ModifiedBlue Cross Blue Shield - New MexicoPolicy CPCP005

Home Health Care Policy

Defines billing, coding, and reimbursement guidance for home health care services (skilled and custodial) for 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 CPCP005

Change TypeRevised (HCPCS updates, structural edits)

Effective DateMar 21, 2025

Next Review Date

Key ActionSubmit supporting documentation upon request to substantiate billed services (e.g., nurse progress notes, medication records, seizure logs, ventilator logs).

SourceLink

POLICY UPDATE CHANGES

Policy underwent annual review and on 03/11/2025 included title change, definition updates, added professional and facility sections, revenue codes, updated HCPCS including new G and S codes, removed certain T codes, revised PDN section, added reporting time examples, removed Custodial Care section, and updated references.

Reporting time examples were added.

Version 1.0policy version

2025-03-21effective date

2025-03-11approval date

T1002,T1003,T1031HCPCS codes removed

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

G0151-G0162, G0299, G0300, G0493-G0496, G2168-G2169, S9125-S9131

10/31/2018 → 03/11/2025history range

Coverage and Billing Criteria

Eligibility and coverage notes

General coverage guidance and limitations

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

Providers are expected to exercise independent clinical judgment; this policy is not intended to dictate care decisions or medical practice.

Home health care is reimbursable only when the service performed in the home is eligible for benefits under the member's plan.

Providers should bill the most appropriate code that accurately reflects the total time of the service(s) rendered; documentation must support the time billed.

The plan reserves the right to request supporting documentation; failure to adhere to coding and billing policies may impact claims processing and reimbursement.

Claim reimbursement is subject to plan benefits and claims may not be reimbursed if they exceed member benefit limits for days or hours of coverage.

Time reporting and per diem billing criteria

Billing and documentation criteria for time-based services and per diem services:

Per diem services must be billed per day of service, beginning with the day the therapy is initiated and ending with the day the therapy is discontinued.

The expected course and duration for per diem services shall be determined by the plan of care as prescribed by the ordering physician and documented appropriately.

When a code description states 'per hour', report time using the following minute buckets: 0 = less than 31 minutes; 1 = 31 to 90 minutes; 2 = 91 to 150 minutes.

Providers must document the plan of care and clinical records to support billed per-hour or per-diem units; the plan may request supporting documentation during claim review.

Coding, Time Units, and Revenue Codes

Sample HCPCS/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
G0160	Services performed by a qualified occupational therapist, in the home setting, in the establishment or delivery of a safe and effective occupational 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
G0300	Direct skilled nursing services of a licensed practical nurse (LPN) in the home health or hospice setting, each 15 mins
G0493	Skilled services of a registered nurse (RN) for the observation and assessment of the patient's condition, each 15 mins
G0494	Skilled services of a licensed practical nurse (LPN) for the observation and assessment of the patient's condition, each 15 mins
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 mins

1–10 of 15

1/2

Home health revenue codesRevenue

0421	Physical Therapy; Visit charge
0551	Skilled Nursing; Visit charge
0571	Home Health Aide; Visit charge
0636	Pharmacy; Drugs requiring detailed coding

HCPCS updatesHCPCS

G0151-G0153	Examples of HCPCS codes added in 03/11/2025 update
G0155-G0162	Examples of HCPCS codes added in 03/11/2025 update
G0299	HCPCS code added
G0300	HCPCS code added
G0493-G0496	HCPCS codes added
G2168-G2169	HCPCS codes added
S9125-S9129	HCPCS S codes added
S9131	HCPCS S code added
T1002, T1003, T1031	HCPCS codes removed

15-minute unit increments — mapping minutes to 15-min units (unit 1 = 8-22 mins; unit 2 = 23-37 mins, etc.)

Unit definitionOne unit = 15 minutes; report visits based on length of service.

Unit 1Time = 8 to 22 minutes.

Unit 2Time = 23 to 37 minutes.

Unit 3Time = 38 to 52 minutes.

Unit 4Time = 53 to 67 minutes.

Unit 5Time = 68 to 82 minutes.

Unit 6

Provider Documentation and Claim Actions

Documentation Required

General documentation and claim review

Providers are responsible for submission of accurate documentation of services performed. Providers are expected to submit claims for services rendered using valid code combinations from HIPAA-approved code sets and to code according to industry-standard guidelines (including but not limited to UB, AMA CPT, CPT Assistant, HCPCS, ICD-10-CM/PCS, NDCs, DRG guidelines, CMS NCCI policy manual and CCI edits). Claims are subject to review for coding edits and against plan benefits, provider contract language, medical policies, clinical payment and coding policies, and coding software logic. The plan reserves the right to request supporting documentation at initial request, recertification, or upon revision of services; providers are urged to submit additional documentation upon request. Failure to adhere to coding and billing policies may impact claims processing and reimbursement; claim reimbursement is subject to plan benefits and member limits for days or hours of coverage.

