ModifiedUnitedHealthcarePolicy CS137NM.C

Home Health, Skilled, and Custodial Care Services (for New Mexico Only)

Defines coverage reference and coding guidance for home health, skilled, and custodial care services for members in New Mexico; applies to providers and claims adjudication within New Mexico.

Policy Summary

PayerUnitedHealthcare

PolicyHome Health, Skilled, and Custodial Care Services (for New Mexico Only)

Policy CodePolicy CS137NM.C

Change TypeCodes removedrelated policy links updatedprior version archived

Effective DateJan 1, 2026

Next Review Date

Key ActionVerify federal, state, and contractual benefit and authorization requirements prior to using this policy and bill using the listed HCPCS/T codes with documentation that supports medical necessity per MAD 97-12, Chapter 768.

SourceLink

POLICY UPDATE CHANGES

Removed reference link to the Medical Policy titled Home Hemodialysis (for New Mexico Only) (retired Apr. 1, 2026).

Added reference link to the Medical Policy titled Chelation Therapy (for New Mexico Only).

Removed HCPCS codes S9339 and T1031 from Applicable Codes.

Archived previous policy version CS137NM.B.

100+codes listed

New Mexicostate-specific

MAD 97-12clinical reference

1archived versions

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Coverage & Medical Necessity

Medical necessity reference

Coverage determination

Reference-based medical necessity: Medical necessity clinical coverage criteria are determined by New Mexico MAD 97-12, Chapter 768: Home Health Services.

Providers must use the referenced MAD chapter for specific clinical criteria.

The list of procedure and diagnosis codes included 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, nor does inclusion guarantee reimbursement or payment. Benefit coverage and claim payment are determined by applicable federal, state, or contractual requirements and laws; other policies and guidelines may also apply. Providers should verify coverage and payment eligibility with the member’s benefit plan and applicable rules before billing.

This policy section is informational only: FDA approval alone is not a basis for coverage. Home health and skilled home care services are provided by licensed health care professionals and are not regulated by the FDA. Coverage determinations must follow the terms of the member’s federal, state, or contractual benefit plan; in the event of a conflict, those requirements govern. UnitedHealthcare may use third‑party criteria (for example, InterQual®) to assist in administering benefits.

Note for providers: FDA approval alone is not a basis for coverage. This FDA information is included for reference and does not establish coverage by itself.

Applicable Codes and Billing Units

CPT/Home visit and infusion CPT 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).

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HCPCS G and related therapy/skilled service codesHCPCS

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.
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.
G0089	Professional services, initial visit, 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.
G0090	Professional services, initial visit, for the administration of intravenous chemotherapy or other highly complex infusion drug or biological for each infusion drug administration calendar day in the individual's home, each 15 minutes.
G0151	Services performed by a qualified physical therapist in the home health or hospice setting, each 15 minutes.
G0152	Services performed by a qualified occupational therapist in the home health or hospice setting, 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.

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HCPCS S codes (select examples)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.

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T codes / miscellaneous home health codesHCPCS

T1001	Nursing assessment/evaluation.
T1002	RN services, up to 15 minutes.
T1003	LPN/LVN services, up to 15 minutes.
T1004	Services of a qualified nursing aide, up to 15 minutes.
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.

Related HCPCS/T CodesHCPCS

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
T1004	Services of a qualified nursing aide, up to 15 minutes
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

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Time interval for infusion codes

Interval unitPer 15 minutes for codes that specify time-based billing; per visit (up to 2 hours) for specified home infusion CPT codes (e.g., 99601/99602).

Example time-based HCPCS/G codesG0069, G0070, G0088, G0089, G0090 and many G0xxx therapy/skilled service codes are billed each 15 minutes as indicated in their descriptors.

CPT home infusion examples99601 — Home infusion/specialty drug administration, per visit (up to 2 hours); 99602 — each additional hour (list separately).

Billing guidanceFollow the individual code descriptor for whether the service is billed per 15-minute increment or per visit; do not combine time units inconsistently.

Provider Responsibilities and Authorization

Prior Authorization

Prior Authorization Required

Prior authorization requirements may apply. Refer to MAD 97-12, Chapter 768 and related authorization guidance for New Mexico Medical Assistance Division requirements. Verify whether prior authorization is required under the member's federal, state, or contractual benefit plan before providing services.

