Clinical UM Guideline



Subject: Home Health
Guideline #:  CG-MED-23 Current Effective Date:    09/27/2017
Status: Reviewed Last Review Date:    08/03/2017

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:

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 should pose 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.
    2. If the individual does in fact leave the home, he or she may nevertheless be considered homebound if 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:
      1. Medical Absences - to receive health care treatment, including but not limited to:
        1. ongoing receipt of outpatient kidney dialysis; 
        2. receipt of outpatient chemotherapy or radiation therapy;
        3. participation in therapeutic, 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.
      2. Non-medical Absences:
        1. to attend a funeral, religious service, or graduation;
        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).
    3. 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.
      *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.
  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.
  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, licensed mental health professionals ,and speech pathologists or audiologists; and
    2. The home health services are provided directly by or under the general supervision of these skilled nursing or skilled rehabilitation and/or skilled licensed mental health professional personnel to assure safety and to achieve the desired result.
  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.

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: 

Not Medically Necessary: 

Home health services are considered not medically necessary when:

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
99510 Home visit for individual, family, or marriage counseling
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 and psychosocial factors. 

The homebound criteria set forth in this guideline are largely based on the recommendations made by the Department of Health and Human Services and the Centers for Medicaid and Medicare Services which state the following:

Any absence of an individual from the home attributable to the need to receive health care treatment, including regular absences for the purpose of participating in therapeutic, 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 in the State shall not disqualify an individual from being considered to be confined to his home. Any other absence of an individual from the home shall not so disqualify an individual if the absence is of infrequent or of relatively short duration. For purposes of the preceding sentence, any absence for the purpose of attending a religious service shall be deemed to be an absence of infrequent or short duration.

The criteria set forth in this document 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 June 13, 2017.
  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 June 13, 2017.
  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&Key
    WordLookUp=Title&KeyWordSearchType=And&bc=gAAAABAAAAAA&. Accessed on June 13, 2017.
  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 June 13, 2017.
Index

Home Health

History
Status Date Action
Reviewed 08/03/2017 Medical Policy & Technology Assessment Committee (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