ModifiedBlue Cross Blue Shield - New MexicoPolicy CPCPOO5

Home Health Care Policy

Defines billing, coding, and reimbursement guidance for various types of home health care services (skilled, unskilled/custodial, PDN, respite) and the appropriate HCPCS/CPT codes and revenue codes for claim submissions; applies to providers submitting claims to Blue Cross and Blue Shield of New Mexico.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyHome Health Care Policy

Policy CodePolicy CPCPOO5

Change TypeCoding updates, definition changes, section removals

Effective DateMar 21, 2025

Next Review DateN/A

Key ActionProviders must update billing to reflect the revised HCPCS code lists and use provided time-to-unit reporting examples when submitting claims.

SourceLink

POLICY UPDATE CHANGES

Annual review; Policy title change; Definition updates; Professional and facility sections added; Revenue codes added; HCPCS coding updated including new G and S codes and removed specific T codes.

Removed Custodial Care section.

Added reporting time examples.

GO151-G0153HCPCS codes added

S9125-S9131S-code additions

T1002/T1003/T1031HCPCS codes removed

15-min table

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Time-to-unit guidance

Custodial CareSection removed

Coverage and Billing Rules

Coverage and billing criteria

Covered when ALL of the following conditions are met:

Plan documents and provider contracts govern in case of conflict; BCBSNM may use reasonable discretion in interpreting/applying this policy.

Inclusion of a code in this policy does not guarantee coverage or payment; providers must refer to member benefits, applicable statutes, regulations, and laws.

Home health care is reimbursable only when the service is performed in the home and is eligible under the member's benefits; claim reimbursement is subject to plan benefits.

Providers must submit accurate documentation supporting the time and services billed; the plan reserves the right to request supporting documentation and may request additional documentation upon review.

Providers must use valid HIPAA‑approved code sets and follow industry coding guidelines (e.g., UB, CPT, HCPCS, ICD‑10), and claims are subject to code edit protocols and review.

When a code description states 'each 15 minutes', use the policy's time‑to‑unit conversion bands to determine units billed.

Professional claims should include appropriate HCPCS/CPT and revenue code combinations and, where applicable, use UB‑04 Type of Bill 032x for services under a plan of treatment or 034x for services not under a plan of treatment.

See coding section for examples and revenue code guidance.

Infusion services coding and administrative updates

Policy revisions and coding changes applicable to infusion services and related billing:

HCPCS coding updated to add example G and S codes (policy lists added codes GO151, G0153, S9125–S9129, S9131) and to remove codes T1002, T1003, and T1031.

Reporting time examples were added to clarify how to report time for services billed under the updated HCPCS codes; providers should update billing practices accordingly.

This infusion services policy (CPCPO19) is referenced for clinical payment and coding guidance and should be read with this home health policy where applicable.

HCPCS/CPT Coding, Units, and Reporting

Home health HCPCS and S-codesHCPCSCovered

G0151	Services performed by a qualified physical therapist in the home health or hospice setting, each 15 mins
G0152	Services performed by a qualified occupational therapist in the home health or hospice setting, each 15 mins
G0153	Services performed by a qualified speech-language pathologist in the home health or hospice setting; each 15 mins
G0156	Services of home health/hospice aide in home health or hospice settings, each 15 mins
G0159	Services performed by a qualified physical therapist; in the home setting; in the establishment or delivery of a safe and effective physical therapy maintenance program, each 15 mins
G0299	Direct skilled nursing services of a registered nurse (RN) in the home health or hospice setting, each 15 mins
G0493	Skilled services of a registered nurse (RN) for observation and assessment, 15 mins
S9123	Nursing care, in the home; by registered nurse, per hour
S9122	Home health aide or certified nurse assistant; providing care in the home; per hour
T1000	Private duty nursing continuous care (example usage)

HCPCS updatesHCPCS

G0151	Example added HCPCS code (policy lists added G/S codes)
G0153	Example added HCPCS code
S9125-S9129	Range of S-codes added
S9131	S-code added
T1002	Removed from coding list
T1003	Removed from coding list
T1031	Removed from coding list

Intermittent vs PDN unit thresholds

Intermittent care exampleThree one-hour nursing visits in one week (Monday, Wednesday, Friday) billed as 3 units of HCPCS S9123 or S9124.

PDN exampleContinuous nursing care of 12 hours/day for 5 days (60 hours total) billed as 240 units of HCPCS T1000.

Billing implicationIntermittent visits are billed as discrete visit units (hourly codes); PDN is billed based on total hours converted to units per the code definition.

15-minute unit conversion

Definition of a 15-minute unitOne unit equals 15 minutes when the code description states 'each 15-minutes'.

