CurrentBlue Cross Blue Shield - North CarolinaPolicy NC-HB-CD-009700-26-S2837

Claims and Billing Guidance for Home Health EVV - REV/HCPC/CPT Codes

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Guidance for institutional claims billing of home health services (EVV-related) including revenue codes, HCPCS/CPT codes, and prior authorization requirements for Blue Cross Blue Shield - North Carolina (Healthy Blue) providers.

Policy Summary

PayerBlue Cross Blue Shield - North Carolina

PolicyClaims and Billing Guidance for Home Health EVV - REV/HCPC/CPT Codes

Policy CodePolicy NC-HB-CD-009700-26-S2837

Change TypeNo material changes

Effective DateApr 1, 2026

Next Review Date

Key ActionUse only the listed HCPCS/CPT codes for PA requests and claims and verify prior authorization requirements (PAs are always required for out-of-network providers) via the prior authorization lookup tool.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~20+listed HCPCS/CPT and related codes across service lines

PA required for OONPrior authorizations required for OON

NC Health Plan GuideBilling guide referenced

N/AEVV code combos

Billing and Coverage Criteria

Billing and PA Criteria for Home Health EVV Services

Use the listed revenue and HCPCS/CPT codes for the indicated service types and follow the prior authorization indicators in the table when submitting claims or prior authorization (PA) requests.

Only use the specific HCPCS/CPT codes listed for each revenue code/service type when submitting institutional claims or PA requests; do NOT use any codes not listed in the table (column F).

Service rows and codes

Physical Therapy (Revenue Code RC420): Prior Auth Required = Yes; Use codes G0151, G0157, G0159, G0283, G2168, S9131 for PA requests and claims; do not use any other codes.
Physical Therapy Evaluation (Revenue Code RC424): Prior Auth Required = Yes; Use codes 97161, 97162, 97163, 97164, G0159 for PA requests and claims; do not use any other codes.
Occupational Therapy (Revenue Code RC430): Prior Auth Required = Yes; Use codes G0152, G0160, G2169, S9129 for PA requests and claims; do not use any other codes.
Occupational Therapy Evaluation (Revenue Code RC434): Prior Auth Required = No; Use codes 97165, 97166, 97167 for claims/PA as indicated; do not use any other codes.
Speech Therapy (Revenue Code RC440): Prior Auth Required = Yes; Use codes G0153, G0161, S9128 for PA requests and claims; do not use any other codes.
Speech Therapy Evaluation (Revenue Code RC444): Prior Auth Required = No; Use codes 92521, 92522, 92523 for claims/PA as indicated; do not use any other codes.

Skilled nursing, venipuncture, and home health aide rows

Skilled nursing assessment/re-assessment (Revenue Code RC550): Prior Auth Required = Yes; Use code G0162 for PA requests and claims; do not use any other codes.
Skilled nursing visit (Revenue Code RC550 - alternate rows): Prior Auth Required = No; Use codes G0493, G0494, T1001 for claims/PA where indicated; do not use any other codes.
Skilled nursing treatment/visits (Revenue Code RC551): Use codes G0299, G0300, S9123, S9124 for claims/PA where indicated; do not use any other codes.
Skilled Nursing - Dually Eligible Beneficiary when visit does not meet Medicare criteria (Revenue Code RC559): Prior Auth Required = No; Use codes G0299, G0300 for these visits and use G0495 for RC559 when specified; do not use any other codes.
Skilled Nursing - Venipuncture (Revenue Code RC580): Prior Auth Required = Yes; Use G0299, G0300 for PA requests and claims; do not use any other codes.
Skilled Nursing - Prefilling insulin syringes/mediplanners (Revenue Code RC581): Prior Auth Required = Yes; Use codes G0299, G0300, S9124 for PA requests and claims; do not use any other codes.
Home Health Aide Visit (Revenue Code RC570): Use codes S9122, G0156, T1021 for claims/PA as indicated; do not use any other codes.

Out-of-network providers: Prior authorizations are always required; verify PA requirements via the prior authorization lookup tool on the provider portal.

Institutional claims should be submitted in accordance with the NC Health Plan Billing Guide referenced in this document.

