Clinical UM Guideline |
Subject: Home Health | |
Guideline #: CG-MED-23 | Publish Date: 01/03/2024 |
Status: Reviewed | Last Review Date: 11/09/2023 |
Description |
This document addresses home health care and the conditions under which it would be considered medically necessary. Home health care refers to intermittent skilled health care related services provided by or through a licensed home health agency to an individual in his or her place of residence. Home health care includes skilled nursing care, as well as other skilled care services including, but not limited to, physical, occupational, and speech therapies.
Note: Please see the following related documents for additional information:
Note: This document does not address home health care for mental health conditions.
Clinical Indications |
Medically Necessary:
Not Medically Necessary:
Home health services are considered not medically necessary when:
Duration |
Duration: Dependent upon the individual needs of the person receiving home health services.
Coding |
The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.
When services may be Medically Necessary when criteria are met:
CPT |
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99500 | Home visit for prenatal monitoring and assessment to include fetal heart rate, non-stress test, uterine monitoring, and gestational diabetes monitoring |
99503 | Home visit for respiratory therapy care (eg, 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) (eg, urinary, drainage, and enteral) |
99509 | Home visit for assistance with activities of daily living and personal care |
99511 | Home visit for fecal impaction management and enema administration |
99512 | Home visit for hemodialysis |
99600 | Unlisted home visit service or procedure |
99601 | Home infusion/specialty drug administration, per visit (up to 2 hours) |
99602 | Home infusion/specialty drug administration, per visit , each additional hour |
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HCPCS |
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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 |
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 |
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 |
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 non-skilled care achieves its purpose in the home health or hospice setting) |
G0299 | Direct skilled nursing services of a registered nurse (RN) in the home health or hospice setting, each 15 minutes |
G0300 | Direct skilled nursing services of a licensed practical nurse (LPN) in the home health or hospice setting, each 15 minutes |
G0320 | Home health services furnished using synchronous telemedicine rendered via a real-time two-way audio and video telecommunications system |
G0321 | Home health services furnished using synchronous telemedicine rendered via telephone or other real-time interactive audio-only telecommunications system |
G0322 | The collection of physiologic data digitally stored and/or transmitted by the patient to the home health agency (i.e., remote patient monitoring) |
G0493 | Skilled services of a registered nurse (RN) for the observation and assessment of the patient's condition, each 15 minutes (the change in the patient's condition requires skilled nursing personnel to identify and evaluate the patient's need for possible modification of treatment in the home health or hospice setting) |
G0494 | Skilled services of a licensed practical nurse (LPN) for the observation and assessment of the patient's condition, each 15 minutes (the change in the patient's condition requires skilled nursing personnel to identify and evaluate the patient's need for possible modification of treatment in the home health or hospice setting) |
G0495 | Skilled services of a registered nurse (RN), in the training and/or education of a patient or family member, in the home health or hospice setting, each 15 minutes |
G0496 | Skilled services of a licensed practical nurse (LPN), in the training and/or education of a patient or family member, in the home health or hospice setting, each 15 minutes |
G2168 | Services performed by a physical therapist assistant in the home health setting in the delivery of a safe and effective physical therapy maintenance program, each 15 minutes |
G2169 | Services performed by an occupational therapist assistant in the home health setting in the delivery of a safe and effective occupational therapy maintenance program, each 15 minutes |
Q5001 | Hospice or home health care provided in patient's home/residence |
Q5002 | Hospice or home health care provided in assisted living facility |
Q5009 | Hospice or home health care provided in place not otherwise specified (NOS) |
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-S5111 | Home care training, family |
S5115-S5116 | Home care training, non-family |
S5180-S5181 | Home health respiratory therapy |
S5497-S5523 | Home infusion therapy, catheter care maintenance and supplies (includes codes S5497, S5498, S5501, S5502, S5517, S5518, S5520, S5521, S5522, S5523) |
