CurrentBlue Cross Blue Shield - New MexicoPolicy CPCP005

Home Health Care/Private Duty Nursing Policy

Governs coding, billing, and reimbursement guidance for home health care and private duty nursing services for Blue Cross Blue Shield - New Mexico members; applies to providers submitting claims under BCBSNM plans.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyHome Health Care/Private Duty Nursing Policy

Policy CodePolicy CPCP005

Change TypeNo material change

Effective DateNov 3, 2023

Next Review DateN/A

Key ActionVerify member benefits and submit additional documentation when requested to support PDN services and claims.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

S9122,S9123,S9124,T1000,T1002,T1003,T1031Example HCPCS codes listed

Oct 30, 2023Last approval

<7 days/wk or <8 hrs/dayIntermittent care threshold

Coverage, Medical Necessity, and Billing Rules

Coverage criteria and billing rules

Coverage and billing are subject to member benefit limits, plan documents, and medical necessity; custodial care is generally not covered.

Claims reimbursement is subject to member plan benefits and plan documents will govern in the event of a conflict with this CPCP; provider contracts may govern where applicable.

Providers must submit accurate documentation and bill using valid HIPAA‑approved code sets and industry standard coding guidelines; claims are subject to code edit protocols and review and providers may be asked to submit additional documentation upon request.

Claims may not be reimbursed if they exceed member benefit limits for days or hours of coverage; verify member maximum benefits and applicable contract compensation schedules prior to billing.

Custodial care is generally not a covered benefit.

Examples include assistance with meal feeding, bathing, dressing, mobility assistance, food preparation, and supervision of medication administration.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyHome Health Care/Private Duty Nursing Policy

Policy CodePolicy CPCP005

Change TypeNo material change

Effective DateNov 3, 2023

Next Review DateN/A

Key ActionVerify member benefits and submit additional documentation when requested to support PDN services and claims.

SourceLink

On This Page

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HCPCS / Billing Guidance

Example HCPCS/HCPCS-like codes for home health and PDNHCPCSCovered

S9122	Home health aide or certified nurse assistant, providing care in the home; per hour.
S9123	Nursing care, in the home; by registered nurse, per hour (use for general nursing care only, not to be reported when CPT codes 99500-99602 can be used).
S9124	Nursing care, in the home; by licensed practical nurse, per hour.
T1000	Private duty/independent nursing service(s), licensed, up to 15 minutes.
T1002	RN services, up to 15 minutes.
T1003	LPN/LVN services, up to 15 minutes.
T1031	Nursing care, in the home, by licensed practical nurse, per diem.

Intermittent care billing threshold

Intermittent care billing thresholdFewer than 7 days per week or less than 8 hours per day for periods of 21 days or less.

Billing methodBill actual units/hours (e.g., three one-hour visits = three units of S9123/S9124).

Medically predictable needMember must have a medically predictable recurring need for skilled nursing services for intermittent care to apply.

Documentation, Verification, and Billing Actions

Documentation Required

Provide documentation and verify member benefits before billing PDN services

Providers may be asked to submit additional documentation to support PDN services and claims. The plan may request supporting documentation and claims may not be reimbursed if they exceed member benefit limits for days or hours of coverage; verify member benefits and plan contract compensation schedules before billing.

On request (initial, recertification, or revision), submit nurse progress notes, medication administration records, seizure logs, ventilator logs as applicable.
Verify member's maximum benefits and the plan's home health contract base compensation schedules via the provider website prior to claim submission.
Include appropriate revenue codes and CPT/HCPCS code combinations on claim submissions; failure to adhere may impact claims processing and reimbursement.

Key Definitions

Custodial or Unskilled Care

DefinitionCustodial or Unskilled Care: Personal care that does not require the technical skills, professional training, or clinical assessment ability of medical or nursing personnel; supports activities of daily living (ADLs) and is generally non‑medical.

Coverage implicationGenerally not a covered benefit under this policy; claims reimbursement is subject to plan benefits and plan documents.

Typical servicesAssistance with ADLs such as bathing, dressing, feeding, mobility and supervision of medication when these do not require skilled nursing.

Home Health Care

DefinitionHome Health Care: Healthcare services provided to a patient at home due to sickness or injury that require services from a skilled and licensed professional on an intermittent or part‑time basis.

Service settingProvided in the member's home (or inpatient facility setting when applicable) and delivered by skilled/licensed professionals.

Reimbursement noteClaim reimbursement is subject to plan benefits and may be limited by member benefit days/hours; verify member benefits and contract schedules.

Intermittent home care

DefinitionIntermittent home care: Part‑time skilled nursing care provided in the home or inpatient facility for fewer than seven days per week or less than 8 hours per day for periods of twenty‑one (21) days or less.

RequirementMember must have a medically predictable recurring need for skilled nursing services for intermittent home care to apply.

Billing exampleOne‑hour visits on Monday, Wednesday and Friday (three one‑hour visits in a seven‑day period) are intermittent care billed as three units of S9123/S9124.

Private Duty Nursing (PDN)

DefinitionPrivate Duty Nursing (PDN): Skilled nursing services for patients requiring more individual and continuous care than is available from a visiting nurse providing intermittent home care.

ExclusionsServices that can be provided by a medical assistant, nurse's aide, home health aide or other non‑nurse caregiver are not considered PDN.

Billing exampleContinuous nurse care for half of the day for five days (12 hours/day × 5 days = 240 units) should be billed with HCPCS code T1000 (15‑minute units).

Respite Care

DefinitionRespite Care: Short‑term, temporary relief to a primary or usual caregiver; the caregiver is generally a family member.

PurposeProvides temporary relief from caregiving duties rather than ongoing skilled medical care.

Typical useShort durations intended to support caregiver respite; coverage subject to plan benefits and medical necessity determinations.

Skilled Care

DefinitionSkilled Care: Medical care provided in the home or inpatient facility that may only be provided by or under the supervision of a skilled or licensed medical professional and requires technical skills and professional training.

Provider qualificationsServices must be delivered by or under supervision of a licensed professional nurse or rehabilitation therapist.

Relationship to coverageSkilled care eligibility and reimbursement remain subject to member benefits, medical necessity, and plan documents.