Effective Date: 06/23/2010
Title: Skilled Home Health Care
Revision Date: 10/01/2017
CPT Code(s): 99500-99507, 99509, 99510, 99512 , G0156, G0299, G0300, S0320, S5108-S5111, S5115, S5116, S9098, S9122-S9124, S9474, T1000-T1004, T1019-T1021, T1030, T1031
will apply to all services performed on or after the above revision date which
will become the new effective date.
services referred to in this policy that were performed before the revision
date, contact customer service for the rules that would apply.
All home health services require preauthorization.
Skilled Home Health Care is health care given
when a person needs licensed skilled staff- like registered nurse (RN), licensed
practical nurse (LPN), physical or respiratory therapist to manage, observe, and
evaluate care after they have returned home. Skilled care requires the
involvement of licensed staff in order to be given safely and effectively. Care
that can be given by untrained, non-professional staff is not considered skilled
care. The goal of skilled care is to help improve the patient`s condition or to
maintain the patient`s condition and prevent it from getting worse.
QualChoice does not cover custodial care.
Custodial care is care that helps persons with usual or modified activities of
daily living like getting out of bed, walking or using a walker or wheelchair,
eating, or bathing. It may also include care that most people do themselves,
like using eye drops, oxygen, and taking care of colostomy or bladder
Private duty nursing is not covered.
Skilled home health care is the provision of intermittent skilled services to
a member in the home for the purpose of restoring and maintaining his or her
maximal level of function and health. These services are rendered in lieu of
hospitalization, confinement in an extended care facility, or going outside of
the home for the service.
QualChoice considers skilled home health services medically necessary when all
of the following criteria are met:
1. The services are ordered by a physician and are directly related to an active
treatment plan of care established by the physician; and
2. The skilled care is appropriate for the active treatment of a condition,
illness, disease, or injury to avoid placing the member at risk for serious
medical complications; and
3. The skilled care is intermittent or hourly in nature; and
4. The services are provided in lieu of a continued hospitalization, confinement
in a skilled nursing facility (SNF), or receiving outpatient services outside of
the home; and
5. The treatment provided is appropriate for the member`s condition including
the amount of time spent providing the service as well as the frequency and
duration of the services; and
6. The member is homebound because of illness or injury (i.e., the member leaves
home only with considerable and taxing effort and absences from home are
infrequent, or of short duration, or to receive medical care); and
7. The skilled services provided are not primarily for the comfort or
convenience of the member or custodial in nature.
Codes used in this BI:
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.
99504 Home visit for mechanical ventilation care.
99505 Home visit for stoma care and maintenance including colostomy and
99506 Home visit for intramuscular injections.
99507 Home visit for care and maintenance of catheter(s).
99509 Home visit for assistance with activities of daily living and personal
99510 Home visit for individual, family, or marriage counseling.
99512 Home visit for hemodialysis.
G0156 Services of a home health aide in home health or hospice setting, each 15
G0299 Services of skilled nurse in home health or hospice setting, each 15
G0300 Services of an LPN in home health or hospice setting, each 15 minutes
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 can be used).
S9124 Nursing care, in the home; by licensed practical nurse, per hour.
S9474 Enterostomal therapy by a registered nurse certified in enterostomal
therapy, per diem.
T1000 Private duty/independent nursing service(s) - licensed, up to 15 minutes.
T1001 Nursing assessment/evaluation.
T1002 RN Services, up to 15 minutes.
T1003 LPN/LVN services, up to 15 minutes
T1030 Nursing care, in the home, by registered nurse, per diem.
T1031 Nursing care, in the home, by licensed practical nurse, per diem.
S5108 Home care training to home care client; per 15 minutes.
S5109 Home care training to home care client; per session.
S5110 Home care training, family; per 15 minutes.
S5111 Home care training, family; per session.
S5115 Home care training, nonfamily; per 15 minutes.
S5116 Home care training, nonfamily; per session.
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;
T1004 Services of a qualified nursing aide, up to 15 minutes.
T1021 Home health aide or certified nurse assistant, per visit.
The following services are not covered:
1. S0320 Telephone calls by a registered nurse to a disease management program
member for monitoring purposes, per month
2. T1019 Personal care services, per 15 minutes, not for an inpatient or
resident of a hospital, nursing facility, ICF/MR or IMD, part of the
individualized plan of treatment (code may not be used to identify services
provided by a home health aide or certified nurse assistant)
3. T1020 Personal care services, per diem, not for an inpatient or resident of a
hospital, nursing facility, ICF/MR or IMD, part of the individualized plan of
treatment (code may not be used to identify services provided by a home health
aide or certified nurse assistant)
4. Private duty nursing.
U.S. Department of Health and Human Services,
Health Care Financing Administration (HCFA). Skilled nursing care. Home
Health Agency Manual §205.1. HCFA Pub. 11. Baltimore, MD: HCFA; 2000.
Suddarth DS. Lippincott Manual of Nursing
Practice. Philadelphia, PA: J.B. Lippincott Co.; 1991.
Bernstein LH, et al. Primary Care in the
Home. New York, NY: J.B. Lippincott Company; 1987.
Corkery E. Discharge planning and home health
care: What every staff nurse should know. Orthopaed Nurs. 1989; 8(6):18-27.
American Medical Association, Council on
Scientific Affairs. Home care in the 1990s. JAMA. 1990; 263(9):1241-1244.
Maguire GH, ed. Care of the Elderly: A Health
Team Approach. Boston, MA: Little, Brown and Co.; 1985.
Martinson IM, et al. Home Health Care
Nursing. Philadelphia, PA: W.B. Saunders Co.; 1989.
Olson HH. Home health nursing. Caring. 1986;
Cartier C. From home to hospital and back
again: Economic restructuring, end of life, and the gendered problems of
place-switching health services. Soc Sci Med. 2003; 56(11):2289-2301.
Stein J. Medicare and long-term care. Issue
Brief Cent Medicare Educ. 2003; 4(4):1-6.
Kadushin G. Home health care utilization: A
review of the research for social work. Health Soc Work. 2004;
Office of the Secretary, Department of
Defense. TRICARE; Sub-acute care program; Uniform skilled nursing facility
benefit; Home health care benefit; Adopting Medicare payment methods for
skilled nursing facilities and home health care providers. Final rule. Fed
Regist. 2005; 70(204):61368-61379.
Vincent HK, Vincent KR. Functional and
economic outcomes of cardiopulmonary patients: A preliminary comparison of
the inpatient rehabilitation and skilled nursing facility environments. Am J
Phys Med Rehabil 2008; 87(5):371-380.
Birmingham J. Understanding the Medicare
"Extended Care Benefit" a.k.a. the 3-midnight rule. Prof Case Manag. 2008;
Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.