Commercial
Advanced Search

Home Health Care Services
02.01.01f


Policy

State mandates do not automatically apply to self-funded groups; therefore, individual group benefits must be verified.

Home health care services provided by a home health agency (HHA) are considered medically necessary and, therefore, covered when all of the following criteria are met:
  • The primary service(s) provided is a skilled home health care service on a part-time or intermittent basis.
  • To meet the requirements of part-time or intermittent skilled nursing services, all of the following requirements must be met:
    • The individual must have a medically predictable, recurring need for skilled nursing services.
    • The services are provided to individuals who need at least one skilled nursing visit every 60 days.
    • Part-time or intermittent is generally defined as skilled care that is not required for more than 21 days, within a 60-day period, and the service is provided less than 8 hours each day and for 35 hours or less each weekIn situations where an individual care plan requires both skilled provider and unskilled aide services, the sum of both types of services combined must equal less than 8 hours per day and less than 35 hours per week.
      Note: The time parameters do not apply for those group products that do not observe the imposition of limits such as number of days or number of hours with respect to coverage under the home health care section of the plan. Individual member benefits must be verified.
  • The home health care services are medically necessary for the individual's condition and meet the specific treatment requirements for that condition, as ordered by the individual's prescribing professional provider.
  • The home setting is an appropriate setting for the treatment of the individual's condition.
  • The individual is homebound. However, the homebound requirement may be waived for any of the following reasons, to the extent of the terms of the member contract and/or as mandated by the state:
    • Mother's Option Program: when the individual receives home health care services following delivery of a newborn as part of the Company's Mother's Option Program
    • New Jersey (NJ) Members: For NJ members only, when the home health care services are provided in lieu of, or as an alternative to, hospitalization​
    • Pennsylvania (PA) Members: For PA members only, when a home health care visit is requested by the individual's attending or primary care provider (PCP) following a mastectomy
SKILLED SERVICES

The requested service must meet the definition of skilled service.

All skilled home health care services must be specifically ordered by a managing professional provider who is responsible for establishing, monitoring, and periodically reviewing the care plan, which includes all care provided in the home.

Home care visits rendered by a skilled provider (e.g., registered nurse, physical/occupational therapist) requested only for supervision of the home health aide are not considered skilled services and are, therefore, not covered services unless there is documentation that the home health aide's duties are so complex that such duties must be supervised by skilled nursing personnel or a therapist in order to promote the individual's recovery and medical safety.

Note: Once skilled nursing or therapy services are no longer required or approved, home health aide services are no longer covered.

UNSKILLED SERVICES

Unskilled services that are supportive in nature are only eligible for reimbursement consideration when provided in direct support of, or as an adjunct to, a medically necessary skilled home health care service approved by the Company (e.g., intermittent home health aide assistance with range-of-motion exercises requested as an adjunct to Company-approved home health physical therapy services) and when provided on a part-time or intermittent basis. Part-time or intermittent unskilled services are generally those furnished to the member in combination with skilled services where the sum of both types of services combined equal less than 8 hours each day and less than 35 hours each week, and not for more than 21 days within a 60-day period.

Note: The time parameters do not apply for those group products that do not observe the imposition of limits such as number of days or number of hours with respect to coverage under the home health care section of the plan. Individual member benefits must be verified.

EXTENSIONS OF HOME HEALTH CARE SERVICES

Extensions of home health care services are arranged and covered when all other policy requirements are met and approved in accordance with the member's benefit contract. Annual limits may apply. Therefore, individual member benefits must be verified.

REQUIRED DOCUMENTATION

The Company may conduct reviews and audits of services to our members regardless of the participation status of the provider. Medical record documentation must be maintained on file to reflect the medical necessity of the care and services provided. These medical records may include but are not limited to: records from the professional provider’s office, hospital, nursing home, home health agencies, therapies, and test reports.

PRESCRIPTION (ORDER) REQUIREMENTS
Before submitting a claim to the Company, the supplier must have on file a timely, appropriate, and complete order for each item billed that is signed and dated by the professional provider who is treating the member. Requesting a provider to sign a retrospective order at the time of an audit or after an audit for submission as an original order, reorder, or updated order will not satisfy the requirement to maintain a timely professional provider order on file.

BILLING REQUIREMENTS


Inclusion of a code in this policy does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.


Modifier CO and CQ must be used to report services performed by an occupational therapy assistant or physical therapy assistant.


Guidelines

When skilled nursing visits associated with the Direct Ship Injectables Program are required, up to two visits are authorized at the time of facilitating the request for shipment.

Physical and occupational therapies provided by a home health agency (HHA) in the home setting are not included in capitation.

