Clinical UM Guideline



Subject: Custodial Care
Guideline #:  CG-MED-19 Current Effective Date:    03/29/2017
Status: Revised Last Review Date:    02/02/2017

Description

This document defines custodial care, a type of care that generally provides assistance in performing activities of daily living (ADL), (for example, assistance walking, transferring in and out of bed, bathing, dressing, using the toilet, preparation of food, feeding 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.

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

Clinical Indications

Care that does not meet the criteria for skilled nursing or skilled rehabilitation services is considered custodial. 
Note: Not all benefit contracts/certificates include benefits for custodial services as defined by this document. Benefit language supersedes this document.

Definition of Custodial Care:

Note: Custodial care may occur in settings other than the home.  

Examples of Custodial Care, include, but are not limited to, the following:

Coding

Coding edits for medical necessity review are not implemented for this guideline. Where a more specific policy or guideline exists, that document will take precedence and may include specific coding edits and/or instructions. 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.

Discussion/General Information

In determining whether care is custodial, consideration should be given to the complexity of care and medical supervision required and furnished. Determinations are not based on the diagnosis, type of condition, degree of functional limitation, or rehabilitation potential.

Institutional care that is below the level of care covered in a Skilled Nursing Facility (SNF) is custodial care. Some examples of custodial care in hospitals and SNFs include, but are not limited to:

Definitions

Acute Medical Event (includes behavioral health events): A relatively abrupt change in condition that requires medical services, intervention(s) intended to arrest and, hopefully, reverse the condition or conditions. Stabilization can be associated with limited ability to meet basic needs, which are addressed with custodial care.

Cardiac Disorder: Condition(s) that affect heart structures or function such as: coronary artery disease, heart attack, heart failure, abnormal heart rhythms, congenital heart disease, vascular disease or heart valve disease.

Severe and Persistent Mental Illness: A mental, behavioral or emotional disorder according to the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders, in members 18 years and older, that results in functional impairment which substantially interferes with or limits one or more major life activities (e.g., maintaining interpersonal relationships, activities of daily living, self-care, employment, recreation) that have occurred within the last year. All of these disorders may have acute episodes as part of the chronic course of the disorder. An organization may also use its state's definition or the definition of another appropriate regulatory authority (National Committee for Quality Assurance [NCQA], 2014).

References

Government Agency, Medical Society, and Other Authoritative Publications:

  1. Centers for Medicare and Medicaid Services. Medicare Benefit Policy Manual. Chapter 8. Coverage of Extended Care (SNF) Services under Hospital Insurance. Rev. 228, 10-13-16. Available at: http://www.cms.hhs.gov/manuals/Downloads/bp102c08.pdf. Accessed on January 3, 2017.
  2. Centers for Medicare and Medicaid Services. Medicare Benefit Policy Manual. Chapter 16. General Exclusions from Coverage. Rev.198, 11-06-14. Available at: http://www.cms.hhs.gov/manuals/Downloads/bp102c16.pdf. Accessed on January 3, 2017.
  3. Centers for Medicare and Medicaid Services. Medicare Benefit Policy Manual. Chapter 7. Home Health Services. Rev. 208, 05-11-15. Available at: http://www.cms.hhs.gov/manuals/Downloads/bp102c07.pdf. Accessed on January 3, 2017.
Websites for Additional Information
  1. National Committee for Quality Assurance (NCQA). Definition of severe and persistent mental illness (SPMI). 2014. Available at: http://app04.ncqa.org/faq/FAQReportList.asp?Product=146&PrintReport=Select+Report. Accessed on February 3, 2017.
History
Status Date Action
Revised 02/02/2017 Medical Policy & Technology Assessment Committee (MPTAC) review. Note added to Clinical Indications section. Definition of custodial care updated. Examples of custodial care updated in Clinical Indications and Discussion/General Information sections. Definition and Websites for Additional Information sections added.
Reviewed 02/04/2016 MPTAC review. Reference section updated.
Reviewed 02/05/2015 MPTAC review. Description and Reference sections updated.
Reviewed 02/13/2014 MPTAC review. Reference links updated.
Reviewed 02/14/2013 MPTAC review. Reference links updated.
Reviewed 02/16/2012 MPTAC review. Reference links updated.
Revised 02/17/2011 MPTAC review. Definition of custodial care and examples of custodial care updated in the Clinical Indication section. Discussion and Reference links updated.
Reviewed 02/25/2010 MPTAC review. Custodial care examples for stable bolus feeding and chronic uncomplicated oral or tracheal suctioning clarified. Place of Service section removed. References updated.
  06/23/2009 Removed CG-MED-25 Hospice, Inpatient Setting from note referring to related documents as CG MED-25 has been archived.
Reviewed 02/26/2009 MPTAC review. References updated. Note under description updated with additional related document. Removed case management section.
Reviewed 02/21/2008 MPTAC review. Note added under description referring to other documents for additional information. References updated.
Reviewed 03/08/2007 MPTAC review. References updated.
Revised 03/23/2006 MPTAC review. Referenced Skilled Nursing and Rehabilitation clinical guideline and aligned definition of custodial care on both documents. 
Revised 12/01/2005 MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.
Pre-Merger Organizations

Last Review Date

Document Number

Title

Anthem, Inc.

 

 

None  
Anthem Mid West

02/11/2005

MA-020 Skilled Nursing Facility Setting, Skilled and Custodial Services Defined
Anthem Mid West

02/11/2005

MA-021 Home Health Care Setting, Skilled and Custodial Services Defined for NASCO use only
WellPoint Health Networks, Inc.

06/24/2004

Definitions Custodial Care