Prior authorization guidance: MAD 97-12 Chapter 768 (New Mexico Medical Assistance Division)
Check plan-level authorization tools and UnitedHealthcare prior authorization portals as applicable

Documentation Required

Verify Benefits and Authorizations

Verify benefit coverage and any applicable authorization requirements before delivering services. Benefit coverage is governed by the federal, state, or contractual requirements for the member's plan and may differ from this Medical Policy. In case of conflict, the federal, state, or contractual requirements govern. UnitedHealthcare may require use of tools (for example, InterQual®) to assist in benefit determinations.

Confirm member eligibility and benefits, including Alternative Benefit Package (ABP) limitations where applicable
Check for prior authorization, service limits, provider network requirements, and site-of-service restrictions

Documentation Required

Document/Justify Medical Necessity

Document and justify medical necessity in the medical record. Reference MAD 97-12, Chapter 768 for documentation expectations and required locations of clinical information. Include sufficient clinical detail to demonstrate that services meet medical necessity criteria and any plan-specific requirements.

Include assessment, plan of care, skilled nursing notes, visit frequency and duration, patient response to treatment, and supporting diagnostics
Maintain documentation to support initial and ongoing medical necessity, as required by the plan and state regulations

Billing Rule

Billing and Documentation

Bill using the appropriate HCPCS/CPT/T codes and include charges for nursing visits, drugs, and supplies as appropriate. The presence of a code in policy does not guarantee coverage or payment; verify coverage and billing rules with the member's plan.

Bill services with the listed HCPCS/T and other applicable codes (see Applicable Codes and Related Policies sections)
Include separate billing for nursing visits, drugs, and supplies when applicable; use correct modifiers and units
Retain clinical documentation to support billed services and be prepared to provide it upon request

Note

Providers must ensure compliance with federal, state, and contractual requirements. If this Medical Policy conflicts with applicable federal, state, or contractual provisions, those provisions take precedence. UnitedHealthcare reserves the right to modify Policies and Guidelines as necessary.

In event of conflict between this Policy and plan/federal/state rules, the latter govern
Check for state-specific limitations (e.g., ABP members) and plan amendments prior to service delivery

Note

Code Inclusion Advisory

Code inclusion is informational and is not a guarantee of coverage. Providers should verify payment and coverage determinations with the member's plan prior to providing services.

Listing of a code does not imply service is covered or reimbursable
Coverage decisions are based on plan terms, applicable law, and medical necessity criteria

Definitions & Code Notes

Home health care / skilled care — definition and regulatory note

DefinitionServices rendered by licensed health care professionals in the home; coverage is determined by federal, state, or contractual requirements.

Regulatory noteHome health care, including skilled care, are services rendered by licensed health care professionals and therefore are not subject to FDA regulation.

Documentation referenceMedical necessity clinical criteria are determined by New Mexico MAD 97-12, Chapter 768 (refer to that guidance for specific clinical justifications).

S9560 — definition and description

CodeS9560

DescriptionHome 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.

Billing noteDrugs and nursing visits are coded separately; S9560 represents the per‑diem administrative/coordination component.

S9562 — definition and description

CodeS9562

DescriptionHome 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.

Billing noteUse for home administration of palivizumab/RSV monoclonal antibody; code excludes separate billing for the drug and nursing visits.

S9590 — definition and description

CodeS9590

DescriptionHome 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.

Use caseApplies to sterile irrigation therapies delivered at home; drugs and nursing visits must be billed separately.

T-series codes — T1001/T1002/T1003/T1004/T1021/T1022/T1028/T1030/T1502 descriptions

T1001Nursing assessment/evaluation.

T1002RN services, up to 15 minutes.

T1003LPN/LVN services, up to 15 minutes.

T1004Services of a qualified nursing aide, up to 15 minutes.

T1021Home health aide or certified nurse assistant, per visit.

T1022Contracted home health agency services, all services provided under contract, per day.

T1028/T1030/T1502T1028 — Assessment of home/physical and family environment; T1030 — Nursing care in the home by RN, per diem; T1502 — Administration of oral, IM and/or subcutaneous medication by agency/professional, per visit.

OpenPayer

Home Health, Skilled, and Custodial Care Services (for New Mexico Only)

Coverage & Medical Necessity

Applicable Codes and Billing Units

Provider Responsibilities and Authorization

Policy Background

Definitions & Code Notes

Policy Changes & Version Notes