Laboratory specimens collected by an HHA should always be submitted to a participating laboratory or the individual's capitated laboratory, as appropriate, for the individual to receive the highest level of benefits.

The information in this policy does not supersede the terms outlined in Company HHA contracts.

BENEFIT CONTRACT EXCLUSION

The following are examples of, but are not limited to, situations when home health care services are not covered by the Company because they are benefit contract exclusions and, therefore, not eligible for reimbursement consideration:

  • Custodial care, which is care provided primarily for maintenance of the individual or care that is designed essentially to assist the individual in meeting his/her activities of daily living; and which is not primarily provided for its therapeutic value in the treatment of an illness, disease, bodily injury, or condition.
  • The hours requested exceed the benefit limits, if any.
BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, home health care services are covered under the medical benefits of the Company’s products when the medical necessity criteria listed in this medical policy are met.

MANDATES

This policy is consistent with applicable state mandates. The laws of the state where the group benefit contract is issued determine the mandated coverage.

Description

Home health care services are defined as services that are provided in the home setting by a licensed home health agency (HHA). Home health care services include the following:
  • Skilled services (e.g., nursing, rehabilitative therapies) that provide treatment for a condition
  • Unskilled services that are supportive in nature (e.g., bathing, feeding, assistance with dressing) and are provided in conjunction with a skilled service
Home is defined as the individual's place of residence (e.g., private residence/domicile, assisted living facility, long-term care facility, skilled nursing facility [SNF] at a custodial level of care).

HOMEBOUND
An individual is considered to be homebound with one of the following:
  • When the individual is unable to leave home due to severe restrictions on mobility
  • The individual would require a considerable and taxing effort in an attempt to leave home
  • The individual is unable to use transportation without another's assistance.
An individual who is a child, an unlicensed driver, or an individual who cannot drive is not automatically considered homebound.

If the individual can leave the home, the individual may still be considered homebound if the absences from the home are infrequent, for periods of relatively short duration, attributable to obtaining health care treatment, or for occasional nonmedical purposes such as, but not limited to:
  • A trip to the barber​
  • A walk around the block or a drive
  • Other infrequent or unique events (e.g., attendance at a funeral)
SKILLED SERVICES
Skilled home health care services include skilled nursing care, physical and occupational therapy, speech therapy, and medical social services as provided by a clinical social worker. The provision of these services requires the knowledge, expertise, and skills of a health care professional who has met the educational and licensing and/or certification requirements to practice the specific discipline in the state in which the service is provided.

skilled nursing service requires the knowledge, expertise, and skills provided by a registered nurse (RN), or a licensed practical (vocational) nurse (LPN) under the supervision of an RN, to be safe and effective. Some services are classified as a skilled nursing service on the basis of complexity alone (e.g., intravenous and intramuscular injections, insertion of catheters). However, in some cases, the condition and/or situation of the individual may cause a service that would ordinarily be considered unskilled to be considered skilled (e.g., simple dressing changes [that in most circumstances would not require the knowledge, expertise, and skills of a nurse] in the absence of a competent person, to provide care, and when wounds exist in areas where the individual cannot reach but for which no other care options are available).

Part-time or intermittant skilled nursing care is that which is provided in the home setting and furnished to an individual fewer than 8 hours each day and for 35 hours or less each week. This service is provided to individuals who generally need at least one skilled nursing visit every 60 days and do not require daily skilled nursing care for more than 21 days. Services requested solely for venipuncture (i.e., for the purposes of obtaining a blood sample) are not considered skilled nursing services.

HOME HEALTH AIDE SERVICES
Home health aide services include hands-on personal care of the member or services needed to facilitate treatment of the member's illness or injury. These services may include, but are not limited to:
  • Personal care
    • Bathing, dressing, grooming, caring for hair, nail, and oral hygiene that are needed to facilitate treatment or to prevent deterioration of the member's health, changing the bed linens of an incontinent member, shaving, deodorant application, skin care with lotions and/or powder, foot care, and ear care; feeding, assistance with elimination (including enemas unless the skills of a licensed nurse are required due to the member's condition, routine catheter care, and routine colostomy care), assistance with ambulation, changing position in bed, assistance with transfers
  • Simple dressing changes that do not require the skills of a licensed nurse
  • Assistance with medications that are ordinarily self-administered and do not require the skills of a licensed nurse to be provided safely and effectively
  • Assistance with activities that are directly supportive of skilled therapy services but do not require the skills of a therapist to be safely and effectively performed, such as routine maintenance exercises and repetitive practice of functional communication skills to support speech-language pathology services
  • Provision of services incidental to personal care services, not care of prosthetic and orthotic devices
    • When a home health aide visits a member to provide a health-related service as discussed above, the home health aide may also perform some incidental services that do not meet the definition of a home health aide service (e.g., light cleaning, preparation of a meal, taking out the trash, shopping). However, the purpose of a home health aide visit may not be primarily to provide these incidental services because they are not health-related services, but rather are necessary household tasks that must be performed to maintain a home.

