Aetna Skilled Home Health Nursing Coverage Update

Coverage Criteria for Skilled Home Health Nursing

Medical necessity criteria

Covered when ALL of the following are met

Core medical necessity criteria: 1) Service must be performed by or under the supervision of a registered nurse (RN) or licensed practical (vocational) nurse (LPN) and, pursuant to physician orders, be so inherently complex that it can be safely and effectively performed only by, or under the supervision of, a licensed nurse; 2) Provided on an intermittent (visit up to 4 hours) or hourly basis; 3) The skilled nursing service is not custodial in nature; 4) Services are reasonable and necessary for treatment of the illness or injury and consistent with accepted standards of medical and nursing practice; 5) Member is homebound (leaves home only with considerable and taxing effort, infrequent or short absences, or to receive medical care); 6) Ordered by a physician, physician assistant, or nurse practitioner and directly related to an active treatment plan of care established by the provider; 7) Services are provided in lieu of continued hospitalization, confinement in a skilled nursing facility, or receiving outpatient services outside the home; 8) Skilled nursing care is appropriate to avoid risk of serious medical complications; 9) The treatment is intermittent or hourly in nature and appropriate in amount, frequency, and duration.all criteria

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

Covered CPT codes if selection criteria are metCPTCovered

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.

Covered HCPCS codes if selection criteria are metHCPCSCovered

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.

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Other CPT codes related to the policyCPT

99509	Home visit for assistance with activities of daily living and personal care.
99510	Home visit for individual, family, or marriage counseling.

HCPCS codes not covered for indications listed in the CPBHCPCSNot Covered

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).

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Other related HCPCS codesHCPCS

G0156	Services of a home health aide in home health 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 aide or certified nurse assistant, per visit.

Intermittent visit duration definition

DefinitionIntermittent (part‑time) skilled home care nursing is defined as a visit of up to 4 hours in duration.

ContextApplies when skilled nursing is provided on an intermittent or hourly basis as part of home health skilled nursing services.

Related noteSee policy criteria that services must be ordered, homebound, not custodial, and reasonable/necessary for treatment.

Provider Requirements and Administrative Guidance

Documentation Required

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

Prior Authorization — see plan provisions

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

Intermittent skilled nursing — visit up to 4 hours

DefinitionHome health skilled nursing care is defined as a consecutive 4‑hour period of time (for example, an 8‑hour shift equals 2 visits).

Use caseCounts visits by consecutive 4‑hour blocks when scheduling and billing intermittent/hourly skilled nursing services.

ImplicationProviders should document start and end times to demonstrate each 4‑hour consecutive period when applicable.

Custodial care definition

DefinitionCustodial care: services and supplies furnished mainly to help a person with activities of daily living or tasks that can be performed by persons without the technical skills of a health care provider (e.g., assistance with bathing, dressing, feeding).

ExamplesRoutine patient care (changing dressings, periodic turning), administering oral medications, care of stable tracheostomy, stable enterostomy/gastrostomy care, care of a stable indwelling bladder catheter.