T2031 Assisted Living Waiver Per Diem Reimbursement | OpenPayer

Summary & Overview

HCPCS T2031: Assisted Living Waiver, Per Diem

HCPCS Level II code T2031 denotes a per diem assisted living waiver service, covering daily residential supports and personal care provided in assisted living or community-based residential settings. Nationally, this code is relevant for Medicaid waiver programs and payers managing long-term services and supports because it identifies bundled daily payments for non-institutional residential care that can affect utilization, care coordination, and payment models for beneficiaries needing supportive living services.

Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. The publication provides a concise benchmark-oriented perspective on reimbursement practices, payer coverage approaches, and clinical context for use of T2031 in waiver-funded assisted living arrangements.

Readers will learn: the clinical service represented by the code and typical site of service; how major payers and Medicare approach coverage and payment conceptually for assisted living per diem waiver services; common operational and billing considerations tied to per diem residential supports; and where to find related codes and policy references. Data not available in the input will be noted where applicable. This national overview is intended to orient providers, payers, and policy analysts to the coding and service context of T2031.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareT2031HCPCS Level IIassisted-livingwaiver-servicesper-diemlong-term-services-and-supportsresidential-carehome-and-community-based-services

Billing Code Overview

HCPCS Level II code T2031 describes assisted living; waiver, per diem. The service represents per diem payments for assisted living supports provided under a waiver program. Service type: Residential supportive care and personal assistance delivered within an assisted living setting. Typical site of service: Assisted living facility or community-based residential setting.

Data not available in the input.

Clinical & Coding Specifications

Clinical Context

A typical patient is a frail older adult or an adult with chronic disability enrolled in a Medicaid home- and community-based waiver program who resides in an assisted living facility. The patient requires daily supervision, assistance with activities of daily living (ADLs) such as bathing, dressing, medication reminders, and monitoring for behavioral or cognitive issues related to dementia or severe chronic medical conditions. A social services coordinator or case manager conducts an initial assessment, documents the level of need, and places the member on a per diem assisted living waiver benefit paid under T2031 for the duration of eligibility.

The clinical workflow begins with a referral from primary care or a hospital discharge planner to the state waiver program. A licensed clinician or care manager completes a functional assessment and documents medical necessity for assisted living services. The assisted living facility provides round-the-clock supervision and implements the individualized service plan. Periodic reassessments and documentation of continued need are completed by the case manager to support ongoing per diem billing under T2031. Billing is typically submitted monthly or per payer-defined intervals to Medicaid or managed Medicaid plans such as Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, BUCA, or Medicare if applicable, using T2031 as the per diem assisted living waiver rate.

Coding Specifications

Modifier	Description	When to Use

HCPCS T1503: Administration of Non-Oral/Non-Injectable Medication, Per Visit

HCPCS-T4526-ADULT-DISPOSABLE-PROTECTIVE-UNDERWEAR-MEDIUM

HCPCS Level II T4526: Adult Disposable Protective Underwear, Medium

HCPCS-T2036-THERAPEUTIC-OVERNIGHT-CAMPING-SESSION-WAIVER

HCPCS Level II T2036: Therapeutic Overnight Camping Session

HCPCS-T4527-ADULT-DISPOSABLE-PROTECTIVE-UNDERWEAR-LARGE

HCPCS Level II T4527: Adult Disposable Protective Underwear, Large

HCPCS-T1012-ALCOHOL-SUBSTANCE-ABUSE-SKILLS-DEVELOPMENT

HCPCS T1012: Alcohol and/or Substance Abuse Skills Development

HCPCS-T1024-INTEGRATED-SPECIALTY-TEAM-CARE-MULTIPLE-SEVERELY-HANDICAPPED-CHILDREN

HCPCS T1024: Integrated Specialty Team Evaluation and Treatment for Severely Handicapped Children

HCPCS-LEVEL-II-T2014-PREVOCATIONAL-HABILITATION-PER-DIEM

HCPCS Level II T2014: Habilitation Prevocational Waiver Per Diem

HCPCS-T1013-SIGN-LANGUAGE-ORAL-INTERPRETATION-15-MIN

HCPCS Level II T1013: Sign Language or Oral Interpretive Services, per 15 Minutes

