ModifiedBlue Cross Blue Shield - TexasPolicy CPCPOOS

Home Health Care Policy

Defines types of home health care services, appropriate code sets and billing guidance for claim submissions to Blue Cross and Blue Shield of Texas; applies to providers submitting home health claims under BCBSTX plans.

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyHome Health Care Policy

Policy CodePolicy CPCPOOS

Change TypeAnnual review with coding and structural updates

Effective DateMar 21, 2025

Next Review DateN/A

Key ActionProvide supporting documentation on request, including nurse progress notes, medication administration records, seizure logs, and ventilator logs for PDN claims.

SourceLink

POLICY UPDATE CHANGES

Annual review; Policy title change; Definition updates; Professional and facility sections added; Revenue codes added; HCPCS coding updated including Sand G code examples and new HCPCS codes G0151-G0153, S9125-S9129, S9131; Removed T1002, T1003, and T1031.

Removed Custodial Care section.

Added reporting time examples; Added Professional and facility sections; Added Revenue codes.

UpdatedHCPCS coding changes noted

G/S/Texample code groups illustrated

15-minunitization guidance

PDN vs intermittentbilling examples

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.

Since 2018Number of recorded update entries

IncludedExternal citations

Coverage, Adjudication, and Policy Summaries

Coverage and claim adjudication

General rules governing reimbursement and precedence of plan documents and contracts:

ALL of the following

If a conflict arises between this Clinical Payment and Coding Policy (CPCP) and any plan document under which a member is entitled to Covered Services, the plan document will govern.
If a conflict arises between this CPCP and any provider contract pursuant to which a provider participates in and/or provides Covered Services to an eligible member and/or plans, the provider contract will govern.
Providers are responsible for submission of accurate documentation of services performed and must submit claims using valid HIPAA code sets and industry-standard coding guidelines.
Claims are subject to code edit protocols and claim review, including but not limited to benefit coverage terms, provider contract language, medical policies, clinical payment and coding policies, and coding software logic; the plan may request supporting documentation upon request.
Home health care is reimbursable only when the service performed in the home is eligible under the member's benefits; claim reimbursement is subject to plan benefits.

Providers should bill the most appropriate code that accurately reflects the total time of the services rendered and maintain documentation to support the time billed.

Summary nodes

Policy update summaries; coding and section changes noted.

Policy update history records multiple annual reviews; the most recent entry dated 03/11/2025 includes an annual review with policy title change, definition updates, addition of professional and facility sections, revenue codes, and HCPCS coding updates (including G0151–G0153, S9125–S9129, S9131) and removal of T1002, T1003, and T1031.

The 03/11/2025 update also revised the Private Duty Nursing (PDN) section, added reporting time examples, removed the Custodial Care section, and moved Additional Information Reminders; infusion services are referenced under CPCPO19.

HCPCS, Unitization, and Coding Updates

HCPCS/S codes and examplesHCPCS

G0151-G0161, G0299, G0493-G0495	HCPCS G-codes for home health PT/OT/SLP, skilled nursing, observation/assessment, training/education; 15-minute units
S9122-S9131	S-codes for home health aide, nursing care, respite, therapy per diem or per hour
T1000	PDN continuous nursing care billing

HCPCS updates and removalsHCPCS

G0151	Home health aide or homemaker services (example added in update)
G0152	Home health aide (example added in update)
G0153	Services performed by a qualified speech-language pathologist in the home health or hospice setting; each 15 mins (example added in update)
S9125	Respite care, in the home, per diem (new HCPCS code example added)
S9126	Hospice care, in the home, per diem (new HCPCS code example added)
S9127	Social work visit; in the home, per diem (new HCPCS code example added)
S9128	Speech therapy, in the home, per diem (new HCPCS code example added)
S9129	Occupational therapy, in the home, per diem (new HCPCS code example added)
S9131	Physical therapy, in the home, per diem (new HCPCS code example added)
T1002	Removed

1–10 of 12

1/2

Unitization rules — 15-minute codes and rounding/units guidance

Unit definitionOne unit = 15 minutes when code description states 'each 15-minutes'; use the policy's minute-to-unit conversion bands to determine units.

