Home Health Services - Skilled
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Defines coverage, authorization, clinical criteria, and coding for skilled home health services (nursing, PT/OT/SLP, home health aide, social services) for BCBSRI Medicare Advantage and Commercial products. Applies to participating home health providers billing BCBSRI.
No material clinical or coverage changes in this revision.
Coverage Criteria for Skilled Home Health Services
Covered when all criteria met
Home health services are covered for Medicare Advantage and Commercial Products when ALL of the following are met:
Coverage criteria
- Homebound status: Patient is homebound: due to illness or injury needs aid of supportive devices (e.g., crutches, canes, wheelchairs, walkers), special transportation, or assistance of another person to leave home; OR leaving home is medically contraindicated; AND there exists a normal inability to leave home and leaving home requires a considerable and taxing effort.
- Under provider care: Patient is under the care of a provider (MD, DO, or midlevel practitioner).
- Plan of care: Receiving services under a plan of care established and periodically reviewed by a provider (every 60 days).
- Skilled need: Patient is in need of intermittent skilled nursing, physical therapy, or speech-language pathology; OR has a continuing need for occupational therapy.
- Inherent complexity: Care is inherently complex and can be performed safely and/or effectively only by or under the general supervision of a skilled therapist or nurse.
- Reasonable frequency and duration: Services are reasonable in amount, frequency, and duration consistent with the nature and severity of the illness or injury and the patient's particular medical needs.
- Standard of practice: Services are considered specific, safe, and effective treatment for the member's condition under standards of medical practice.
(end)
The following services are excluded from coverage: custodial care, homemaking, maintenance therapy, services of a personal care attendant, and private duty nursing. Custodial care is defined as nonmedical personal care used to assist with activities of daily living (for example: bathing, dressing, food preparation, eating, transferring in/out of bed or chair, and toileting), and includes homemaking, companionship, and maintenance therapy; these are contract exclusions.
Services that are custodial in nature or that exceed stated aide or nursing hour limits are not covered as medically necessary home health. Specifically, home health aide services are covered up to 2 hours per day; services beyond this will be retrospectively reviewed and may be excluded if deemed custodial. In addition, skilled nursing services alone should not exceed 8 hours per day, since longer periods are considered private duty nursing and are excluded.
Coding and Service Limits
| S9122 | Home health aide or certified nurse assistant, providing care in the home. |
| S9123 | Nursing care, in the home; by registered nurse. |
| S9124 | Nursing care, in the home; by licensed practical nurse*. |
| S9127 | Social work visit, in the home, per diem. |
| S9128 | Speech therapy, in the home, per diem. |
| S9129 | Occupational therapy, in the home, per diem. |
| S9131 | Physical therapy; in the home, per diem. |
| S9470 | Nutritional counseling, dietitian visit |
| G0151 | Services of Physical Therapist in home health setting, each 15 minutes |
| G0152 | Services of Occupational Therapist in home health setting, each 15 minutes |
| G0153 | Services of Speech and Language Pathologist in home health setting, each 15 minutes |
| G0156 | Services of Home Health Aide in home setting, each 15 minutes |
| G0157 | Services performed by a qualified physical therapy assistant in the home health setting, each 15 minutes |
| G0158 | Services performed by a qualified occupational therapy assistant in the home health setting, each 15 minutes |
| 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 license practical nurse (LPN) in the home health or hospice setting, each 15 minutes |
Provider Responsibilities, Notification, and Authorization
Prior Authorization / Notification
Effective July 1, 2018, submission of the required notification to BCBSRI authorizes initial home health services up to 30 units for up to 90 days. Prior authorization is required for continued services beyond the initial 30 units or the 90-day period. Providers are responsible for verifying member eligibility, benefit coverage, and submitting notification or prior authorization as applicable.
- Notification administratively authorizes up to 30 units/90 days.
- Prior authorization required for services beyond 30 units or 90 days.
Prior Authorization Submission and Documentation Requirements
Requests for ongoing services must be submitted at least four business days prior to the visit including the 30th unit. Documentation required for prior authorization of continued services includes: initial evaluation results, evidence of homebound status, individualized goals and plan of care, number of visits needed and duration, per-discipline goals met/not met, progress toward unmet goals, any barriers to progress and the plan to address them (including follow-up with the ordering provider), and the anticipated number of visits needed to meet goals. Note: when barriers to progress are identified, documentation of provider follow-up is required prior to continued authorization.
- Submit requests at least 4 business days before the visit including the 30th unit.
- Include initial evaluation, homebound evidence, individualized goals/plan of care, visit counts/duration, per-discipline goal status, progress, barriers and follow-up plan, anticipated visits.
Denial Risk — Custodial Care and Private Duty Nursing
Services that are custodial in nature (nonmedical personal care, homemaking, companion care, or maintenance therapy) and personal care attendant services are excluded from coverage and will be denied. Home health aide services are covered only when directly related to the skilled plan of care and are typically limited to up to 2 hours per day; services exceeding 2 hours/day will be retrospectively reviewed and may be considered custodial and excluded. Skilled nursing services that exceed a total of 8 hours per day are considered private duty nursing and are not covered under home health.
- Custodial care, homemaking, maintenance therapy, and personal care attendant services are not covered.
- Home health aide services: up to 2 hours/day; >2 hours/day may be denied as custodial care.
- Skilled nursing alone >8 hours/day is considered private duty nursing and not covered.
Billing/Coding — Local Provider Code Use
Local participating BCBSRI home health providers should use the S9xxx (HCPCS) home health codes listed by policy for covered services. Certain G‑codes (G0151, G0152, G0153, G0156, G0157, G0158, G0299) are not applicable for participating BCBSRI in‑state providers and will deny if filed by a local participating provider; they may be accepted if filed by out‑of‑state providers when applicable.
Background
Homebound patients with skilled needs may receive intermittent skilled services at home when those services are reasonable in amount, frequency, and duration and can only be safely and effectively provided by or under the supervision of a skilled clinician. Covered skilled services include nursing, physical therapy, occupational therapy, speech-language pathology, home health aide services (when directly related to the skilled plan of care), and medical social services, provided the patient meets homebound status and the care is established under a plan of care and reviewed periodically.
Key Definitions
Revision History
Policy became effective for notification and prior authorization processes for home health services on July 1, 2018.
Policy last updated/reviewed on March 16, 2022.
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