Coverage Policies

Use the index below to search for coverage information on specific medical conditions.

QualChoice reserves the right to alter, amend, change or supplement medical policies as needed. QualChoice reviews and authorizes services and substances. CPT and HCPCS codes are listed as a convenience and any absent, new or changed codes do not alter the intent of the policy.

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QualChoice follows care guidelines published by MCG Health.

INDEX:
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Effective Date: 06/23/2010 Title: Skilled Home Health Care
Revision Date: 10/01/2017 Document: BI269:00
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
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all 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 catheters.  

Private duty nursing is not covered.


Medical Statement

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 cystostomy.
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 care.
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 minutes.
G0299 Services of skilled nurse in home health or hospice setting, each 15 minutes.
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; per hour.
T1004 Services of a qualified nursing aide, up to 15 minutes.
T1021 Home health aide or certified nurse assistant, per visit.
 


Limits

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.
 


Reference
  1. 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.
  2. Suddarth DS. Lippincott Manual of Nursing Practice. Philadelphia, PA: J.B. Lippincott Co.; 1991.
  3. Bernstein LH, et al. Primary Care in the Home. New York, NY: J.B. Lippincott Company; 1987.
  4. Corkery E. Discharge planning and home health care: What every staff nurse should know. Orthopaed Nurs. 1989; 8(6):18-27.
  5. American Medical Association, Council on Scientific Affairs. Home care in the 1990s. JAMA. 1990; 263(9):1241-1244.
  6. Maguire GH, ed. Care of the Elderly: A Health Team Approach. Boston, MA: Little, Brown and Co.; 1985.
  7. Martinson IM, et al. Home Health Care Nursing. Philadelphia, PA: W.B. Saunders Co.; 1989.
  8. Olson HH. Home health nursing. Caring. 1986; Aug: 53-61.
  9. 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.
  10. Stein J. Medicare and long-term care. Issue Brief Cent Medicare Educ. 2003; 4(4):1-6.
  11. Kadushin G. Home health care utilization: A review of the research for social work. Health Soc Work. 2004; 29(3):219-244.
  12. 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.
  13. 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.
  14. Birmingham J. Understanding the Medicare "Extended Care Benefit" a.k.a. the 3-midnight rule. Prof Case Manag. 2008; 13(1):7-16.
  15. Addendum: 

    Effective 10/01/2017:  Codes updated.


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.
This policy has recently been updated. Please use the index above or enter policy title in search bar for the latest version.