EVV data note: Code combos for EVV visit data are listed as N/A for multiple service rows; no special EVV code-combination guidance is provided in this document.

Codes by Service Line

Physical Therapy (Revenue Code RC420/RC424)HCPCS | CPTCovered

G0151	Home health physical therapy (visit)
G0157	Physical therapy, other
G0159	Physical therapy evaluation or related
G0283	Therapeutic procedure
G2168	PT-related code
S9131	Home health PT visit

PT Evaluations (Revenue Code RC424/Box 44 entries)CPTCovered

97161	Physical therapy evaluation, low complexity
97162	Physical therapy evaluation, moderate complexity
97163	Physical therapy evaluation, high complexity
97164	Physical therapy re-evaluation

Occupational Therapy (Revenue Codes RC430/RC434)HCPCS | CPTCovered

G0152	Occupational therapy visit
G0160	OT-related code
G2169	OT-related HCPCS
S9129	OT home visit
97165	OT evaluation low complexity
97166	OT evaluation moderate complexity
97167	OT evaluation high complexity
97168	OT re-evaluation
G0158	OT evaluation code

Speech Therapy (Revenue Codes RC440/RC444)HCPCS | CPTCovered

G0153	Speech therapy visit
G0161	Speech therapy related
S9128	Speech therapy home visit
92521	Speech-language evaluation
92522	Speech-language evaluation
92523	Speech-language evaluation

Skilled Nursing, Venipuncture, Home Health Aide (Revenue Codes RC550/RC551/RC559/RC580/RC581/RC570)HCPCS | CPTCovered

G0162	Skilled nursing assessment/re-assessment
G0493	Skilled nursing visit
G0494	Skilled nursing visit
T1001	Home visit by RN/LPN
G0299	Venipuncture/home health service
G0300	Venipuncture/home health service
S9123	Nursing home visit
S9124	Nursing home visit
G0495	Home health skilled nursing (dually eligible non-Medicare)
S9122	Home health aide visit

1–10 of 12

1/2

Allowed codes for PA/claims

Allowed codes for PA requests and claimsOnly use the specific HCPCS/CPT codes listed in column F of the table when submitting prior authorization requests and claims; do NOT use any other codes not listed.

Scope of restrictionApplies to all service rows in the table (therapies, evaluations, skilled nursing, venipuncture, home health aide) as shown in column F entries.

Box mapping requirementPopulate Box 42 (Revenue Code) and Box 44 (HCPCS/CPT) on institutional claims using the revenue and HCPCS/CPT codes listed in the table's column F for each service.

Out-of-network PA rulePrior authorizations are always required for Out of Network providers; verify via the prior authorization lookup tool.

EVV code combos noteThe table indicates 'N/A' for EVV code combos in multiple rows—no special EVV code combinations are provided in this document.

Prior Authorization & Claim Submission Actions

Prior Authorization

PA Required for Out‑of‑Network Providers

Prior authorizations are always required for Out of Network providers; verify prior authorization requirements via the prior authorization lookup tool on the provider portal.

Billing Rule

Use Specified HCPCS/CPT Codes for PA and Claims

Use the listed HCPCS/CPT codes for PA requests and claims where the table indicates 'Use These Codes for PA requests and claims'; do not use codes other than those listed in column F for PA and claims.

Only codes listed in column F of the table should be used for PA requests and claims; do NOT use any other codes not listed.

Key Terms

Prior authorization

Definition of Prior Authorization (PA)Authorization required in advance for certain services; PAs are always required for Out of Network providers and providers should verify PA requirements via the prior authorization lookup tool.

When PA appliesFollow the 'Prior Auth Required?' indicator for each service row in the table; some services (e.g., certain therapy visits and skilled nursing assessment) are marked Yes or No per the table.

How to verify PAUse the prior authorization lookup tool on the provider portal (https://provider.healthybluenc.com/north-carolina-provider/prior-authorization-lookup) to confirm requirements.

PA for code useUse the listed HCPCS/CPT codes (column F) when requesting PA; do not request PA for codes not listed in column F.

