Colorado Rocky Mountain Health Plans Home Health Coverage

Coverage Criteria for Home Health, Skilled, and Custodial Care

Medical Necessity per InterQual LOC

Covered when InterQual LOC criteria for home care are met

InterQual requirement: Home health and skilled care services are considered medically necessary in certain circumstances; for medical necessity clinical coverage criteria, refer to the InterQual® LOC: Home Care Q & A (Home Care Services, Adult; Home Care Services, Pediatric).

Providers must follow InterQual criteria and member-specific benefit terms.

Covered skilled home health care

Covered when ALL of the following are met

Ordered by qualified practitioner: Service is ordered and directed by a treating practitioner or specialist (M.D., D.O., P.A., or N.P.).

chunk 25

Delivered or supervised by licensed professional: The care must be delivered or supervised by a licensed professional in order to obtain a specified medical outcome.

chunk 25

Not custodial: Services are not custodial in nature and are not provided for the comfort or convenience of the member or the member's family.

chunks 25,24

Alternative to facility care: Provided in the home in lieu of skilled care in another setting (e.g., nursing facility, acute inpatient rehabilitation, or hospital).

chunk 25

Clinically appropriate and cost effective: Care is clinically appropriate and not more costly than an alternative health service.

chunk 25

Intermittent and part-time: Services are intermittent and part-time (typically provided for less than four hours per day); exceptions may be made when the need for more care is finite and predictable.< 4 hours/day typical

chunks 25,26

Requires clinical training: The care provided must require clinical training to be delivered safely and effectively (e.g., skilled nursing, skilled rehabilitation, or skilled teaching).

chunk 26

Supplies and medications in visit: Medical supplies and medications used in conjunction with a home health visit (for example catheters, irrigation devices, surgical dressings, syringes) are covered as part of that visit but may be subject to separate benefit categories per the member specific benefit plan.

chunk 26

The listing of a procedure or diagnosis code in this policy is provided for reference only. Listing of a code does not imply that the service described by the code is a covered or non-covered health service; ultimate benefit coverage is determined by the member-specific benefit plan document and applicable laws. The inclusion of a code does not guarantee reimbursement or claim payment and other policies or guidelines may apply.

Home health care benefits expressly exclude services that are non-skilled or primarily for personal care or convenience. Excluded services include custodial care, domiciliary care, private duty nursing, respite care, rest cures, homemaker services (for example, meal delivery or transportation), independent nurses hired directly by the member or family, and services provided by personal care attendants, family members, or other unlicensed caregivers. Services beyond the plan's benefit limits (such as number of visits) are also excluded. UnitedHealthcare will evaluate whether benefits are available by reviewing both the skilled nature of the service and the need for physician-directed medical management.

Medical necessity determinations for home health and skilled care reference external clinical criteria. For claims and prior authorization decisions, refer to the InterQual level-of-care guidance and the member-specific benefit plan to confirm whether requested services meet clinical coverage criteria.

Services that are not skilled in nature or that can be safely provided by available non-licensed caregivers will not be determined to be skilled home health. In other words, services that are custodial, personal, or can be performed by unlicensed caregivers will not qualify as skilled home health even if no caregiver is otherwise available; skilled classification requires physician-directed medical management and licensure-appropriate delivery or supervision.

Applicable Codes and Billing

Listed CPT Home Visit CodesCPT

99500	Home visit for prenatal monitoring and assessment to include fetal heart rate, non-stress test, uterine monitoring, and gestational diabetes monitoring.
99501	Home visit for postnatal assessment and follow-up care.
99502	Home visit for newborn care and assessment.
99503	Home visit for respiratory therapy care (e.g., bronchodilator, oxygen therapy, respiratory assessment, apnea evaluation).
99504	Home visit for mechanical ventilation care.
99505	Home visit for stoma care and maintenance including colostomy and cystostomy.
99506	Home visit for intramuscular injections.
99507	Home visit for care and maintenance of catheter(s) (e.g., urinary, drainage, and enteral).
99511	Home visit for fecal impaction management and enema administration.
99601	Home infusion/specialty drug administration, per visit (up to 2 hours).