PHYSICAL THERAPY AND OCCUPATIONAL THERAPY ASSISTANT SERVICES


PHYSICAL THERAPY ASSISTANT


A physical therapy assistant (PTA) implements certain components of patient care, obtains data related to the treatments provided, and collaborates​ with the physical therapist (PT) to modify care as necessary. PTAs are not permitted to perform evaluations, assessment procedures, or certain complex procedures; nor do they design plans of care or develop treatment plans.


Under the direction and supervision of PTs, PTAs treat patients with exercise, massage, gait and balance training, and other therapeutic interventions. They record the patient's progress and report the results of each treatment to the PT.


OCCUPATIONAL THERAPY ASSISTANT


An occupational therapy assistant (OTA) assists individuals to develop, recover, improve, as well as maintain the skills needed for daily living.


OTAs help provide treatments to assist individuals with disabilities to learn how to function independently in their homes and communities and record their observations regarding the individual's progress. They help patients regain the skills they may have lost due to injury and help them rebuild their health and self-esteem.


An OTA does not establish the plan of care or treatment goals.


References

American Physical Therapy Association (APTA). Becoming a PTA. [APTA Web site]. 2022. Available at: https://www.apta.org/your-career/careers-in-physical-therapy/becoming-a-pta. Accessed June 3, 2022.


Centers for Medicare and Medicaid Services (CMS). Coding and Billing Information. 04/07/2021. Available at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HomeHealthPPS/coding_billing.html. Accessed June 3, 2022.

Centers for Medicare & Medicaid Services (CMS). Medicare and home health care. [Medicare Web site]. September 2020. Available at: https://www.medicare.gov/Pubs/pdf/10969-Medicare-and-Home-Health-Care.pdf. Accessed June 3, 2022.

Centers for Medicare & Medicaid Services (CMS). Medicare Benefit Policy Manual. Chapter 7: Home health services. [CMS Web site]. Original: 05/07/21. (Revised: 04/27/22 ). Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c07.pdf. Accessed June 3, 2022.

Commonwealth of Pennsylvania (PA). PA Title 28. Code 601: Home Health Care Agencies. § 601.31: Acceptance of patients, plan of treatment and medical supervision. [PA Code Web site]. 04/23/87. Available at: http://www.pacodeandbulletin.gov/Display/pacode?file=/secure/pacode/data/028/chapter601/chap601toc.html&d=reduce#:~:text=§ 601.31.,the patient's place of residence. Accessed June 3, 2022.

Company Benefit Contracts.


Cross, N., McWay, D. Stanfield's Introduction to Health Professionals. Seventh edition. James & Bartlett Learning; 2017:213.

Department of Health and Human Services (DHHS)/Centers for Medicare and Medicaid Services (CMS) Medicare Home Health Agency Manual, Transmittal 298. 01/22/02. Available at: http://www.cms.gov/transmittals/downloads/R298HHA.pdf. Accessed June 3, 2022.

New Jersey (NJ) Department of Banking and Insurance (DOBI). New Jersey individual health coverage program: health maintenance organization (HMO) contract. [NJ DOBI Web site]. 01/01/05. Available at: http://www.state.nj.us/dobi/division_insurance/ihcseh/rules/exb_stanhmo0206.docAccessed June 3, 2022.

New Jersey (NJ) Department of Banking and Insurance (DOBI). Small Employer Health (SEH) benefits program. Advisory bulletin: 99-SEH-05: HMO-based coverage for home health care and private duty nursing. [NJ DOBI Web site]. 06/18/99. Available at: http://www.state.nj.us/dobi/division_insurance/ihcseh/bulletins/seh9905.htmAccessed June 3, 2022.

New Jersey (NJ) Department of Banking and Insurance (DOBI). Small Employer Health (SEH) benefits program. Advisory bulletin: 00-SEH-03: coverage for home health care and private duty nursing. [NJ DOBI Web site]. 09/21/2000. Available at: http://www.state.nj.us/dobi/division_insurance/ihcseh/bulletins/seh0003.htmAccessed June 3, 2022.