EVV Visit Data Code Combos

EVV Visit Data code combosThe table indicates 'N/A' for code combos for EVV visit data in multiple service rows, meaning this document does not provide special EVV code-combination guidance.

Relationship to listed codesEVV reporting should use the same revenue and HCPCS/CPT codes listed in column F for each service; no alternate EVV-specific combinations are supplied.

Implication for claimsWhen submitting institutional claims, populate Box 42 (Revenue Code) and Box 44 (HCPCS/CPT) per the codes listed in the table; EVV combos are not provided separately.

Examples from the tableExamples show 'N/A' for EVV code combos for Physical Therapy (RC420/RC424), Occupational Therapy (RC430/RC434), and Speech Therapy (RC440/RC444) rows.

Policy Summary

PayerBlue Cross Blue Shield - North Carolina

PolicyClaims and Billing Guidance for Home Health EVV - REV/HCPC/CPT Codes

Policy CodePolicy NC-HB-CD-009700-26-S2837

Change TypeNo material changes

Effective DateApr 1, 2026

Next Review Date

SourceLink

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Claims and Billing Guidance for Home Health EVV - REV/HCPC/CPT Codes

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Billing and Coverage Criteria

Billing and PA Criteria for Home Health EVV Services

Use the listed revenue and HCPCS/CPT codes for the indicated service types and follow the prior authorization indicators in the table when submitting claims or prior authorization (PA) requests.

Only use the specific HCPCS/CPT codes listed for each revenue code/service type when submitting institutional claims or PA requests; do NOT use any codes not listed in the table (column F).

Service rows and codes

Physical Therapy (Revenue Code RC420): Prior Auth Required = Yes; Use codes G0151, G0157, G0159, G0283, G2168, S9131 for PA requests and claims; do not use any other codes.
Physical Therapy Evaluation (Revenue Code RC424): Prior Auth Required = Yes; Use codes 97161, 97162, 97163, 97164, G0159 for PA requests and claims; do not use any other codes.
Occupational Therapy (Revenue Code RC430): Prior Auth Required = Yes; Use codes G0152, G0160, G2169, S9129 for PA requests and claims; do not use any other codes.
Occupational Therapy Evaluation (Revenue Code RC434): Prior Auth Required = No; Use codes 97165, 97166, 97167 for claims/PA as indicated; do not use any other codes.
Speech Therapy (Revenue Code RC440): Prior Auth Required = Yes; Use codes G0153, G0161, S9128 for PA requests and claims; do not use any other codes.
Speech Therapy Evaluation (Revenue Code RC444): Prior Auth Required = No; Use codes 92521, 92522, 92523 for claims/PA as indicated; do not use any other codes.

Skilled nursing, venipuncture, and home health aide rows

Skilled nursing assessment/re-assessment (Revenue Code RC550): Prior Auth Required = Yes; Use code G0162 for PA requests and claims; do not use any other codes.
Skilled nursing visit (Revenue Code RC550 - alternate rows): Prior Auth Required = No; Use codes G0493, G0494, T1001 for claims/PA where indicated; do not use any other codes.
Skilled nursing treatment/visits (Revenue Code RC551): Use codes G0299, G0300, S9123, S9124 for claims/PA where indicated; do not use any other codes.
Skilled Nursing - Dually Eligible Beneficiary when visit does not meet Medicare criteria (Revenue Code RC559): Prior Auth Required = No; Use codes G0299, G0300 for these visits and use G0495 for RC559 when specified; do not use any other codes.
Skilled Nursing - Venipuncture (Revenue Code RC580): Prior Auth Required = Yes; Use G0299, G0300 for PA requests and claims; do not use any other codes.
Skilled Nursing - Prefilling insulin syringes/mediplanners (Revenue Code RC581): Prior Auth Required = Yes; Use codes G0299, G0300, S9124 for PA requests and claims; do not use any other codes.
Home Health Aide Visit (Revenue Code RC570): Use codes S9122, G0156, T1021 for claims/PA as indicated; do not use any other codes.

Out-of-network providers: Prior authorizations are always required; verify PA requirements via the prior authorization lookup tool on the provider portal.

Institutional claims should be submitted in accordance with the NC Health Plan Billing Guide referenced in this document.