15-minute rounding bandsUse the provided conversion table: e.g., 8–22 mins = 1 unit; 23–37 mins = 2 units; 38–52 mins = 3 units; 53–67 mins = 4 units; 68–82 mins = 5 units; 83–97 mins = 6 units; 98–112 mins = 7 units; 113–127 mins = 8 units.

Per-hour codesWhen code description states 'per hour', follow hour-based bands (e.g., <31 mins = 1 unit; 31–90 mins = 2 units; 91–150 mins = 3 units) as specified in the policy.

Per diem vs time-basedPer diem reporting follows the plan of care and is reported each day therapy is provided; per diem timing rules are treated separately from 15‑minute and per‑hour codes.

Reporting time examples — illustrative reporting time examples for unitization and billing

Documentation, Billing, and Provider Notifications

Documentation Required

Provide PDN supporting documentation upon request

The plan may request additional documentation from the PDN provider to support services billed. Requests may occur during the initial request, a recertification request, or a revision-to-services request and may include nurse progress notes, medication administration records, seizure logs, and ventilator logs.

Documentation may be requested during initial, recertification, or revision requests.
Examples of requested records: nurse progress notes; medication administration records; seizure logs; ventilator logs.

Note

Follow CPCPO19 for infusion services

Infusion services are governed by the Clinical Payment and Coding Policy titled CPCPO19 (Infusion Services); providers should follow that policy for infusion-related authorization, documentation, and billing requirements.

Key Definitions and Section Structure

Custodial or Unskilled Care — Definition

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

Skill requirementDoes not require technical skills or clinical assessment by medical/nursing personnel.

ScopeTypically includes non-medical assistance with activities of daily living rather than skilled medical treatment.

Home Health Care — Definition

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.

Setting

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyHome Health Care Policy

Policy CodePolicy CPCPOOS

Change TypeAnnual review with coding and structural updates

Effective DateMar 21, 2025

Next Review DateN/A

Key ActionProvide supporting documentation on request, including nurse progress notes, medication administration records, seizure logs, and ventilator logs for PDN claims.

SourceLink

On This Page

Short visit example (15-min units)A visit lasting 25 minutes maps to the 23–37 minute band and is billed as 2 units when the code is 'each 15-minutes'.

Long visit example (15-min units)A visit lasting 100 minutes falls into the 98–112 minute band and is billed as 7 units under 15‑minute codes.

Per-hour exampleA visit lasting 45 minutes is billed as 2 units under 'per hour' codes using the 31–90 minute band.

Policy update noteReporting time examples and the conversion guidance were added in the 03/11/2025 policy update.

Provided in the patient's home when the member is homebound due to sickness or injury.

Provider qualificationsRequires a skilled and licensed professional (e.g., nurse, therapist) to deliver care.

Intermittent Home Care — Definition

DefinitionPart-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 21 days or less with a medically predictable recurring need.

Duration limitsFewer than 7 days/week or less than 8 hours/day, and typically for periods of 21 days or less.

Clinical requirementMember must have a medically predictable, recurring need for skilled nursing services.

Private Duty Nursing (PDN) — Definition

DefinitionNursing services for a member who requires more individual and continuous care, provided by a registered nurse or licensed practical nurse under the direction of the member's physician.

Care intensityProvides individualized, continuous nursing care rather than intermittent visits.

DocumentationPolicy notes the PDN section was revised in the 03/11/2025 update; plan may request supporting documentation for PDN services.

Respite Care — Definition

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

PurposeProvides temporary respite for the primary caregiver rather than ongoing skilled care.

Typical durationIntended as short-term or temporary support.

Skilled Care — Definition

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; services require technical skills and professional training.

Provider requirementMust be provided by or under supervision of a licensed professional nurse or rehabilitation therapist.

Nature of servicesIncludes procedures and assessments needing clinical skill and professional training, not custodial support.

Section structure — Professional and facility sections added; PDN section revised

Structural changeProfessional and facility sections were added to the policy structure.

PDN sectionPrivate Duty Nursing (PDN) section was revised during the 03/11/2025 update.

Other updatesRevenue codes were added and reporting time examples were added as part of the update.