DraftBlue Cross Blue Shield - TexasPolicy CPCP005

Home Health Care Policy

Governs coding, billing, and reimbursement guidance for various types of home health care services (skilled and custodial) and applicable code sets for claim submissions affecting providers billing Blue Cross and Blue Shield of Texas plans.

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyHome Health Care Policy

Policy CodePolicy CPCP005

Change TypeRevised — material coding and definition updates

Effective DateMarch 21, 2025

Next Review DateN/A

Key ActionSubmit supporting documentation upon request; the plan may request additional PDN documentation during initial requests, recertification, or revisions.

SourceLink

POLICY UPDATE CHANGES

Revenue codes and multiple new HCPCS codes (including G0151-G0153, G0155-G0162, G0299, G0300, G0493-G0496, G2168, G2169, S9125-S9129, S9131) were added and examples expanded.

Policy title changed; definition updates; Professional and facility sections added; Revenue codes added; HCPCS coding updated with S and G code examples and new HCPCS codes.

1.0policy version

03/11/2025committee approval

03/21/2025plan effective

multipleHCPCS codes added

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Coverage Criteria

General coverage statements

High-level coverage guidance and limitations

Inclusion of services or codes in this policy does not guarantee coverage or payment; coverage is subject to the member's benefits, applicable state and federal statutes, regulations, laws, and mandates.

Providers must bill the most appropriate code that accurately reflects the total time and type of service rendered, and documentation must support the time and services billed.

The plan reserves the right to request supporting documentation; failure to adhere to coding and billing policies may impact claims processing and reimbursement, and claims may not be reimbursed if they exceed member benefit limits for days or hours of coverage.

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

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

HCPCS 'G' vs 'S' code usage

Coding restrictions and upcoding risk

HCPCS 'G' codes identify intermittent home health services for PT/OT/ST, skilled nursing, and home health aide services when provided by a qualified home health provider.

Report the code type that accurately reflects the service rendered; reporting a HCPCS 'G' code when an 'S' code or other code is more appropriate, or using an incorrect combination of codes, could be considered upcoding.

Per diem criteria

Per diem coverage day definition and requirement for plan of care documentation

Per diem represents each day that the 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.

The expected course and duration of treatment shall be determined by the plan of care as prescribed by the ordering physician and documented appropriately; per diem billing must be supported by the plan of care documentation.

Per hour billing rules

When billing codes are described as 'per hour', time reporting must follow defined brackets

Use these reporting time brackets when a code description states 'per hour': 0 = less than 31 minutes; 1 = 31 to 90 minutes; 2 = 91 to 150 minutes.

Documentation must support the time bracket reported and the total time billed for the service.

Coding and Billing Codes

Example HCPCS/G/S/T codes referencedHCPCS

G0151	Physical therapist in home/hospice, each 15 mins
G0152	Occupational therapist in home/hospice, 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
S9123	Nursing care, in the home; by registered nurse, per hour
S9124	Nursing care, in the home; by licensed practical nurse, per hour

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Home health revenue codes (examples)Revenue

0421	Phsyical Therapy; Visit charge
0551	Skilled Nursing; Visit charge
0552	Skilled Nursing; Hourly charge
0571	Home Health Aide; Visit charge
0623	Medical Surgical Supplies
0636	Pharmacy; Drugs requiring detailed coding

HCPCS codes added (examples)HCPCS

G0151-G0153, G0155-G0162, G0299, G0300, G0493-G0496, G2168, G2169, S9125-S9129, S9131

New HCPCS codes added to policy (examples listed in update).

HCPCS/CPT codes removedHCPCSNot Covered

T1002, T1003, T1031

Codes removed from policy

PDN units example — T1000

Example calculationMember receives continuous nursing care 12 hours/day for 5 days (12 x 5 = 60 hours); billed as 240 units of HCPCS code T1000

Units basisT1000 billed in units that reflect 15-minute increments (240 units represent 60 hours)

Service classificationThis scenario is classified as Private Duty Nursing (PDN) and should be billed accordingly

Intermittent care example — S9123 / S9124

Example scenarioMember receives one-hour nursing visits on Monday, Wednesday and Friday (three one-hour visits within a seven-day period); billed as 3 units of S9123 or S9124

Provider Actions and Documentation

Documentation Required

Private Duty Nursing (PDN) — Additional Documentation

The plan may request additional documentation from the PDN provider to support billed services. Requests can occur during the initial request, at recertification, or when services are revised. Examples of additional documentation include, but are not limited to: nurse progress notes, medication administration records, seizure logs, and ventilator logs.