S9061 | Home administration of aerosolized drug therapy (e.g., pentamidine); per diem |
S9097 | Home visit for wound care |
S9122 | Home health aide or certified nurse assistant, providing care in the home, per hour |
S9123 | Nursing care, in the home; by registered nurse, per hour |
S9124 | Nursing care, in the home; by licensed practical nurse, per hour |
S9127 | Social work visit, in the home, per diem |
S9128 | Speech therapy, in the home, per diem |
S9129 | Occupational therapy, in the home, per diem |
S9131 | Physical therapy, in the home, per diem |
S9209-S9214 | Home management of complications of pregnancy (includes codes S9209, S9211, S9212, S9213, S9214) |
S9325-S9328 | Home infusion therapy, pain management infusion, per diem (includes codes S9325, S9326, S9327, S9328) |
S9329-S9331 | Home infusion therapy, chemotherapy infusion, per diem (includes codes S9329, S9330, S9331) |
S9336 | Home infusion therapy, continuous anticoagulant infusion therapy (e.g., Heparin); per diem |
S9338 | Home infusion therapy, immunotherapy; per diem |
S9345 | Home infusion therapy, anti-hemophilic agent infusion therapy (e.g., factor VIII); per diem |
S9346 | Home infusion therapy, alpha-1-proteinase inhibitor (e.g., Prolastin); per diem |
S9348 | Home infusion therapy, sympathomimetic/inotropic agent infusion therapy (e.g., Dobutamine); per diem |
S9351 | Home infusion therapy, continuous antiemetic infusion therapy; per diem |
S9353 | Home infusion therapy, continuous insulin infusion therapy; per diem |
S9357 | Home infusion therapy, enzyme replacement intravenous therapy (e.g., Imiglucerase); per diem |
S9361 | Home infusion therapy, diuretic intravenous therapy; per diem |
S9363 | Home infusion therapy, antispasmotic therapy; per diem |
S9364-S9368 | Home infusion therapy, total parenteral nutrition (TPN); per diem (includes codes S9364, S9365, S9366, S9367, S9368) |
S9370 | Home therapy, intermittent antiemetic injection therapy; per diem |
S9372 | Home therapy, intermittent anticoagulant injection therapy (e.g., Heparin), per diem |
S9373-S9377 | Home infusion therapy, hydration therapy; per diem (includes codes S9373, S9374, S9375, S9376, S9377) |
S9379 | Home infusion therapy, infusion therapy not otherwise classified; per diem |
S9490 | Home infusion therapy, corticosteroid infusion; per diem |
S9494-S9504 | Home infusion therapy, antibiotic, antiviral, or antifungal therapy; per diem (includes codes S9494, S9497, S9500, S9501, S9502, S9503, S9504) |
S9538 | Home transfusion of blood product(s); per diem |
S9542 | Home injectable therapy, not otherwise classified; per diem |
S9560 | Home injectable therapy, hormonal therapy (e.g., leuprolide, goserelin); per diem |
S9590 | Home therapy, irrigation therapy (e.g., sterile irrigation of an organ or anatomical cavity); per diem |
S9810 | Home therapy, professional pharmacy services, per hour |
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 |
T1030 | Nursing care, in the home, by registered nurse, per diem |
T1031 | Nursing care, in the home, by licensed practical nurse, per diem |
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ICD-10 Diagnosis |
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| All diagnoses |
When services are Not Medically Necessary:
For the procedure codes listed above when criteria are not met or for situations designated in the Clinical Indications section as not medically necessary.
Discussion/General Information |
Home health services are generally considered when the skilled services currently being provided by a facility (on an in-patient basis) can be provided in the home setting. Home health services are frequently provided by the following professionally trained practitioners:
It is not unusual for a skilled nurse or other medical professional to educate the person receiving care, family member, or caregiver with regard to how to manage the treatment regimen and to provide skills for overcoming or adapting to functional loss. While services may be received from several skilled providers, it is important that the services provided during the home health visits are not duplicative. The determination of how long an individual requires home health care and what type of skilled practitioners will provide care is determined by the clinical response to treatment.
The homebound criteria set forth in this document are largely based on the recommendations made by the Department of Health and Human Services and the Centers for Medicaid and Medicare Services. The criteria are intended to be used as a tool to aid in the identification of individuals who will experience a significant hardship in obtaining the medical care needed for the treatment of an illness or recovery from an injury if medical services are not provided in the home setting. The lack of transportation does not automatically qualify an individual to be considered homebound.