HCPCS-T2016-HABILITATION-RESIDENTIAL-WAIVER-PER-DIEM

HCPCS T2016: Habilitation, Residential Waiver Per Diem

HCPCS-T1023-PROGRAM-PARTICIPATION-SCREENING

HCPCS T1023: Screening for Program or Protocol Participation

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`22`	Increased procedural services	Use when additional documentation supports substantially greater services than typical for care coordination or extensive care planning beyond the usual per diem scope.
`23`	Unusual anesthesia	Not commonly used with `T2031`; include only if an anesthesia event related to services is billed with facility components and meets payer rules.
`52`	Reduced services	Use when assisted living services are partially provided for a day and a reduced per diem applies per payer policy.
`53`	Discontinued procedure	Use if planned onsite services were started but discontinued for clinical reasons and billing must reflect partial day services.
`54`	Surgical care only	Not typically applicable; included only if a separate surgical episode is billed with shared responsibility and facility per diem applies.
`55`	Postoperative management only	Not typically applicable to `T2031`; use only if billing split between inpatient/outpatient postsurgical management and assisted living per diem.
`56`	Preoperative management only	Rarely applicable; use when preoperative management is billed separately alongside per diem assisted living services.
`62`	Two surgeons	Uncommon for per diem assisted living; use only if two providers share a billed procedural responsibility that affects facility billing.
`AS`	Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery	Not typically used with `T2031`; include only if assistant-at-surgery services intersect with facility billing per payer rules.
`CO`	Reserved for State Medicaid Agency use	Use when state Medicaid guidance requires this modifier for waiver-related claims processing.
`CQ`	Service furnished by a qualified respiratory therapist	Use when a respiratory therapist provides billable skilled respiratory interventions in the assisted living setting covered under the waiver.
`FX`	Used to indicate clinical trial modifier (investigational device exemption)	Rarely applicable; use only if services relate to a qualifying clinical trial and payer accepts this modifier.
`FY`	Used to indicate services related to a clinical trial (drug/device)	As above, apply only when the assisted living services are part of an approved clinical trial billing scenario.
`QK`	Medical direction of two, three, or four qualified health professionals	Use when the primary clinician provides medical direction to multiple qualified personnel delivering covered skilled services under the waiver program.
`QX`	CRNA service: medically directed by anesthesiologist	Not typical; include only if anesthesia services intersect with facility billing and meet CRNA-medical direction criteria.

Taxonomy Code	Specialty	Notes
`251B00000X`	Nursing Facility/Long Term Care	Providers overseeing assisted living waiver services and facility-level care coordination.
`193200000X`	Geriatric Medicine	Clinicians performing comprehensive geriatric assessments, care planning, and medical oversight for waiver recipients.
`207Q00000X`	Internal Medicine	Primary care physicians managing chronic conditions and certifying medical necessity for assisted living services.
`261QM0800X`	Case Management	Case managers and care coordinators responsible for assessments, service planning, and documentation for waiver billing.
`367200000X`	Hospice and Palliative Medicine	Clinicians providing comfort-focused management when assisted living residents have advanced illness and require palliative oversight.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`Z74.3`	Need for continuous supervision	Common reason for enrollment in an assisted living waiver with per diem coverage under `T2031`.
`Z74.01`	Bed confinement status	Indicates significant mobility limitation that supports need for assisted living services.
`F03.90`	Unspecified dementia without behavioral disturbance	Dementia frequently necessitates assisted living with supervision and care planning covered by waiver per diem.
`F02.80`	Dementia in other diseases classified elsewhere without behavioral disturbance	Supports need for facility-based supervision and assistance.
`I50.9`	Heart failure, unspecified	Chronic medical conditions like heart failure increase care needs met by assisted living services.
`E11.9`	Type 2 diabetes mellitus without complications	Chronic disease management needs often drive waiver enrollment for assisted living support.
`R26.89`	Other abnormalities of gait and mobility	Mobility impairment that justifies assisted living placement and daily assistance.
`M62.81`	Muscle weakness (generalized)	Functional decline contributing to need for per diem assisted living services.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`99304`	Initial nursing facility care, typically 30 minutes per day	May be used for initial comprehensive assessment when a physician documents medical necessity and establishes care for a newly admitted assisted living waiver resident.
`99307`	Subsequent nursing facility care, typically 10 minutes per day	Used for follow-up medical visits addressing acute or chronic issues during assisted living residency; documents ongoing physician involvement complementary to the per diem.
`99406`	Smoking and tobacco use cessation counseling, intermediate (3-10 minutes)	Ancillary service that may be provided in the assisted living setting and billed separately when payer policies allow separate counselling charges alongside the per diem.
`96161`	Developmental testing; with interpretation and report	Used when cognitive or functional assessments are required to document ongoing need for assisted living waiver services.
`99334`	Domiciliary, rest home, or custodial care visit for established patient, typically 25 minutes	Applies when clinicians provide face-to-face medical evaluation in an assisted living/residential facility setting and the service is billable in addition to per diem coverage.

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