Providers must bill the most appropriate code that accurately reflects total time or service rendered.
Upon request, submit supporting documentation to substantiate billed services (e.g., nurse progress notes, MARs, seizure logs, ventilator logs).
Claims are subject to code edit protocols and review against benefit coverage and contract terms.

Documentation Required

Key Definitions

Custodial or Unskilled Care — definition of personal care that does not require technical skills

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

Clinical skill requirementDoes not require technical skills or clinical assessment ability of medical/nursing personnel.

Service natureGenerally non-medical; supportive of activities of daily living.

Home Health Care — services provided to a patient at home requiring skilled/licensed professional

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.

Location

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyHome Health Care Policy

Policy CodePolicy CPCP005

Change TypeRevised (HCPCS updates, structural edits)

Effective DateMar 21, 2025

Next Review Date

Key ActionSubmit supporting documentation upon request to substantiate billed services (e.g., nurse progress notes, medication records, seizure logs, ventilator logs).

SourceLink

On This Page

Time = 83 to 97 minutes.

Per hour unit mapping — per hour codes unit buckets (unit 0 = <31 mins; unit 1 = 31-90 mins; unit 2 = 91-150 mins)

Per-hour mapping summaryUse defined buckets when code description states 'per hour'.

Unit 0Less than 31 minutes.

Unit 131 minutes to 90 minutes.

Unit 291 minutes to 150 minutes.

Per-hour reporting buckets (minutes) — 0: <31; 1: 31-90; 2: 91-150

Reporting bucket 0< 31 minutes.

Reporting bucket 131 to 90 minutes.

Reporting bucket 291 to 150 minutes.

Per diem service reporting

Per diem represents each day a member is provided services for a prescribed therapy, beginning the day therapy is initiated and ending the day therapy is discontinued. The expected course and duration of treatment must be determined by the plan of care as prescribed by the ordering physician and documented in the record. Providers should document start and stop dates for per diem services and the plan of care supporting the expected course/duration. Per diem services are reimbursed only when the service performed in the home is eligible for benefits and when documentation supports the dates and medical necessity of services billed.

Document the per diem start date (therapy initiation) and stop date (therapy discontinuation).
Include the ordering physician’s plan of care that establishes expected course and duration.
Ensure services billed per diem are eligible under the member’s benefit plan.

Documentation Required

Per-hour time reporting examples

When a code description states 'per hour', report time using the following reporting buckets to match billed units to documented time.

0 = Less than 31 minutes
1 = 31 to 90 minutes
2 = 91 to 150 minutes

Services provided in the patient's home.

Provider requirementRequires a skilled and licensed professional.

Intermittent Home care — part-time skilled nursing care fewer than seven days a week or less than 8 hours a day

DefinitionPart-time skilled nursing care provided in the home or inpatient facility for fewer than seven days a week or less than 8 hours a day for periods of 21 days or less.

Duration requirementPeriods of twenty-one (21) days or less with a medically predictable recurring need.

FrequencyFewer than seven days per week or less than 8 hours per day.

Private Duty Nursing (PDN) — nursing services for members requiring continuous individual care by RN or LPN

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.

Care intensityMore individual and continuous nursing care.

Provider typeServices provided by RN or LPN under physician direction.

Respite Care — short-term temporary relief to a primary caregiver

DefinitionShort-term, temporary relief to a primary or usual caregiver; the caregiver is generally a family member.

PurposeProvides temporary respite to primary caregiver.

Typical caregiverGenerally a family member.

Skilled Care — medical care in the home provided by or under supervision of a skilled/licensed professional

DefinitionMedical care provided in the home or inpatient facility setting that may only be provided by or under the supervision of a skilled or licensed medical professional.

Skill requirementServices require the technical skills and professional training of a licensed professional nurse or rehabilitation therapist.

SettingProvided in the home or inpatient facility setting.

Per diem — per diem represents each day services are provided, beginning with initiation and ending with discontinuation

DefinitionPer diem represents each day that a member is provided services for a prescribed therapy, beginning with the day the therapy is initiated and ending with the day the therapy is discontinued.

DocumentationExpected course and duration determined by the plan of care as prescribed by the ordering physician and documented appropriately.

Per hour (reporting) — when code description states 'per hour', use buckets: 0 = <31 mins; 1 = 31-90 mins; 2 = 91-150 mins

When to use bucketsUse defined reporting buckets when code description states 'per hour'.

Bucket 0Less than 31 minutes.

Bucket 131 to 90 minutes.

Bucket 291 to 150 minutes.