Home Health, Skilled, and Custodial Care Services (for Ohio Only)
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Policy governing medical necessity, coverage, and applicable billing codes for home health, skilled, and custodial care services for UnitedHealthcare Community Plan members in Ohio.
Supporting information updated in References; previous policy version CS137OH.D archived.
Coverage Criteria
Medical necessity (referenced InterQual criteria)
Covered when medical necessity is met per InterQual and Ohio Administrative Code
InterQual LOC: Home Care Q & A is the primary clinical criteria source referenced by this policy; Ohio Administrative Code 5160-101 applies for unproven services or those with coverage/quantity limits.
General coverage criteria
Covered when services are prescribed and meet applicable medical necessity and state/contractual rules
Documentation should support that skilled care is intermittent, ordered by an authorized prescriber, and meets InterQual/OAC medical necessity 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 health service. Benefit coverage and reimbursement are determined by applicable federal, state, or contractual requirements and laws; inclusion in this list is not a guarantee of payment.
For informational purposes only: home health and skilled care are services delivered by licensed health care professionals and are not regulated by the U.S. Food and Drug Administration (FDA). FDA approval or regulation does not determine coverage for these services under this policy.
Services described in this policy as unproven, or services that do not meet the medical necessity requirements of InterQual and Ohio Administrative Code 5160-101, may be considered not medically necessary and therefore not covered. Providers should note that code listing alone does not establish coverage; requests for such services will be evaluated against Ohio Administrative Code requirements and InterQual clinical criteria before a coverage determination is made.
Coding and Procedure Codes
| 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). |
| G0151 | Professional services for the administration of anti-infective, pain management, chelation, pulmonary hypertension, inotropic, or other intravenous infusion drug or biological ... each 15 minutes. |
| G0152 | Professional services for the administration of subcutaneous immunotherapy or other subcutaneous home, each 15 minutes. |
| G0153 | Services performed by a qualified occupational therapist 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. |
| 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. |
| G0160 | Services performed by a qualified occupational therapist, in the home health setting, in the establishment or delivery of a safe and effective occupational therapy maintenance program, each 15 minutes. |
| G0161 | Services performed by a qualified speech-language pathologist, in the home health setting, in the establishment or delivery of a safe and effective speech-language pathology maintenance program, each 15 minutes. |
| G0162 | Skilled services by a registered nurse (RN) for management and evaluation of the plan of care; each 15 minutes (the patient's underlying condition or complication requires an RN to ensure that essential nonskilled care achieves its purpose in the home health or hospice setting). |
| S9366 | Home infusion therapy, uninterrupted, long-term, controlled rate intravenous or subcutaneous = Home infusion therapy, total parenteral nutrition (TPN); up to two liters per day, administrative services, professional pharmacy services, care coordination, and supplies, per diem |
| S9367 | Home infusion therapy, total parenteral nutrition (TPN); more than two liters but no more than three liters per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment including standard TPN formula (lipids, specialty amino acid formulas, drugs other than in standard formula and nursing visits coded separately), per diem. |
| S9368 | Home infusion therapy, total parenteral nutrition (TPN); more than three liters per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment including standard TPN formula (lipids, specialty amino acid formulas, drugs other than in standard formula and nursing visits coded separately), per diem. |
| 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 |
| S9474 | Enterostomal therapy by a registered nurse certified in enterostomal therapy, 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. |
| 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. |
| T1002 | Nursing assessment/evaluation. 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. |
Provider Actions and Prior Authorization
InterQual + Ohio rule-based prior authorization
Medical necessity for home health and skilled care in Ohio is determined using InterQual LOC: Home Care Q & A; services stated as unproven or with coverage/quantity limits will be evaluated under Ohio Administrative Code 5160-101 and may require prior authorization.
- Use InterQual LOC: Home Care Q & A (Adult and Pediatric) to evaluate level-of-care and medical necessity.
- Services described as unproven or with limits are evaluated per Ohio Administrative Code 5160-101 and may require authorization.
Verify code-level prior authorization requirements
Verify plan-specific prior authorization requirements at the code level before submitting claims for listed HCPCS/home infusion and nursing service codes; the policy provides numerous applicable HCPCS/T and S codes that may be subject to prior authorization.
Provider actions — summary reminder
Follow the documentation, prescribing, and medical necessity requirements described below to support coverage and authorization decisions.
- Document services using the CPT/HCPCS codes listed in the policy when applicable.
- Ensure clinical documentation supports the code-level service billed.
InterQual-based clinical criteria and step requirements
InterQual is the primary medical/surgical criteria used to determine coverage and may define required steps of care prior to authorization or coverage decisions.
- If InterQual criteria apply, use its step and level-of-care logic to establish medical necessity and any required prior steps of care.
- If InterQual lacks applicable criteria, UnitedHealthcare may use approved Medical Policies, Coverage Determination Guidelines, or Utilization Review Guidelines.
Document services using listed CPT/HCPCS codes
Providers must document services using the CPT/HCPCS codes listed in the policy; inclusion of a code is for reference only and does not guarantee coverage—benefit coverage is determined by federal, state, or contractual requirements.
- Use the policy’s code lists when assigning billing codes, but verify coverage and reimbursement eligibility against applicable benefit rules.
- Do not assume listing implies reimbursement or authorization.
Prescriber and medical necessity documentation requirements
Home health services must be prescribed by an MD, DO, PA, or NP and documented as intermittent skilled care delivered in the member’s residence; documentation should support medical necessity per Ohio Administrative Code and InterQual criteria.
- Ensure the prescriber (MD, DO, PA, or NP) documents the order and clinical rationale that services are intermittent skilled care in the member’s residence.
- Include documentation that satisfies InterQual LOC and Ohio Administrative Code 5160-101 where applicable.
Denial risk for unproven or limited services
Requests for services described as unproven or for services that have coverage or quantity limits will be evaluated for medical necessity using Ohio Administrative Code 5160-101 and may be denied if Ohio administrative medical necessity is not met.
- When submitting requests for unproven services or services with limits, include documentation addressing Ohio Administrative Code 5160-101 criteria.
- Failure to meet Ohio administrative medical necessity criteria may trigger denial.
Follow federal, state (OAC), or contractual precedence
When this policy differs from federal, state (Ohio Administrative Code), or contractual requirements, the federal, state (OAC) or contractual requirements govern; verify and follow those requirements to avoid coverage denial.
- Check applicable federal, OAC, or contractual plan terms before relying on this policy for coverage decisions.
- If a conflict exists, follow the governing federal, state (OAC), or contractual requirement.
Background
Home health and skilled care services provide nursing, therapy, infusion, and other supportive services in the member's residence for individuals who meet medical necessity criteria. These services are intended to restore or maintain function, manage chronic conditions, and help prevent or shorten hospitalizations. Medical necessity for home care is determined using the InterQual LOC: Home Care Q & A clinical criteria (adult and pediatric) and must also satisfy applicable Ohio Administrative Code requirements.
Definitions
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