Home Behavioral Healthcare Services
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Defines clinical coverage and medical necessity criteria for skilled behavioral health services delivered in the member's home under Aetna benefits, and lists applicable billing codes and ICD-10 categories.
No material clinical or coverage changes in this revision.
Coverage / Medical Necessity Criteria
Medical Necessity Criteria
Covered when ALL of the following are met:
Derived from Scope of Policy
Custodial care is excluded from coverage when services are provided primarily to assist with activities of daily living or to train/assist a family member in personal hygiene and other routine tasks rather than to deliver therapeutic treatment. Such services are not considered skilled behavioral health care and are therefore outside the scope of covered home behavioral healthcare services.
Services that can be safely and adequately provided by persons without the technical skills of a health care provider (for example, a nurse) are also excluded as custodial care.
Additional exclusions and limitations emphasize that skilled home behavioral healthcare is intended for active therapeutic treatment and not for comfort, convenience, or routine assistance. If the primary purpose of a visit is training, assistance with activities of daily living, or provision of non-skilled tasks, the service does not meet medical necessity and may be denied.
The policy notes that skilled home behavioral healthcare services are covered under the member’s behavioral healthcare benefit; providers should check individual benefit plan descriptions for applicability and any plan-specific restrictions.
Billing Codes and Coding Details
| 99341 | Home visit for the evaluation and management of a new patient (problem focused history/exam; straightforward MDM) |
| 99342 | Home visit for the evaluation and management of a new patient (expanded problem focused; low complexity MDM) |
| 99344 | Home visit for the evaluation and management of a new patient (comprehensive history/exam; moderate complexity MDM) |
| 99345 | Home visit for the evaluation and management of a new patient (comprehensive; high complexity MDM) |
| 99347 | Home visit for the evaluation and management of an established patient (problem focused; straightforward MDM) |
| 99348 | Home visit for the evaluation and management of an established patient (expanded problem focused; low complexity MDM) |
| 99349 | Home visit for the evaluation and management of an established patient (detailed; moderate complexity MDM) |
| 99350 | Home visit for the evaluation and management of an established patient (detailed; high complexity MDM) |
| G0155 | Services of clinical social worker in home health or hospice settings, each 15 minutes |
| G0177 | Training and educational services related to the care and treatment of patients disabling mental health problems per session (45 minutes or more) |
| 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 licensed practical nurse (LPN) in the home health or hospice setting, each 15 minutes |
| H0002 | Behavioral health screening to determine eligibility for admission to treatment program |
| H0004 | Behavioral health counseling and therapy, per 15 minutes |
| H0023 | Behavioral health outreach service |
| H0031 | Mental health assessment, by non-physician |
| H0032 | Mental health service plan development by non-physician |
| H0036 | Community psychiatric supportive treatment, face-to-face, per 15 minutes |
| H0037 | Community psychiatric supportive treatment program, per diem |
| H0046 | Mental health services, not otherwise specified |
| H2019 | Therapeutic behavioral services, per 15 minutes |
| H2020 | Therapeutic behavioral services, per diem |
| S0273 | Physician visit at member's home, outside of a capitation arrangement |
| S0274 | Nurse practitioner visit at member's home, outside of a capitation arrangement |
| S9127 | Social work visit, in the home, per diem |
| S9482 | Family stabilization services, per 15 minutes |
| S9484 | Crisis intervention mental health services, per hour |
| S9485 | Crisis intervention mental health services, per diem |
| F01.50 - F99 | Mental and behavioral disorders |
Ordering, Authorization, and Documentation Requirements
Prior authorization and ordering — Coverage applies only when medical necessity criteria are met
Coverage applies only when the listed medical necessity criteria are met and the service is ordered by or under the supervision of an independently licensed behavioral health professional (BHP) or physician and is directly related to an active treatment plan of care.
- Services must be ordered by a physician or independently licensed BHP and be directly related to an active treatment plan established by that provider.
- Skilled behavioral health care must be appropriate for active treatment of a condition, intermittent or hourly in nature (visit up to 1 hour), and provided under supervision of an independently licensed BHP.
- Services must be provided in lieu of continued hospitalization, confinement in a residential treatment facility, or receiving outpatient services outside the home.
- Services that are primarily custodial, for comfort or convenience, or can be provided safely by non-skilled persons risk denial.
Providers must ensure services are ordered and supervised by eligible clinicians and that documentation supports medical necessity, frequency, duration, and relation to the active treatment plan.
Order and supervision — Services must be ordered by a physician or independently licensed BHP
Services must be ordered by a physician or independently licensed behavioral health professional and be directly related to an active treatment plan of care established by that physician or licensed BHP. The skilled behavioral health care must be intermittent or hourly in nature and provided under the supervision of an independently licensed BHP.
- Intermittent or part-time skilled home behavioral health care is defined as a visit of up to 1 hour in duration.
- Treatment must be appropriate in amount of time, frequency, type and duration for the member's condition.
Custodial care exclusion — Custodial or comfort-only services risk denial
Services that are primarily custodial — provided mainly to assist with activities of daily living, for comfort or convenience, or that can be safely furnished by non‑skilled persons — are not considered skilled behavioral health care and may be denied as custodial care.
- Custodial care is defined as services and supplies furnished mainly to help with activities of daily living.
- Behavioral health services must not be primarily for comfort or convenience of the member or family.
Background and Scope
Skilled home behavioral health care delivers intermittent, skilled therapeutic services in the member’s home as an alternative to hospitalization, residential treatment, or outpatient care provided outside the home. It is intended to treat behavioral disorders through an active treatment plan rather than to supply custodial or non-skilled assistance.
Services must be therapeutic and delivered by appropriately qualified clinicians; routine personal care or tasks that can be safely provided by non-skilled persons are not part of this level of care. As noted in the policy, coverage for these services falls under the member’s behavioral healthcare benefit, and providers should verify benefit details before providing services.
Definitions
Level of Care / Setting Criteria
Permitted Treatment Modalities
Behavioral therapy/counseling and supportive services
See applicable HCPCS/H/S codes (e.g., H0004, H0036, H2019, S9484)
Visit Length and Limits
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