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CLINICAL POLICY
HOME HEALTH CARE
Policy Number: HOME 002.20 T1
Effective Date: May 1, 2014
Table of Contents
Page
CONDITIONS OF COVERAGE...................................
BENEFIT CONSIDERATIONS....................................
COVERAGE RATIONALE...........................................
DEFINITIONS..............................................................
APPLICABLE CODES.................................................
DESCRIPTION OF SERVICES...................................
REFERENCES............................................................
POLICY HISTORY/REVISION INFORMATION...........
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Related Policies:
• Assisted
Administration of
Clotting Factors and
Coagulant Blood
Products
• Clotting Factors and
Coagulant Blood
Products
• Custodial and Skilled
Care
• Drug Coverage
Guidelines
• Home Hemodialysis
• Inpatient Maternity
Stay and Subsequent
Home Nursing
• Maximum Frequency
• Private Duty Nursing
The services described in Oxford policies are subject to the terms, conditions and limitations of the Member's
contract or certificate. Unless otherwise stated, Oxford policies do not apply to Medicare Advantage
enrollees. Oxford reserves the right, in its sole discretion, to modify policies as necessary without prior written
notice unless otherwise required by Oxford's administrative procedures or applicable state law. The term
Oxford includes Oxford Health Plans, LLC and all of its subsidiaries as appropriate for these policies.
Certain policies may not be applicable to Self-Funded Members and certain insured products. Refer to the
Member's plan of benefits or Certificate of Coverage to determine whether coverage is provided or if there are
any exclusions or benefit limitations applicable to any of these policies. If there is a difference between any
policy and the Member’s plan of benefits or Certificate of Coverage, the plan of benefits or Certificate of
Coverage will govern.
CONDITIONS OF COVERAGE
Applicable Lines of Business/Products
This policy applies to Oxford Commercial plan
and Oxford USA plan membership 2
Benefit Type
General benefits package
Home Care benefit
Referral Required
No
(Does not apply to non-gatekeeper products)
Yes1
Authorization Required
(Precertification always required for inpatient admission)
Precertification with Medical Director
Review Required
Applicable Site(s) of Service
No1
Home
(If site of service is not listed, Medical Director review is
required)
Home Health Care: Clinical Policy (Effective 05/01/2014)
©1996-2014, Oxford Health Plans, LLC
1
1
New York Individual plans with out of network
benefits do not require pre-certification when
services are provided out of network.
2
New Jersey large and small groups and New
York Lines of Business: For coverage of
assisted administration of clotting factors and
coagulant blood products, refer to: Assisted
Administration of Clotting Factors and
Coagulant Blood Products .For coverage of
clotting factor and coagulant blood products,
refer to: Clotting Factors and Coagulant Blood
Products.
Special Considerations
BENEFIT CONSIDERATIONS
All Members have specific benefit limitations/benefit maximums determined by group and
individual plans. Please refer to the Member's health benefits plan for specific limitations/
maximums.
Benefits for services under the Home Health Care and Skilled Nursing Facility/Inpatient Facility
benefits are available only for services that are skilled care services. Each of those benefits
defines “skilled care” to be:
•
•
•
Skilled Nursing
Skilled Teaching
Skilled Rehabilitation
To be skilled, the service must meet all of the following requirements:
•
•
•
•
•
It must be delivered or supervised by licensed technical or professional medical
personnel in order to obtain the specified medical outcome, and provide for the safety of
the patient; and
It is ordered by a Physician; and
It is not delivered for the purpose of assisting with activities of daily living (dressing,
feeding, bathing or transferring from bed to chair); and
It requires clinical training in order to be delivered safely and effectively; and
It must not be custodial care.
To determine whether benefits for services under these benefit categories, we will review each
service for the skilled nature of the service and the need for physician–directed medical
management.
The fact that there is no available caregiver does not mean that an otherwise “un-skilled” service
becomes a “skilled” service. (Refer to the Member’s specific certificate of coverage and/or
summary of benefits for definition of Skilled Services)
Essential Health Benefits for Individual and Small Group:
For plan years beginning on or after January 1, 2014, the Affordable Care Act of 2010 (ACA)
requires fully insured non-grandfathered individual and small group plans (inside and outside of
Exchanges) to provide coverage for ten categories of Essential Health Benefits (“EHBs”). Large
group plans (both self-funded and fully insured), and small group ASO plans, are not subject to
