DraftUnitedHealthcarePolicy CSNC.MP.022.07

Home Health, Skilled, and Custodial Care Services (for North Carolina Only)

Defines applicability, coding references, and directs readers to North Carolina Medicaid clinical coverage criteria for medical necessity for home health, skilled, and custodial care services in North Carolina.

Policy Summary

PayerUnitedHealthcare

PolicyHome Health, Skilled, and Custodial Care Services (for North Carolina Only)

Policy CodePolicy CSNC.MP.022.07

Change TypeCode removalreference update

Effective DateJan 1, 2026

Next Review Date

Key ActionRefer to North Carolina Medicaid Clinical Coverage Policy 3A for all medical necessity determinations for home health services.

SourceLink

POLICY UPDATE CHANGES

Removed HCPCS codes S9339 and T1031

Removed reference link to the Medical Policy titled Home Hemodialysis (for North Carolina Only) (retired May 1, 2026).

Archived previous policy version CSNC.MP.022.06.

North CarolinaState-specific

>150Codes referenced

~40+Home infusion codes listed

NC Medicaid 3AMedical necessity source

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.

Coverage direction

Coverage stance and where to find medical necessity criteria:

Medical necessity clinical coverage criteria are contained in NC Medicaid Clinical Coverage Policy, Community-Based Services, 3A: Home Health Services.

Listing of procedure and/or diagnosis codes in this policy is for reference only and does not imply that a service is covered; benefit coverage is determined by federal, state, or contractual requirements and applicable laws.

This policy applies only to the state of North Carolina.

Coverage and billing rules (excerpt)

Billing and use instructions for listed home infusion and home therapy codes, including code-specific usage notes and exclusions.

Per diem HCPCS S93xx/S94xx/S95xx codes cover administrative services, professional pharmacy services, care coordination, and necessary supplies and equipment; drugs and nursing visits are coded separately.

Do not use S9373 with S9374-S9377 when using daily volume scales for hydration therapy.

Do not use S9494 with home infusion codes for hourly dosing schedules S9497–S9504.

Do not use S9372 for flushing of infusion devices with Heparin to maintain patency.

Do not use S9810 with any per diem code (S93xx/S94xx/S95xx per diem codes); S9810 is per hour and should not be billed with per diem services.

Volume-based hydration codes correspond to daily volumes: S9374 = 1 L/day; S9375 = >1–2 L/day; S9376 = >2–3 L/day; S9377 = >3 L/day.

FDA approval is informational only and not a basis for coverage; home health services are provided by licensed professionals and are not regulated by the FDA.

Refer to North Carolina Medicaid Clinical Coverage Policies, Home Health Services (3A) for medical necessity determinations and other policy details.

Referenced Procedure and Billing Codes

Selected CPT codes referencedCPT

92521	Evaluation of speech fluency (e.g., stuttering, cluttering).
97161	Physical therapy evaluation: low complexity; typically 20 minutes.
97162	Physical therapy evaluation: moderate complexity; typically 30 minutes.

Selected HCPCS / S / G codes referencedHCPCS

G0320	Home health services via real-time two-way audio and video telemedicine.
S9123	Nursing care, in the home; by registered nurse, per hour.
S9340	Home therapy; enteral nutrition; per diem.

Selected HCPCS/T codes for home infusion and home therapyHCPCSCovered

S9368	Home infusion therapy, TPN; more than three liters per day, per diem
S9374	Home infusion therapy, hydration; 1 liter per day, per diem
S9377	Home infusion therapy, hydration; more than 3 liters per day, per diem
S9494	Home infusion therapy, antibiotic/antiviral/antifungal; per diem
S9497	Home infusion antibiotic/etc.; once every 3 hours, per diem
S9504	Home infusion antibiotic/etc.; once every 4 hours, per diem
S9538	Home transfusion of blood product(s); per diem
S9810	Home therapy; professional pharmacy services for infusion/specialty drug administration, per hour (do not use with per diem codes)
T1001	Nursing assessment/evaluation
T1030	Nursing care, in the home, by registered nurse, per diem

Typical face-to-face time for PT/OT evaluations — inv-06

Typical face-to-face time range20–60 minutes depending on complexity (PT/OT evaluations: typically 20 min for low complexity up to 60 min for high complexity)

PT evaluation time examples97161 typically 20 minutes; 97162 typically 30 minutes; 97163 typically 45 minutes

PT re-evaluation97164 typically 20 minutes face-to-face

OT evaluation time examples97165 typically 30 minutes; 97166 typically 45 minutes; 97167 higher complexity (duration noted in source)

Volume-based hydration thresholds — inv-07

S9374Hydration therapy; 1 liter per day (per diem)

S9375Hydration therapy; more than 1 liter but no more than 2 liters per day (per diem)

S9376Hydration therapy; more than 2 liters but no more than 3 liters per day (per diem)

S9377Hydration therapy; more than 3 liters per day (per diem)

Provider Guidance and Billing Notes

Note

Medical necessity source

For medical necessity clinical coverage criteria, refer to the North Carolina Medicaid (Division of Health Benefits) Clinical Coverage Policy, Community-Based Services, 3A: Home Health Services.

Billing Rule

Billing/authorization codes and notes

List of applicable HCPCS and T-code services for home infusion and related home therapies. Some codes are designated per diem and some per hour. Do not bill per-hour codes in combination with per-diem codes when noted.

T1000 — Home therapy; professional pharmacy services for provision of infusion, specialty drug administration, and/or disease state management, not otherwise classified, per hour (do not use this code with any per diem code).
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. (designated codes may be per visit)
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.

Scope, Notes, and Definitions

Application — inv-10

Geographic applicabilityThis Medical Policy only applies to the state of North Carolina.

ScopeApplies to code lists and guidance for home health, skilled, and custodial care services in North Carolina.

Related guidanceMedical necessity determinations are governed by North Carolina Medicaid Clinical Coverage Policy 3A (see related policies).

Applicable Codes - note — inv-11

Listing does not imply coverageListing of a code in this policy does not imply the service is covered; coverage determined by federal, state, contractual requirements and applicable laws.

No reimbursement guaranteeInclusion of a code does not imply any right to reimbursement or guarantee claim payment.

Other policies may applyOther Policies and Guidelines may affect coverage determinations (see related policies referenced).

FDA approval — inv-12

Informational purposeFDA information in this policy is for informational purposes only; FDA approval alone is not a basis for coverage.

Scope of FDA regulationHome health care services are provided by licensed health care professionals and are not subject to FDA regulation.

Coverage basisCoverage decisions are based on applicable coverage policies and laws, not solely on FDA status.

Per diem / Per hour — inv-13

S9810 designationS9810 is for professional pharmacy services for infusion/specialty drug administration and is billed per hour (do not use this code with any per diem code).

Per diem codesMany S- and T-series home infusion codes (e.g., S93xx/S94xx/S95xx) are designated per diem for administrative services, professional pharmacy services, care coordination and supplies.

Do not mix billing unitsPer hour codes (e.g., S9810) should not be used concurrently with per diem home infusion codes to avoid billing conflicts.

Examples of per diem T-codesT1030 is a per diem nursing care in the home; other T-codes (T1001–T1030) may be per visit or per diem as specified.