CG-MED-23 Home Health

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:

Home health services are considered medically necessary when all of the following criteria A through D are met:
1. The individual is confined to the home:
  1. The individual’s overall physical/medical condition poses a serious and significant impediment to receiving intermittent or occasional, skilled, medically necessary services outside the home setting. This includes those who are bedridden and those who are non-bedridden but whose medical condition is such that they meet all other criteria for home health services. In general, the condition of these individuals should be such that there exists a normal inability to leave home and, consequently, leaving home would require a considerable and taxing effort; and
  2. If the individual does in fact leave the home, the absences from the home are infrequent or for periods of relatively short duration, or are attributable to the need to receive health care treatment. The following are examples of acceptable medical and non-medical absences (these examples are not all-inclusive and are provided as a means to illustrate the kinds of infrequent or unique events an individual may attend):
    1. Medical absences to receive health care treatment, including but not limited to:
      1. Ongoing receipt of outpatient kidney dialysis; or
      2. Receipt of outpatient chemotherapy or radiation therapy; or
      3. Participation in psychosocial or medical treatment in an adult day-care program that is licensed or certified by a state, or accredited, to furnish adult day-care services; or
    2. Non-medical absences:
      1. To attend a funeral, religious service, or graduation; or
      2. An occasional trip to the barber, a walk around the block; or
      3. Other infrequent or unique event (for example, a family reunion or other such occurrence);
        Note: Any absence of an individual from the home attributable to the need to receive health care treatment of the types described above shall not disqualify an individual from being considered to be confined to the home. Any other absence from the home shall not so disqualify an individual if the absence is of infrequent or of relatively short duration. It is expected that in most instances, absences from the home that occur will be for the purpose of receiving health care treatment. However, occasional absences from the home for nonmedical purposes, as described above, would not necessitate a finding that one is not homebound if the absences are undertaken on an infrequent basis or are of relatively short duration and do not indicate that the individual has the capacity to obtain the health care provided outside rather than in the home.
        and
2. The service must be prescribed by the attending physician, health care provider practicing within the scope of license, or the primary care physician in coordination with the attending physician as part of a written plan of care; and
3. The service(s) is so inherently complex that it can be safely and effectively performed only by:
  1. Qualified technical or professional health personnel such as registered nurses, licensed practical (vocational) nurses, physical therapists, licensed social-workers, speech pathologists, or audiologists; and
  2. The home health services are provided directly by or under the general supervision of these skilled nursing, skilled rehabilitation, or professional personnel to assure safety and to achieve the desired result; and
4. The primary care physician, health care provider practicing within the scope of license, or attending physician in coordination with the primary care physician should review the treatment plan at least once every 30 days to assess the continued need for skilled intervention.
Certain extended home infusion treatments are considered medically necessary because they are more appropriately performed in the home setting, even if the member is not homebound. The optimal location for these treatments is dependent upon a number of factors including the toxicity of the medication, the individual’s previous response to the treatment, the monitoring required for safe administration, and the individual’s underlying medical condition. Examples of infusion treatments sometimes performed in the home setting include, but are not limited to, the following:
1. Intravenous gamma globulin; or
2. Intravenous hydration for a variety of conditions; or
3. Infusions for pain control; or
4. Some chemotherapy regimens.
Other conditions for which intermittent intravenous infusions of medications provided in the home setting are considered medically necessary either because of the complexity of the underlying condition, or the infusion itself include, but are not limited to, the following:
1. Infections requiring a prolonged treatment course; or
2. Coagulation disorders; or
3. Enzyme deficiency states; or
4. Pain management.

Not Medically Necessary:

Home health services are considered not medically necessary when:

The treatment plan provided by the primary care physician does not demonstrate the continued need for skilled intervention; or
Goals have been achieved per plan of care.

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
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

HCPCS
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

ICD-10 Diagnosis
	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:

Physical therapists;
Occupational therapists;
Speech-language therapists;
Licensed social workers; and
Registered Nurses and Licensed Practical Nurses. Examples of skilled nursing services may include, but are not limited to, the following:
- IV infusions;
- Central line dressing changes; and
- Sterile dressing changes for wounds with the application of a prescribed medication.

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:

Centers for Medicare and Medicaid Services. Medicare Benefit Policy Manual. Chapter 7. Home Health Services. Rev. 258, Issue date 03-22-19. Available at: http://www.cms.hhs.gov/manuals/Downloads/bp102c07.pdf. Accessed on September 26, 2023.
Centers for Medicare and Medicaid Services (CMS). National Coverage Determination. Home nurses' visits to patients requiring heparin injection. NCD #290.2. Effective date not posted. Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=210&ncdver=‌1&DocID=290.2&bc=gAAAAAgAAAAA&. Accessed on September 26, 2023.
Centers for Medicare and Medicaid Services (CMS). National Coverage Determination. Home health visits to a blind diabetic. NCD #290.1. Version #2. Effective October 1, 2006. Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=209&ncdver=2&‌CoverageSelection=Both&ArticleType=All&PolicyType=Final&s=All&KeyWord=home+health+visits&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAABAAAAAA&. Accessed on September 26, 2023.
Centers for Medicare and Medicaid Services (CMS). National Coverage Determination. Postural drainage procedures and pulmonary exercises. NCD #240.7. Effective September 1, 1988. Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=17&ncdver=‌1&DocID=240.7&bc=gAAAAAgAAAAA&. Accessed on September 26, 2023.

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. Former PMW document entitled “Home Health” archived. New Clinical Guideline entitled “Home Health” developed. Expanded explanation of “homebound status”. A review of the peer reviewed scientific literature from 08/01/2004 to 08/05/2005 did not yield information that would result in a modification to the current patient selection criteria. References updated to reflect correct titles and web sites (when applicable).

Pre-Merger Organizations

Last Review Date

Guideline Number

Title

Anthem, Inc.

No prior document.

WellPoint Health Networks, Inc.

09/23/2004

Definition vi

Home Health

Federal and State law, as well as contract language, and Coverage Guidelines take precedence over Clinical UM Guidelines. We reserve the right to review and update Clinical UM Guidelines periodically. Clinical guidelines approved by the Medical Policy & Technology Assessment Committee are available for general adoption by plans or lines of business for consistent review of the medical necessity of services related to the clinical guideline when the plan performs utilization review for the subject. Due to variances in utilization patterns, each plan may choose whether 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 member's card.

Alternatively, commercial or FEP plans or lines of business which determine there is not a need to adopt the guideline to review services generally across all providers delivering services to Plan’s or line of business’s members may instead use the clinical guideline for provider education and/or to review the medical necessity of services for any provider who has been notified that his/her/its claims will be reviewed for medical necessity due to billing practices or claims that are not consistent with other providers, in terms of frequency or in some other manner.

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.