Applicable to Private Duty Nursing (PDN) billing and requests

Documentation Required

General documentation and claim review

Upon request, the provider should submit supporting documentation to validate services billed. Providers are responsible for accurate submission of documentation and correct coding using applicable code sets and industry coding guidelines. Claims are subject to review against benefit coverage, provider contract language, medical policies, clinical payment and coding policies, and code-edit protocols; the plan reserves the right to request supporting documentation. Failure to adhere to coding and billing policies may affect claims processing and reimbursement. Claim reimbursement is subject to plan benefits and may be denied if services exceed member benefit limits for days or hours of coverage.

Definitions

Custodial or Unskilled Care

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

PurposeSupports patient's care and activities of daily living rather than providing medical treatment

ReferenceSee ADM1001.014 Custodial Care for additional guidance

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

SettingProvided in the patient's home when skilled/licensed professional care is needed

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyHome Health Care Policy

Policy CodePolicy CPCP005

Change TypeRevised — material coding and definition updates

Effective DateMarch 21, 2025

Next Review DateN/A

Key ActionSubmit supporting documentation upon request; the plan may request additional PDN documentation during initial requests, recertification, or revisions.

SourceLink

On This Page

Applicable codesS9123 (RN per hour) or S9124 (LPN per hour)

ClassificationThis scenario is considered Intermittent Home Care for billing purposes

Per-hour time reporting brackets

Bracket 0Less than 31 minutes

Bracket 131 to 90 minutes

Bracket 291 to 150 minutes

Per diem — definition

Per diem definitionEach day services are provided from initiation to discontinuation as documented in the plan of care

Documentation expectationExpected course and duration of treatment must be determined by the plan of care and documented by the ordering physician

Billing unitPer diem represents a single day of provided prescribed therapy and is billed accordingly

Providers must use valid code combinations from HIPAA-approved code sets (CPT, HCPCS, ICD-10, NDC, etc.)

Claims are subject to coding software logic, CCI edits, and other CMS guidelines

The plan may request documentation to substantiate time or units billed

Documentation Required

Per diem definition and documentation expectation

Per diem represents each day that a member receives prescribed therapy, beginning the day therapy is initiated and ending the day therapy is discontinued. The expected course and duration of treatment shall be determined by the plan of care as prescribed by the ordering physician and documented appropriately.

Per diem = one day of service; must be supported by plan of care documentation

Documentation Required

Per hour reporting time brackets

When a code description states 'per hour', report time using the following brackets: 0 = less than 31 minutes; 1 = 31 to 90 minutes; 2 = 91 to 150 minutes. Documentation must support the time bracket billed.

Use defined time brackets for hourly codes
Ensure documentation substantiates the billed time bracket

ScopeMay include skilled nursing and rehabilitation services as clinically indicated

Intermittent Home care

DefinitionPart-time skilled nursing care in the home or inpatient facility for fewer than seven days/week or less than 8 hours/day for periods of 21 days or less, with a medically predictable recurring need

Billing exampleThree one-hour nursing visits in a seven-day period billed as 3 units of S9123 or S9124

Duration requirementLimited to periods of twenty-one (21) days or less per medically predictable recurring need

Private Duty Nursing (PDN)

DefinitionNursing services for a member who requires more individual and continuous care, provided by an RN or LPN under the direction of the member's physician

Billing exampleContinuous nursing care 12 hours/day for 5 days (60 hours) billed as 240 units of T1000

Service intensityIntended for members requiring ongoing, individualized nursing beyond intermittent care

Respite Care

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

PurposeProvides temporary respite from caregiving responsibilities rather than ongoing medical care

SettingMay occur in the home or another appropriate setting as needed

Skilled Care

DefinitionMedical 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

RequirementsServices require technical skills and professional training of a licensed professional nurse or rehabilitation therapist

DistinctionDifferent from custodial care which is non-medical in nature

Per diem — short definition

Short definitionEach day that a member is provided prescribed therapy, from initiation to discontinuation as documented in the plan of care

DocumentationPlan of care must prescribe and document expected course and duration determined by the ordering physician

Billing implicationPer diem is billed as a daily unit for the day services are provided

Per hour (reporting) — time brackets

Reporting bracketsUse time brackets when code is described 'per hour': 0 = less than 31 minutes; 1 = 31 to 90 minutes; 2 = 91 to 150 minutes

PurposeEnsures consistent reporting of partial-hour nursing services for billing accuracy

ApplicationApply these brackets to HCPCS codes that specify 'per hour' in their description (e.g., S9123, S9124)