New Jersey (NJ) Department of Banking and Insurance (DOBI). Small Employer Health (SEH) program standard plans: small group Health Maintenance Organization (HMO) contract. [NJ DOBI Web site]. 01/01/14. Available at: https://nj.gov/dobi/division_insurance/ihcseh/rules/seh210319/adopt/hmocontract.pdf. Accessed June 3, 2022.

New Jersey Legislature. NJ Permanent Statutes. Title: 17B:26-41. Home health care; requirement for provisions for coverage. [New Jersey Legislature Web site]. 1977. Available at: https://law.onecle.com/new-jersey/title-17b/17b-26-41.html.  Accessed June 3, 2022.

New Jersey Legislature. NJ Permanent Statutes. Title: 17B:26-42. Benefits. [New Jersey Legislature Web site]. 1977. Available at: https://law.onecle.com/new-jersey/title-17b/17b-26-42.html. Accessed June 3, 2022.

PA 1997. ALS 51; 1997 PA SB 176 (amends the Pennsylvania Insurance Company Law of 1921) (P.L. 682, No. 284).

PA Statutes. Health and Accident Insurance. Mastectomy and breast cancer reconstruction. 40 P.S., §764d(3) (06/28/02).

Purdon's Pennsylvania Statutes and Consolidated Statutes Annotated, Act 2007-81, Title 40 P.S. Insurance (Refs and Annos), Chapter 2: Insurance companies, article VI Casualty insurance (b) health and accident insurance (Refs and Annos). §764d: Mastectomy and breast reconstruction. Original: 06/28/02. 2016 Regular Session Acts 1 to 83, 87, 90 to 94 and 96). Westlaw 40 P.S.§764d.

State of New Jersey Department of Banking and Insurance. SEH Program Forms. Available at: https://www.state.nj.us/dobi/division_insurance/ihcseh/sehforms.html. Accessed June 3, 2022.


US Bureau of Labor. Physical Therapy Assistants and Aides. [BLS Web site]. 04/18/2022. Available at: https://www.bls.gov/ooh/healthcare/physical-therapist-assistants-and-aides.htm#:~:text=Physical therapist assistants, sometimes called PTAs​, and physical therapist aides work under the direction and supervision of physical therapists. They help patients who are recovering from injuries and illnesses to regain movement and manage pain. Accessed June 3, 2022.

US Bureau of Labor. Occupational Therapy Assistants an Aides. [BLS Web site]. 04/18/2022. Available at:
https://www.bls.gov/ooh/healthcare/occupational-therapy-assistants-and-aides.htm. Accessed June 3, 2022.

United States Code of Federal Regulations Title 42 Chapter IV Subchapter B Part 409.44 Skilled services requirements. 12/20/1994. (Amended: 05/08/2020). Available at: http://www.law.cornell.edu/cfr/text/42/409.44. Accessed June 3, 2022.


Coding

CPT Procedure Code Number(s)
N/A

ICD - 10 Procedure Code Number(s)
N/A

ICD - 10 Diagnosis Code Number(s)
The appropriate diagnosis code for the member's condition should be reported by the home health agency (HHA).

HCPCS Level II Code Number(s)
N/A

Revenue Code Number(s)
The following coding information does not supersede the terms outlined in Company HHA contracts.

0421 Physical Therapy (PT) Visit

0431 Occupational Therapy (OT) – Visit Charge

0441 Speech Therapy (ST) – Visit Charge

0550 Skilled Nursing – General Classification

0551 Skilled Nursing – Visit Charge

0552 Skilled Nursing – Hourly Charge

0559 Skilled Nursing – Other Skilled Nursing

0560 Medical Social Services – General Classification

0561 Medical Social Services – Visit Charge

0562 Medical Social Services – Hourly Charge

0569 Medical Social Services – Other Medical Social Services

0570 Home Health – Home Health Aide – General Classification

0571 Home Health – Home Health Aide – Visit Charge

0572 Home Health – Home Health Aide – Hourly Charge

0579 Home Health – Home Health Aide – Other Home Health Aide

0580 Home Health – Other Visits – General Classification

0581 Home Health – Other Visits – Visit Charge

0582 Home Health – Other Visits – Hourly Charge

0583 Home Health – Other Visits – Assessment

0589 Home Health – Other Visits – Other Home Health Visit

0590 Home Health – Units of Service – General Classification

Modifiers

CO Outpatient occupational therapy services furnished in whole or in part by an occupational therapy assistant
CQ Outpatient physical therapy services furnished in whole or in part by a physical therapist assistant 

Coding and Billing Requirements


Policy History

8/29/2022
8/29/2022
02.01.01
Medical Policy Bulletin
Commercial
No