Home Health Aides
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This policy defines when home health aide services are considered medically necessary by Aetna and specifies required accompaniment by intermittent skilled home health care; it applies to Aetna members and participating providers.
No material clinical or coverage changes in this revision.
Coverage Criteria for Home Health Aide Services
Medical Necessity Criteria
Covered when ALL of the following are met
Primary medical necessity conditions
- Supporting aide activities: Assisting with a prescribed exercise regimen; Assisting with activities of daily living; Changing non-sterile dressings that do not require the skills of a licensed nurse; Routine care of prosthetic and orthotic devices; Supervising the individual's adherence to prescribed, self-administered medication and/or special diets; Taking blood pressure and other health monitoring activities.one or more examples may apply
These are illustrative examples of acceptable aide activities.
Aetna considers home health aide services medically necessary only when BOTH of the following conditions are met: 1) the aide services are rendered in conjunction with intermittent skilled home health care provided by a licensed practical or registered nurse, occupational therapist, physical therapist, or speech therapist; and 2) the services delivered by the home health aide directly support skilled home health care services. Examples of aide activities that may directly support skilled care include assisting with a prescribed exercise regimen, assisting with activities of daily living, changing non-sterile dressings that do not require the skills of a licensed nurse, routine care of prosthetic and orthotic devices, supervising adherence to prescribed self-administered medication and/or special diets, and taking blood pressure and other health monitoring activities.
Services that are generally considered not medically necessary for home health aide coverage include: babysitting services, house cleaning beyond maintaining the member’s immediate area, and transportation. These items do not meet the policy’s requirement that aide services directly support intermittent skilled home health care.
Procedure and Billing Codes
| 99509 | Home visit for assistance with activities of daily living and personal care. |
| 92507 | Treatment of speech, language, voice communication, and/or auditory processing disorder; individual. |
| 97010-97799 | Physical Medicine and Rehabilitation. |
| 99500-99507, 99510-99600 | Home Health Procedures/Services. |
| 99601-99602 | Home Infusion Procedures/Services. |
| G0156 | Services of home health aide in home health or hospice setting, each 15 minutes. |
| 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 aid or certified nurse assistant, per visit. |
| G0068 | Professional services for the administration of anti-infective, pain management, chelation, pulmonary hypertension, and/or inotropic infusion drug(s) for each infusion drug administration calendar day in the individual's home, each 15 minutes. |
Provider Requirements and Authorization
Prior Authorization May Be Required for Specific Codes
Certain CPT and HCPCS codes listed below may require prior authorization. Verify member benefits and obtain prior authorization when applicable before providing services to avoid claim denials.
Providers should be aware that home health aide services are considered medically necessary only when rendered in conjunction with intermittent skilled home health services by a licensed nurse or therapist and when the aide services directly support the skilled services. Documentation should clearly link aide tasks to the skilled plan of care.
- Home health aide services must be provided in conjunction with intermittent skilled services (RN/LPN, PT, OT, or SLP).
- Aide activities must directly support skilled care (e.g., assist with prescribed exercises, ADLs, non‑sterile dressing changes, prosthetic/orthotic care, supervision of self-administered meds/diets, basic vital sign monitoring).
Clinical Linkage Documentation Required
Documentation must demonstrate that home health aide services are provided as part of and to support intermittent skilled home health care. Include the licensed clinician's orders, specific skilled interventions, how the aide's activities support those interventions, frequency/duration, and member progress notes.
- Include licensed clinician plan of care and orders referencing aide support.
- Tie each aide visit/activity to a specific skilled service or skilled goal.
- Record dates, times, duration, and member response/progress for each visit.
Concomitant Skilled Services Required
Failure to provide intermittent skilled home health services by a licensed nurse or therapist in conjunction with billed home health aide services may result in denial of coverage for the aide services.
- Home health aide services billed without concurrent intermittent skilled services documented are generally not medically necessary.
- Routine homemaking, babysitting, transportation, or non‑immediate area cleaning are not covered as home health aide services.
Background
A home health aide provides non‑skilled assistance with activities of daily living to help maintain individuals in their home environment. Aetna requires that aide services be provided in conjunction with intermittent skilled home health services from a registered or licensed practical nurse, physical therapist, occupational therapist, or speech therapist; documentation should show the aide’s activities directly support the skilled care (for example, assisting with prescribed exercises, ADLs, non‑sterile dressing changes, prosthetic/orthotic care, medication or diet supervision, or basic health monitoring).
Definitions
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