References |
Government Agency, Medical Society, and Other Authoritative Publications:
Index |
Home Health
History |
Status | Date | Action |
Reviewed | 11/09/2023 | Medical Policy & Technology Assessment Committee (MPTAC) review. Updated References section. |
Reviewed | 11/10/2022 | MPTAC review. Updated Description and References sections. Updated Coding section with 01/01/2023 HCPCS changes; added G0320, G0321, G0322. |
Reviewed | 11/11/2021 | MPTAC review. Updated References section. |
Revised | 11/05/2020 | MPTAC review. Updated number hierarchy and formatting in MN clinical indications section. Description and References sections updated. Reformatted Coding section; updated with 01/01/2021 HCPCS changes, added G0068, G0069, G0070, G0088, G0089, G0090; removed revenue codes. |
| 04/01/2020 | Updated Coding section with 04/01/2020 HCPCS changes; added G2168, G2169. |
Reviewed | 11/07/2019 | MPTAC review. Description and References sections updated. |
Reviewed | 01/24/2019 | MPTAC review. Updated formatting in Clinical Indications section. References section updated. |
Revised | 03/22/2018 | MPTAC review. Removed BH references from document. Updated Coding section; removed CPT 99510. |
Revised | 02/27/2018 | MPTAC review. |
Revised | 02/23/2018 | Behavioral Health Subcommittee review. The document header wording updated from “Current Effective Date” to “Publish Date.” Updated formatting in Clinical Indications section. Updated Description, Clinical Indications, Discussion/General Information, and References sections. |
Reviewed | 08/03/2017 | MPTAC review. References section updated. |
| 01/01/2017 | Updated Coding section with 01/01/2017 HCPCS changes; removed codes G0163, G0164 deleted 12/31/2016. |
Reviewed | 08/04/2016 | MPTAC review. Updated formatting in Clinical Indications section. References section updated. |
| 01/01/2016 | Updated Coding section with 01/01/2016 HCPCS changes, removed G0154 deleted 12/31/2015; also removed ICD-9 codes. |
Reviewed | 08/06/2015 | MPTAC review. Description and References sections updated. |
Revised | 08/14/2014 | MPTAC review. Clinical indications updated to include additional health professionals and to indicate that primary care physicians and attending physicians may coordinate care. References section updated. |
Reviewed | 08/08/2013 | MPTAC review. References section updated. Web Sites section removed. |
| 07/01/2013 | Updated Coding section to include HCPCS Q5001, Q5002, Q5009. |
| 04/01/2013 | Updated Coding section to include CPT 99512. |
Reviewed | 08/09/2012 | MPTAC review. Description (note), References and Web Sites sections updated. |
Reviewed | 08/18/2011 | MPTAC review. Discussion, References and Web Sites sections updated. |
| 01/01/2011 | Updated Coding section with 01/01/2011 HCPCS changes. |
Reviewed | 08/19/2010 | MPTAC review. Discussion, Reference links and Web sites for additional information updated. |
| 01/01/2010 | Updated Coding section with 01/01/2010 HCPCS changes. |
Reviewed | 08/27/2009 | MPTAC review. Note below Description, Discussion and References updated. Place of Service section removed. |
Reviewed | 08/28/2008 | MPTAC review. Note added (following the description) referring to related documents for additional information. Description, Discussion and References updated. |
Reviewed | 08/23/2007 | MPTAC review. Review date, References, Coding and History sections updated. |
Reviewed | 09/14/2006 | MPTAC review. References and Coding updated. |
| 11/21/2005 | Added reference for Centers for Medicare and Medicaid Services (CMS) – National Coverage Determination (NCD). |
Revised | 09/22/2005 | Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization. MPTAC reviewed and approved revisions.
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Pre-Merger Organizations | Last Review Date | Guideline Number | Title |
Anthem, Inc.
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| No prior document. |
WellPoint Health Networks, Inc. | 09/23/2004 | Definition vi | Home Health |
Federal and State law, as well as contract language including definitions and specific coverage provisions/exclusions, and Medical Policy take precedence over Clinical UM Guidelines and must be considered first in determining eligibility for coverage. The member's contract benefits in effect on the date that services are rendered must be used. Clinical UM Guidelines, which address medical efficacy, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and we reserve the right to review and update Clinical UM Guidelines periodically. Clinical UM guidelines are used when the plan performs utilization review for the subject. Due to variances in utilization patterns, each plan may choose whether or not to adopt a particular Clinical UM Guideline. To determine if review is required for this Clinical UM Guideline, please contact the customer service number on the back of the member's card.
No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from the health plan.
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