EVV data note: Code combos for EVV visit data are listed as N/A for multiple service rows; no special EVV code-combination guidance is provided in this document.

Codes by Service Line

Physical Therapy (Revenue Code RC420/RC424)HCPCS | CPTCovered

G0151	Home health physical therapy (visit)
G0157	Physical therapy, other
G0159	Physical therapy evaluation or related
G0283	Therapeutic procedure
G2168	PT-related code
S9131	Home health PT visit

PT Evaluations (Revenue Code RC424/Box 44 entries)CPTCovered

97161	Physical therapy evaluation, low complexity
97162	Physical therapy evaluation, moderate complexity
97163	Physical therapy evaluation, high complexity
97164	Physical therapy re-evaluation

Occupational Therapy (Revenue Codes RC430/RC434)HCPCS | CPTCovered

G0152	Occupational therapy visit
G0160	OT-related code
G2169	OT-related HCPCS
S9129	OT home visit
97165	OT evaluation low complexity
97166	OT evaluation moderate complexity
97167	OT evaluation high complexity
97168	OT re-evaluation
G0158	OT evaluation code

Speech Therapy (Revenue Codes RC440/RC444)HCPCS | CPTCovered

G0153	Speech therapy visit
G0161	Speech therapy related
S9128	Speech therapy home visit
92521	Speech-language evaluation
92522	Speech-language evaluation
92523	Speech-language evaluation

Skilled Nursing, Venipuncture, Home Health Aide (Revenue Codes RC550/RC551/RC559/RC580/RC581/RC570)HCPCS | CPTCovered

G0162	Skilled nursing assessment/re-assessment
G0493	Skilled nursing visit
G0494	Skilled nursing visit
T1001	Home visit by RN/LPN
G0299	Venipuncture/home health service
G0300	Venipuncture/home health service
S9123	Nursing home visit
S9124	Nursing home visit
G0495	Home health skilled nursing (dually eligible non-Medicare)
S9122	Home health aide visit

1–10 of 12

1/2

Allowed codes for PA/claims

Scope of restrictionApplies to all service rows in the table (therapies, evaluations, skilled nursing, venipuncture, home health aide) as shown in column F entries.

Box mapping requirementPopulate Box 42 (Revenue Code) and Box 44 (HCPCS/CPT) on institutional claims using the revenue and HCPCS/CPT codes listed in the table's column F for each service.

Out-of-network PA rulePrior authorizations are always required for Out of Network providers; verify via the prior authorization lookup tool.

EVV code combos noteThe table indicates 'N/A' for EVV code combos in multiple rows—no special EVV code combinations are provided in this document.

Prior Authorization & Claim Submission Actions

Prior Authorization

PA Required for Out‑of‑Network Providers

Prior authorizations are always required for Out of Network providers; verify prior authorization requirements via the prior authorization lookup tool on the provider portal.

Billing Rule

Use Specified HCPCS/CPT Codes for PA and Claims

Only codes listed in column F of the table should be used for PA requests and claims; do NOT use any other codes not listed.

Key Terms

Prior authorization

How to verify PAUse the prior authorization lookup tool on the provider portal (https://provider.healthybluenc.com/north-carolina-provider/prior-authorization-lookup) to confirm requirements.

PA for code useUse the listed HCPCS/CPT codes (column F) when requesting PA; do not request PA for codes not listed in column F.

EVV Visit Data Code Combos

EVV Visit Data code combosThe table indicates 'N/A' for code combos for EVV visit data in multiple service rows, meaning this document does not provide special EVV code-combination guidance.

Relationship to listed codesEVV reporting should use the same revenue and HCPCS/CPT codes listed in column F for each service; no alternate EVV-specific combinations are supplied.

Implication for claimsWhen submitting institutional claims, populate Box 42 (Revenue Code) and Box 44 (HCPCS/CPT) per the codes listed in the table; EVV combos are not provided separately.

Examples from the tableExamples show 'N/A' for EVV code combos for Physical Therapy (RC420/RC424), Occupational Therapy (RC430/RC434), and Speech Therapy (RC440/RC444) rows.