Skilled Home Health Care Nursing Services
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Governance of when intermittent or hourly skilled nursing services delivered in the home are considered medically necessary under Aetna benefit plans; affects providers delivering home health nursing and adjudicators determining coverage.
No material clinical or coverage changes in this revision.
Coverage Criteria for Skilled Home Health Nursing
Medical necessity criteria
Covered when ALL of the following are met
Intermittent or part-time skilled home care nursing is defined as a visit of up to 4 hours in duration; home health skilled nursing care is defined as a consecutive 4-hour period (see definitions).
Home infusion services and the nursing associated with those services are not considered part of the Home Health Care or Skilled Home Health Care Nursing Services benefit and do not accumulate toward any Home or Skilled Nursing benefit limits. (See excluded service note regarding home infusion.)
Examples of HCPCS ranges and specific codes called out in this policy as outside the scope of the Home Health Care benefit include S0320 and the series S5100–S5175, as well as personal care codes such as T1019 and T1020. These codes represent services (for example, day care, chore, attendant/homemaker, companion, respite, home-delivered meals, laundry, and personal care) that are not covered under the indications listed in this Clinical Policy Bulletin when billed as part of the Home Health Care benefit.
Services that are primarily custodial in nature or that can be safely provided by persons without technical nursing skills are considered not medically necessary under the Home Health Care nursing benefit. Custodial care includes assistance with activities of daily living such as walking, grooming, bathing, dressing, toileting, eating or preparing foods.
Specific examples the policy lists as non-skilled / custodial include routine patient care tasks such as routine dressing changes, periodic turning, administering oral medications, care of a stable tracheostomy, stable enterostomy/gastrostomy/jejunostomy feedings, and care of a stable indwelling bladder catheter. The policy also lists non-skilled service codes (e.g., S5100–S5175, T1019, T1020) that reflect day care, chore, attendant/homemaker, companion, respite, and personal care services which are excluded from skilled home health nursing coverage.
Coding — CPT and HCPCS Codes
| 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 (e.g., 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) (e.g., urinary, drainage, and enteral). |
| 99511 | Home visit for fecal impaction management and enema administration. |
| 99512 | Home visit for hemodialysis. |
| G0162 | Skilled services by a registered nurse (RN) in the delivery of management & 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 achieve 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 license 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. |
| 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. |
| S0320 | Telephone calls by a registered nurse to a disease management program member for monitoring purposes, per month. |
| S5100 | Day care services (S5100 - S5105 series). |
| S5101 | Day care services (S5100 - S5105 series). |
| S5102 | Day care services (S5100 - S5105 series). |
| S5103 | Day care services (S5100 - S5105 series). |
| S5104 | Day care services (S5100 - S5105 series). |
| S5105 | Day care services (S5100 - S5105 series). |
| S5120 | Chore services (S5120 - S5121). |
| S5121 | Chore services (S5120 - S5121). |
| S5125 | Attendant care services (S5125 - S5126). |
Provider Requirements and Administrative Guidance
Coverage requires documented medical necessity
Coverage of skilled home health nursing services requires documented medical necessity. Providers must ensure services are ordered by an authorized clinician (physician, physician assistant, or nurse practitioner) and are directly related to an active treatment plan. The member must be homebound and the services must be intermittent or hourly in nature, not custodial, and reasonable and necessary to treat the illness or injury. Maintain physician orders, documentation of homebound status, and clinical notes showing intermittent/hourly skilled needs tied to the treatment plan.
- Documented physician/PA/NP order required
- Evidence member is homebound required
- Clinical documentation showing intermittent or hourly skilled need and relation to active treatment plan
- Exclude custodial or comfort/convenience services
Prior Authorization — see plan provisions
Prior authorization may be required per the member's benefit plan. Providers must check plan provisions and obtain any necessary authorizations before initiating services.
- Confirm prior authorization requirements with the member's plan
- Follow plan/program referral and prior auth procedures
When to consider private duty nursing
When benefit plans allow additional nursing beyond the home health care benefit, consider visiting or private duty nursing. Check the member's benefit plan for availability and criteria for these benefits (see CPB 0136 for private duty nursing criteria).
- Visiting/private duty nursing may be available under Managed Choice POS, PPO, indemnity, or out-of-network provisions
- Refer to member-specific plan documents for eligibility and limits
Where to find plan and member-specific details
Consult member-specific plan documents, the Clinical Policy Bulletin (CPB), and the member ID card for plan contacts and coverage details. CPBs assist in administering benefits and do not constitute offers of coverage; benefit plan documents and program provisions determine actual coverage and limits.
- Use CPB for clinical criteria guidance but verify coverage with plan documents
- Call the phone number on the member ID card for benefit-specific questions
Denial risk triggers
Providers: be aware that custodial care and services primarily for comfort or convenience are at high risk for denial. Ensure documentation clearly supports skilled, intermittent/hourly nursing tied to active treatment to avoid denials.
- Avoid billing routine ADL assistance or stable device care as skilled nursing without clinical justification
- Document why care is skilled and cannot be provided by non-clinical personnel
Required documentation
Providers must retain and submit orders and clinical records that show skilled services are ordered, related to an active treatment plan, and meet the intermittent/hourly skilled criteria. Documentation should include frequency, duration, clinical rationale, and evidence member is homebound when applicable.
- Physician/PA/NP orders and signed plan of care
- Progress notes documenting skilled interventions, time spent, frequency, and clinical necessity
- Evidence supporting homebound status
Administrative guidance
Administrative note: Clinical Policy Bulletins assist in administering benefits and are not offers of coverage. They provide general guidance; verify all coverage and limits with the member's benefit plan and program provisions.
- CPBs provide clinical criteria but plan documents control coverage
- Contact member services for plan-specific determinations
Provider action
Provider action: follow plan/program requirements for referrals, prior authorization, and documentation; contact the plan using the number on the member ID card for member-specific questions.
- Obtain necessary referrals and prior authorizations
- Submit complete documentation with claims to support medical necessity
Background
Skilled nursing care in the home is care that requires the knowledge and skills of a licensed nurse (registered nurse or licensed practical nurse) to manage, observe, and evaluate the patient’s condition and to perform treatments that cannot be safely provided by non-professional staff.
The policy requires that services be performed by or under the supervision of an RN or LPN and be inherently complex enough to require a licensed nurse per physician orders. Coverage is limited to care that is intermittent or hourly in nature (defined elsewhere as visits of up to 4 hours) and that is not custodial, is reasonable and necessary, ordered by an authorized practitioner, and provided to a homebound member to avoid more intensive institutional care.
Definitions
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