1–10 of 11

1/2

Listed G and Home Health HCPCS Codes (partial list)HCPCS

G0068	Professional services for the administration of anti-infective, pain management, chelation, pulmonary hypertension, inotropic, or other intravenous infusion drug or biological (excluding chemotherapy or other highly complex drug or biological) for each infusion drug administration calendar day in the individual's home, each 15 minutes.
G0069	Professional services for the administration of subcutaneous immunotherapy or other subcutaneous infusion drug or biological for each infusion drug administration calendar day in the individual's home, each 15 minutes.
G0070	Professional services for the administration of intravenous chemotherapy or other intravenous highly complex drug or biological infusion for each infusion drug administration calendar day in the individual's home, each 15 minutes.
G0088	Professional services, initial visit, for the administration of anti-infective, pain management, chelation, pulmonary hypertension, inotropic, or other intravenous infusion drug or biological (excluding chemotherapy or other highly complex drug or biological) for each infusion drug administration calendar day in the individual's home, each 15 minutes.
G0153	Services performed by a qualified speech-language pathologist in the home health or hospice setting, each 15 minutes.
G0155	Services of clinical social worker in home health or hospice settings, each 15 minutes.
G0156	Services of home health/hospice aide in home health or hospice settings, each 15 minutes.
G0157	Services performed by a qualified physical therapist assistant in the home health or hospice setting, each 15 minutes.
G0158	Services performed by a qualified occupational therapist assistant in the home health or hospice setting, each 15 minutes.
G0159	Services performed by a qualified physical therapist, in the home health setting, in the establishment or delivery of a safe and effective physical therapy maintenance program, each 15 minutes.

1–10 of 25

1/3

Listed S and other Home Infusion Codes (partial list)HCPCS

H1004	Prenatal care, at-risk enhanced service; follow-up home visit.
S5035	Home infusion therapy, routine service of infusion device (e.g., pump maintenance).
S5036	Home infusion therapy, repair of infusion device (e.g., pump repair).
S5108	Home care training to home care client, per 15 minutes.
S5109	Home care training to home care client, per session.
S5110	Home care training, family; per 15 minutes.
S5111	Home care training, family; per session.
S5115	Home care training, nonfamily; per 15 minutes.
S5116	Home care training, nonfamily; per session.
S5180	Home health respiratory therapy, initial evaluation.

1–10 of 16

1/2

Home infusion and therapy S-codesHCPCSCovered

S9370	Home therapy, intermittent antiemetic injection therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem.
S9372	Home therapy; intermittent anticoagulant injection therapy (e.g., Heparin); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem (do not use this code for flushing of infusion devices with Heparin to maintain patency).
S9373	Home infusion therapy, hydration therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem (do not use with hydration therapy codes S9374-S9377 using daily volume scales).
S9374	Home infusion therapy, hydration therapy; 1 liter per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem.
S9375	Home infusion therapy, hydration therapy; more than 1 liter but no more than 2 liters per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem.
S9376	Home infusion therapy, hydration therapy; more than 2 liters but no more than 3 liters per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem.
S9377	Home infusion therapy, hydration therapy; more than 3 liters per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies (drugs and nursing visits coded separately), per diem.
S9379	Home infusion therapy, infusion therapy, not otherwise classified; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem.

Home infusion antibiotic/antiviral antifungal S-codes and frequency-based codesHCPCSCovered

S9494	Home infusion therapy, antibiotic, antiviral, or antifungal therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem (do not use this code with home infusion codes for hourly dosing schedules S9497-S9504).
S9497	Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 3 hours; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem.
S9500	Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 24 hours; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem.
S9501	Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 12 hours; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem.
S9502	Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 8 hours, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem.
S9503	Home infusion therapy, antibiotic, antiviral, or antifungal; once every 6 hours; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem.
S9504	Home infusion therapy, antibiotic, antiviral, or antifungal; once every 4 hours; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem.

