CPT Code Description
99500 Home visit for prenatal monitoring and assessment to include fetal heart rate, non-stress test, uterine monitoring, and gestational diabetes monitoring99501Home 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 cystostomy99506Home 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 administration99512Home visit for hemodialysis
99601 Home infusion/specialty drug administration, per visit (up to 2 hours);
99602 Home infusion/specialty drug administration, per visit (up to 2 hours);each additional hour (List separately in addition to code for primary procedure)
G0068 Professional services for the administration of anti infective, pain management, chelation, pulmonary hypertension, and/or inotropic infusion drug(s) for each infusion drug administration calendar day in the individual’s home, each 15 minutes
G0069 Professional services for the administration of subcutaneous immunotherapy for each infusion drug administration calendar day in the individual’s home, each 15 minutes
G0070 Professional services for the administration of chemotherapy for each infusion drug administration calendar day in the individual’s home, each 15 minutes
What Is Home Health Care?
Home health care includes skilled nursing care, as well as other skilled care services, like physical and occupational therapy, speech-language therapy, and medical social services. These services are given by a variety of skilled health care professionals at home.
The home health staff provides and helps coordinate the care and/ortherapy your doctor orders. Along with the doctor, home health staff create a plan of care, which is a written plan for your care. It tells what services you will get to reach and keep your best physical,mental, and social well-being. The home health staff keeps your doctor up-to-date on how you are doing and updates your plan of care as needed, as authorized by your doctor. More information a bout plans of care can be found on pages 19 and 20.
The need for home health care has grown for many reasons. Medical science and technology have improved. Many treatments that could once be done only in a hospital can now be done at home. Also,home health care is usually less expensive and can often be just as effective as care in a hospital or skilled nursing facility. And just a important, most patients and their families prefer to stay at home rather than be in a hospital or a nursing home.While you get home health care, home health staff teach you (and those who help you) to continue any care you may need, including medication, wound care, therapy, and managing stress.
Since most home health care is intermittent and part-time, patients (and their informal caregivers) should learn how to identify and care for possible problems, like confusion or shortness of breath.The goal of short-term home health care is to provide treatment for an illness or injury. It helps you get better, regain your independence,and become as self-sufficient as possible. The goal of long-term home health care (for chronically ill or disabled people) is to maintain your highest level of ability or health, and help you learn to live with your illness or disability.1 –
How long can I get home health services?
Medicare covers your home health services for as long as you are eligible and your doctor says you need these services. However, the skilled nursing care and home health aide services are only covered on a part-time or “intermittent” basis. This means there are limits on the number of hours per day and days per week that you can get skilled nursing or home health aide services. Therapy services do not have to be part-time or intermittent.
To decide whether or not you are eligible for home health care,Medicare defines “intermittent” as skilled nursing care that is needed or given on fewer than seven days each week or less than eight hours each day over a period of 21 days (or less) with some exceptions in special circumstances.
What does the Original Medicare Plan pay for and what can I be billed for?
The Original Medicare Plan pays the full approved amount (cost) of all covered home health visits. The home health agency sends bills to Medicare. Before your care begins, the home health agency must tell you how much of your bill Medicare will pay. The agency must also tell you if any items or services they give you are not covered by Medicare, and how much you will have to pay for them. This must be explained both by talking with you and in writing.
You may be charged for
• medical services and supplies that Medicare doesn’t pay for, such as prescription drugs, and
• 20 percent of the approved amount for Medicare-covered medical equipment such as wheelchairs, walkers, and oxygen equipment. If the home health agency doesn’t supply medical equipment directly,the home health agency staff will arrange for a home equipment supplier to bring the items you need to your home.
Coverage Limitations and Exclusions
Covered pharmaceuticals, drugs, and DME provided in connection with home health services may be subject to separate benefit categories. Reference the Durable Medical Equipment and the Pharmaceutical Products benefit sections of the member specific benefit plan document.Home health care benefits do not include:
* Custodial Care
* Domiciliary care
* Private Duty Nursing[refer to the Coverage Determination Guideline titled Private Duty Nursing (PDN) Services]
*Respite care
* Rest cures and therefore these services are not covered (check the member specific benefit plan document)
* Homemaker services such as home meal delivery services (e.g., Meals-on-Wheels) or transportation services (e.g., Dial-a-Ride)
*Independent nurse hired directly by the family/member
* Personal care attendants (these are not home health aides)
*Home health services beyond benefit limits(e.g., number of visits)We will determine if benefits are available by reviewing both the skilled nature of the service and the need for Physician-directed medical management. A service will not be determined to be “skilled” simply because there is not an available caregiver.
Home Health Services Medicaid Guideline
Home Health Services are defined as intermittent nursing care provided by certified nursing professionals (registered nurses, licensed practical nurses, skilled nurse aides) in the client’s home when the client’s place of residence is the most appropriate and cost-effective setting consistent with the client’s medical need. Home health care is to be rendered by a Medicare-certified Home Health Agency.
Covered Services for Home Health Services
Covered procedure codes are: T1001, S9123, T1999, S1030, T1021, T1003, T1031, S9124, T1020, S9122,T1022, S9131, S9128, G0154, S9485, S9480, T1002, G0081.
Non Covered Services for Home Health Services
a. Nursing or aide services requested for convenience of family, i.e., bathing, feeding, exercising, homemaking services, transfer services, giving medication, or acting as a companion or sitter, which do not require training, medical judgment technical skills of a nurse whether or not another person is available to perform such services, are not covered.
This exclusion applies regardless of whether services were recommended by a provider.
Non-covered services are:
(1) Private duty nursing.
(2) Custodial care.
(3) Respite care.
(4) Transportation, travel, escort services or food services.
QUALIFYING FOR HOME HEALTH SERVICES
What criteria must be met to qualify for home health services?
Medicare covers home health services when all of these criteria are met:
● The beneficiary to whom services are furnished is eligible and enrolled in Part A and/or Part B of the Medicare Program
● The beneficiary is eligible for coverage of home health services
● The HHA furnishing the services has a valid agreement in effect to participate in the Medicare Program
● The services for which payment is claimed are covered under the Medicare home health benefit
● Medicare is the appropriate payer and
● The services are not otherwise excluded from payment
What criteria must a patient meet to be eligible for home health services?
For a patient to be eligible for Medicare home health services, he or she must meet these criteria:
1.Be confined to the home (that is, home bound)
2.Need skilled services
3.Be under the care of a physician
4.Receive services under a home health plan of care (POC) established and periodically reviewed by a physician and
5.Had a face-to-face encounter related to the primary reason the patient requires home health services with a physician or an allowed NPP no more than 90 days prior to the home health start-of-care date or within 30 days of the start of the home health care
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