Rounding band 1

Provider Documentation and Billing Actions

Documentation Required

Documentation requests for Private Duty Nursing (PDN)

The plan may request additional documentation from the PDN provider to support billed services. Requests may occur during the initial authorization request, at recertification, or when a revision to services is submitted. Examples of documentation the plan may request include nurse progress notes, medication administration records, seizure logs, and ventilator logs.

Requests may be made at initial request, recertification, or service revision
Examples of requested documentation: nurse progress notes; medication administration records; seizure logs; ventilator logs

Billing Rule

HCPCS code updates and billing/reporting guidance

HCPCS coding has been updated; providers must use the current HCPCS codes and follow the Plan's reporting guidance when billing. Examples of added and removed codes are shown below. When reporting units/hours, follow the Plan's time-reporting conventions and examples (report service time in the manner prescribed by the Plan).

Definitions

Custodial or Unskilled Care

DefinitionPersonal care that does not require the technical skills, professional training, and clinical assessment ability of medical and/or nursing personnel; generally non-medical support for activities of daily living.

Typical servicesNon-medical assistance with activities of daily living (e.g., bathing, dressing, feeding) that do not require clinical judgement.

Policy noteCustodial care language was present historically but the Custodial Care section was removed in the latest update; refer to plan benefits for coverage determinations.

Home Health Care

DefinitionHealthcare services provided to a patient at home due to sickness or injury requiring services from a skilled and licensed professional on an intermittent or part-time basis.

Setting

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyHome Health Care Policy

Policy CodePolicy CPCPOO5

Change TypeCoding updates, definition changes, section removals

Effective DateMar 21, 2025

Next Review DateN/A

Key ActionProviders must update billing to reflect the revised HCPCS code lists and use provided time-to-unit reporting examples when submitting claims.

SourceLink

On This Page

8 to 22 minutes = 1 unit.

Rounding band 223 to 37 minutes = 2 units.

Rounding band 338 to 52 minutes = 3 units (and subsequent bands continue similarly).

Reporting time examples

Added reporting examplesPolicy update adds examples to clarify time reporting for billing when codes specify 'each 15-minutes'.

Example: intermittent visit reportingReport each visit based on actual visit length using 15-minute unit bands (e.g., a 60-minute visit falls into the appropriate unit count per the conversion table).

Example: PDN aggregate reportingFor continuous PDN, convert total hours over the billing period into units per the HCPCS code definition (see PDN example of 60 hours = 240 units).

Added HCPCS examples: G0151, G0152, G0153; S9125–S9129, S9131
Removed HCPCS: T1002, T1003, T1031
Providers must report time/units per Plan guidance and use current HCPCS code set when submitting claims

Provided in the member's home when clinically appropriate and as outlined in the plan of care.

Coverage caveatInclusion of codes or examples does not guarantee coverage; services must be eligible under the member's benefits.

Intermittent Home care

DefinitionPart-time skilled nursing care provided in the home or inpatient facility for fewer than seven days a week or less than 8 hours per day, typically for periods of 21 days or less and requiring a medically predictable recurring need.

ExampleThree one-hour nursing visits in one week (Monday, Wednesday, Friday) is considered intermittent care and billed as 3 units of S9123/S9124.

RequirementMust meet criteria for medically predictable, recurring skilled nursing need to qualify as intermittent home care.

Private Duty Nursing (PDN)

DefinitionNursing services for a member who requires more individual and continuous care provided by a registered nurse (RN) or licensed practical nurse (LPN) under the direction of the member's physician.

PDN exampleContinuous care of 12 hours/day for 5 days (60 hours) is considered PDN and billed as 240 units of HCPCS T1000.

DocumentationPlan may request supporting documentation (e.g., nurse progress notes, medication administration records) to support PDN services billed.

Respite Care

DefinitionShort-term, temporary relief provided to a primary or usual caregiver, typically a family member.

PurposeProvides temporary respite from caregiving responsibilities; not intended as ongoing replacement for primary caregiver.

SettingMay be provided in the home setting per plan and clinical need.

Skilled Care

DefinitionMedical care provided in the home or inpatient facility and delivered by or under the supervision of a skilled or licensed medical professional; services require technical skills and professional training.

ProvidersIncludes skilled nurses and rehabilitation therapists delivering clinically necessary services per plan of care.

DistinctionSkilled care differs from custodial/unskilled care by requiring clinical assessment and professional training.

Custodial Care (removed)

Policy changeThe Custodial Care section that previously existed was removed in the March 11, 2025 update.

ReferenceSee Policy Update History for removal action and other revisions (03/11/2025).

ImplicationProviders should follow current definitions and plan benefits; historical custodial language is no longer a standalone section in this policy.