by registered nurse, per diem

T1031

Nursing care, in the home, by licensed practical nurse, per diem

 

 

Revenue Code

 

0550-0559

Skilled nursing (includes codes 0550, 0551, 0552, 0559)

0570-0579

Home health aide (includes codes 0570, 0571, 0572, 0579)

0580-0589

Home health, other visits (includes codes 0580, 0581, 0582, 0583, 0589)

0590-0599

Home health, units of service (includes codes 0590, 0599)

 

 

ICD-10 Diagnosis

 

 

All diagnoses

Discussion/General Information

Home health services are generally considered when the skilled services currently being provided by the facility (on an in-patient basis) can be provided in the home setting. Home health services are frequently provided by the following professionally trained practitioners:

It is not unusual for a skilled nurse or other medical professional to educate the person receiving care, family member, or caregiver with regards to how to manage the treatment regimen and to provide skills for overcoming or adapting to functional loss. While services may be received from several skilled providers, it is important that the services provided during the home health visits are not duplicative. The determination of how long an individual requires home health care and what type of skilled practitioners will provide care is determined by the clinical response to treatment.

The homebound criteria set forth in this document are largely based on the recommendations made by the Department of Health and Human Services and the Centers for Medicaid and Medicare Services. The criteria are intended to be used as a tool to aid in the identification of individuals who will experience a significant hardship in obtaining the medical care needed for the treatment of an illness or recovery from an injury if medical services are not provided in the home setting. The lack of transportation does not automatically qualify an individual to be considered homebound.

References

Government Agency, Medical Society, and Other Authoritative Publications:

  1. Centers for Medicare and Medicaid Services. Medicare Benefit Policy Manual. Chapter 7. Home Health Services. Rev. 233, 02-24-17. Available at: http://www.cms.hhs.gov/manuals/Downloads/bp102c07.pdf. Accessed on January 23, 2018.
  2. Centers for Medicare and Medicaid Services (CMS). National Coverage Determination. Home nurses' visits to patients requiring heparin injection. NCD #290.2. Effective date not posted. Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=210&ncdver=1&DocID=290.2&bc=gAAAAAgAAAAA&. Accessed on January 23, 2018.
  3. Centers for Medicare and Medicaid Services (CMS). National Coverage Determination. Home health visits to a blind diabetic. NCD #290.1. Version #2. Effective October 1, 2006. Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=209&ncdver=2&CoverageSelection=Both&ArticleType=All&PolicyType=Final&s=All&KeyWord=
    home+health+visits&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAABAAAAAA&.
    Accessed on January 23, 2018.
  4. Centers for Medicare and Medicaid Services (CMS). National Coverage Determination. Postural drainage procedures and pulmonary exercises. NCD #240.7. Effective September 1, 1988. Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=17&ncdver=1&DocID=240.7&bc=gAAAAAgAAAAA&. Accessed on January 23, 2018.
Index

Home Health

History

Status

Date

Action

Revised

03/22/2018

Medical Policy & Technology Assessment Committee (MPTAC) review.  Removed BH references from document. Updated Coding section; removed CPT 99510.

Revised

02/27/2018

MPTAC review.

Revised

02/23/2018

Behavioral Health Subcommittee review. The document header wording updated from “Current Effective Date” to “Publish Date.” Updated formatting in Clinical Indications section. Updated Description, Clinical Indications, Discussion/General Information, and References sections.

Reviewed

08/03/2017

MPTAC review. References section updated.

 

01/01/2017

Updated Coding section with 01/01/2017 HCPCS changes; removed codes G0163, G0164 deleted 12/31/2016.

Reviewed

08/04/2016

MPTAC review. Updated formatting in Clinical Indications section. References section updated.

 

01/01/2016

Updated Coding section with 01/01/2016 HCPCS changes, removed G0154 deleted 12/31/2015; also removed ICD-9 codes.

Reviewed

08/06/2015

MPTAC review. Description and References sections updated.

Revised

08/14/2014

MPTAC review. Clinical indications updated to include additional health professionals and to indicate that primary care physicians and attending physicians may coordinate care. References section updated.

Reviewed

08/08/2013

MPTAC review. References section updated. Web Sites section removed.

 

07/01/2013

Updated Coding section to include HCPCS Q5001, Q5002, Q5009.

 

04/01/2013

Updated Coding section to include CPT 99512.

Reviewed

08/09/2012

MPTAC review. Description (note), References and Web Sites sections updated.

Reviewed

08/18/2011

MPTAC review. Discussion, References and Web Sites sections updated.

 

01/01/2011

Updated Coding section with 01/01/2011 HCPCS changes.

Reviewed

08/19/2010

MPTAC review. Discussion, Reference links and Web sites for additional information updated.

 

01/01/2010

Updated Coding section with 01/01/2010 HCPCS changes.

Reviewed

08/27/2009

MPTAC review. Note below Description, Discussion and References updated. Place of Service section removed.

Reviewed

08/28/2008

MPTAC review. Note added (following the description) referring to related documents for additional information. Description, Discussion and References updated.

Reviewed

08/23/2007

MPTAC review. Review date, References, Coding and History sections updated.

Reviewed

09/14/2006

MPTAC review. References and Coding updated.

 

11/21/2005

Added reference for Centers for Medicare and Medicaid Services (CMS) – National Coverage Determination (NCD).

Revised

09/22/2005

Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization. MPTAC reviewed and approved revisions.

  • Former PMW document entitled “Home Health” archived.
  • New Clinical Guideline entitled “Home Health” developed.
  • Expanded explanation of “homebound status”.
  • A review of the peer reviewed scientific literature from 08/01/2004 to 08/05/2005 did not yield information that would result in a modification to the current patient selection criteria.
  • References updated to reflect correct titles and web sites (when applicable).
Pre-Merger Organizations Last Review Date Guideline Number Title
Anthem, Inc.     No prior document.

WellPoint Health Networks, Inc.

09/23/2004

Definition vi

Home Health