Home injectable/transfusion and nursing service codesHCPCSCovered

S9537	Home therapy; hematopoietic hormone injection therapy (e.g., erythropoietin, G-CSF, GM-CSF); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem.
S9538	Home transfusion of blood product(s); administrative services, professional pharmacy services, care coordination and all necessary supplies and equipment (blood products, drugs, and nursing visits coded separately), per diem.
S9542	Home injectable therapy, not otherwise classified, including administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem.
S9559	Home injectable therapy, interferon, including administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem.
S9560	Home injectable therapy; hormonal therapy (e.g., leuprolide, goserelin), including administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem.
S9562	Home injectable therapy, palivizumab or other monoclonal antibody for RSV, including administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem.
S9590	Home therapy, irrigation therapy (e.g., sterile irrigation of an organ or anatomical cavity); including administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem.
T1001	Nursing assessment/evaluation.
T1002	RN services, up to 15 minutes.
T1003	LPN/LVN services, up to 15 minutes.

1–10 of 12

1/2

Home health aide, agency, assessment and nursing administration codesHCPCSCovered

T1021	Home health aide or certified nurse assistant, per visit.
T1022	Contracted home health agency services, all services provided under contract, per day.
T1028	Assessment of home, physical and family environment, to determine suitability to meet patient's medical needs.
T1030	Nursing care, in the home, by registered nurse, per diem.
T1502	Administration of oral, intramuscular and/or subcutaneous medication by health care agency/professional, per visit.

TPN volume tiers (S9365-S9368)

S9365TPN; one liter per day

S9366TPN; more than 1 liter but no more than 2 liters per day

S9367TPN; more than 2 liters but no more than 3 liters per day

S9368TPN; more than 3 liters per day

Intermittent care duration

Typical duration

Provider Requirements, Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization required. Prior authorization and medical necessity determinations are made per InterQual® Level of Care (LOC) — Home Care Q & A (Home Care Services, Adult and Pediatric). Providers must obtain prior authorization when required by the member's benefit plan and follow InterQual criteria for clinical review.

InterQual® LOC: Home Care Q & A — Home Care Services, Adult
InterQual® LOC: Home Care Q & A — Home Care Services, Pediatric

Note

Verify Member Benefits and Medical Necessity

Confirm member benefits and applicable state or federal mandates before delivering services. The member-specific benefit plan governs; listing of codes in this policy does not guarantee coverage.

Verify member-specific benefit document for coverage, visit limits, and benefit categories
Check for state/federal mandates that may affect coverage

Key Definitions

Place of Residence

DefinitionWherever the member makes his/her home (dwelling, apartment, relative's home, or facility-based long-term care residence such as board and care, assisted living, nursing home, continuing care retirement community)

ApplicabilityDefinitions may not apply to all plans; refer to the member-specific benefit plan document

Examples of settingsPrivate residence, relative's home, assisted living facility, nursing home

Respite Care

DefinitionShort-term relief for primary caregivers provided at the member's Place of Residence, in a healthcare facility, or at an adult day care center; can range from an afternoon to several days or weeks

PurposeProvides temporary caregiver respite, not ongoing skilled care

Background

Home health services provide short-term, skilled clinical care and supportive services in a member's place of residence as an alternative to facility-based care. Typical services include skilled nursing, skilled rehabilitation (physical, occupational, speech therapy), medical evaluation, wound care, medication teaching, and other clinician-delivered interventions when ordered and directed by a treating practitioner. These services are generally intermittent and part-time (typically less than 4 hours per day) and must meet clinical necessity as defined by InterQual level-of-care criteria and member-specific benefit terms.

OpenPayer

Home Health, Skilled, and Custodial Care Services

Coverage Criteria for Home Health, Skilled, and Custodial Care

Applicable Codes and Billing

Provider Requirements, Authorization, and Documentation

Key Definitions

Background