the requirement to offer coverage for EHBs. However, if such plans choose to provide coverage
for benefits which are deemed EHBs (such as maternity benefits), the ACA requires all dollar
limits on those benefits to be removed on all Grandfathered and Non-Grandfathered plans. The
determination of which benefits constitute EHBs is made on a state by state basis. As such,
when using this guideline, it is important to refer to the enrollee’s specific plan document to
determine benefit coverage.
Home Health Care: Clinical Policy (Effective 05/01/2014)
©1996-2014, Oxford Health Plans, LLC
2
Healthy New York Plans
For Healthy New York Plans, home care visits must be related to an illness or injury for which the
Member was hospitalized* or for which surgery was performed**.
*Hospitalization includes inpatient hospital admissions and visits to the emergency room.
** Includes surgery performed in an inpatient or outpatient hospital setting, ambulatory surgery
center, and physician's office.
Hemophilia: For coverage of assisted administration of clotting factors and coagulant blood
products, refer to: Assisted Administration of Clotting Factors and Coagulant Blood Products.
For coverage of clotting factor and coagulant blood products, refer to: Clotting Factors and
Coagulant Blood Products.
New Jersey Small and Individual Plans
In addition to the above coverage guidelines the following guidelines apply to NJ Small and
Individual plans:
•
•
•
•
•
Each visit by a Member of a home care team on any day shall be considered as one
home health care visit.
The services and supplies must be furnished for care provided by recognized health care
professionals on a part time or intermittent basis, except when full time or 24 hour service
is needed on a short-term (no more than three days) basis.
The home health care plan must be set up in writing by the Member's provider within 14
days after home health care starts. The provider must review the plan at least once every
60 days.
Medical appliances and equipment, drugs and medication and special meals are covered
to the extent such items and services would have been covered if the Member had been
in a hospital.
While the Member is receiving home care, any diagnostic or therapeutic service,
including surgical services performed in a hospital outpatient department, a practitioner's
office or any other licensed health care facility, are covered provided such service would
have been covered if performed as inpatient hospital services.
Note: For members enrolled on the New Jersey Small Plan A each 2 days of Home Health Care
will reduce the number of inpatient hospital days available to a covered person by 1 day
(Members enrolled on the NJ Small Plan A are limited to 30 inpatient days per calendar year).
COVERAGE RATIONALE
1. Member must meet requirements for skilled care (Refer to: Custodial and Skilled Care
Policy)
2. Member’s condition is documented to be such that he/she can receive the skilled nursing,
rehabilitation or teaching in an outpatient setting.
a. The services are ordered by a physician
b. Provided in the Member’s place of residence by a registered nurse, or provided by
either a home health aide or licensed practical nurse and supervised by a registered
nurse
c. Progress is monitored by the ordering physician
3. The Member must be in need of part time or intermittent skilled nursing services on an
intermittent basis or in need of part time or intermittent physical therapy (PT),
occupational therapy (OT)
Home Health Care: Clinical Policy (Effective 05/01/2014)
©1996-2014, Oxford Health Plans, LLC
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4. The home health care services must be furnished under a plan of care that is
established, periodically reviewed and ordered by a physician.
5. The home health care services must be furnished on a per visit basis in the Member’s
place of residence.
6. Services may be furnished on an outpatient basis in a hospital, SNF, or rehabilitation
center if it is necessary to use equipment that is not available in the Members place of
residence (e.g. whirlpool).
7. Examples of home health care service that may be covered:
o
o
o
o
o
o
o
Initial visit in anticipation of home health services (assessment of home setting)
Intravenous infusions and/or total parenteral nutrition (TPN) infusions
Immune Globulin (IVIG) for the treatment of Primary Immune Deficiency Diseases in
the home is covered when determined to be medically appropriate and ordered by a
physician to be given in the Member’s home.
Intramuscular injections administration when licensed personnel are delivering other
skilled services in the home or the patient’s condition does not allow him/her to go to
a physician’s office or outpatient setting.
Infants with high-technology (e.g. respiratory/ventilatory support) in the home setting
Home health visits to Member requiring anticoagulant injection
Home health nurse to teach the Member or the caring person to give subcutaneous
injections of low dose anticoagulant if it is prescribed by a physician for a homebound
enrollee who:


Is pregnant and requires anticoagulant therapy, or
Requires treatment for deep venous thrombosis or pulmonary emboli or for
another condition requiring anticoagulation and documentation justifies that the
Member cannot tolerate warfarin.
1) If the Member or caregiver is unable to administer the injection, nursing visits
to give the injections on a daily basis, 7 days a week, for a period of up to 6
months (in the case of pregnancy, visits may be made for a period beyond
6 months if reasonable and necessary) would be reimbursed. Coverage for
these services after 6 months of treatment would be provided only if the
prescribing physician can justify and document the need for such an
extended course of treatment.
2) Documentation of need for anticoagulant injections beyond 6 months would
not be required for pregnant enrollees who meet the homebound criteria

o
Must meet requirements as defined in the Custodial and Skill Care Services
policy.
Home health services to blind Members with diabetes, if a nurse makes a visit to
provide skilled services, and also pre-fills syringes, the purpose of the visit, which
was to provide skilled services, does not change.

However, if the sole purpose of the nurse's visit is to pre-fill insulin syringes for a
blind Member with diabetes, it is not a skilled nursing visit although it may be
reimbursed as such as indicated below. Filling a syringe can be safely and
effectively performed by the average nonmedical person without the direct
supervision of a licensed nurse. Consequently, it would not constitute a skilled
nursing service even if it is performed by a nurse.

If State law, however, precludes a home health aide from pre-filling insulin
syringes, payment may be made for this service as part of the cost of skilled
nursing services when performed by a nurse for a blind Member with diabetes
who is otherwise unable to pre-fill his or her syringes. There are no adverse
consequences with respect to reimbursement to the home health agency for
providing the service in this manner. If State law does not preclude a home
health aide from pre-filling insulin syringes, but the home health agency chooses
Home Health Care: Clinical Policy (Effective 05/01/2014)
©1996-2014, Oxford Health Plans, LLC
4
to send a nurse to perform only this task, the visit is reimbursed as if made by a
home health aide. (Note: This may vary by contract)
o
Home blood draw (venipuncture) by an independent laboratory technician are
covered in the following circumstances:


Member is confined to home or other place of residence used as his or her home
when the specimen is a type which would require the skills of a laboratory
technician (e.g., where a laboratory technician draws a blood specimen.)
Member’s place of residence is an institution
Additional Information:
•
•
•
•
•
•
•
•
•
Administration of intravenous infusion services may not be subject to visit limitations.
Please check the Member’s specific certificate of coverage and/or summary of benefits
for the home infusion services benefit.
Medical supplies and medications that are used in conjunction with a home health care
visit are covered as part of that visit. Some examples are, but not limited to, surgical
dressing, catheters, syringes, irrigation devices
Reimbursement for home health care visits and supplies are contractually determined.
Eligible physical, occupational and speech therapy received in the home from a Home
Health Agency is covered under the Home Health Care section of the Member’s
certificate of coverage and/or summary of benefits. The Home Health Care section only
applies to services that are rendered by a Home Health Agency.
Physical, occupational, or speech therapy provided by the home health service or agency
will be accumulated and applied to the home care benefit, not the outpatient rehabilitation
services benefit
For skilled and custodial services Please see the Custodial and Skill Care Services
Policy)
Members may be allowed follow-up home visit(s) following a maternity delivery if the
mother elects to leave the hospital before the expiration of 48 hours for a vaginal delivery
or 96 hours for a cesarean section delivery. Refer to Inpatient Maternity Stay and
Subsequent Home Nursing for additional information.
Durable medical equipment is covered under the Members Durable Medical Equipment
benefit package. Refer to the Member's certificate, health benefits plan, or benefit rider
documentation to determine DME benefit coverage.
Laboratory services should be referred to a contracted vendor or otherwise covered per
the Member's benefit package
Hemophilia
Oxford will cover medically necessary and appropriate home treatment services for the bleeding
episodes associated with hemophilia including the purchase of blood products and blood infusion
equipment.
Connecticut Lines of Business and New Jersey Individual Plan Members:
•
•
Assisted administration of clotting factor drugs in the home require pre-certification for the
home care services (not for the clotting factor drugs).
Clotting factor drugs do not require pre-certification and are covered under medical
benefit. Refer to: Drug Coverage Guidelines
New Jersey Large and Small groups and New York Lines of Business
•
•
For coverage of assisted administration of blood products, refer to: Assisted
Administration of Clotting Factors and Coagulant Blood Products
For information regarding coverage of clotting factor and coagulant blood products, refer
to: Clotting Factors and Coagulant Blood Products.
Home Health Care: Clinical Policy (Effective 05/01/2014)
©1996-2014, Oxford Health Plans, LLC
5
Coverage Limitations and Exclusions
1. Home health care does not include Custodial Care, domiciliary care, respite care, or rest
cures and therefore these services are not covered. (Please check the Member’s
certificate of coverage and/or summary of benefits)
2. Services of personal care attendants
3. Oxford 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.
4. Covered pharmaceuticals, drugs, and DME provided in connection with home health
services may be subject to separate benefit categories, please reference the Member’s
certificate of coverage and/or summary of benefits.
5. Homemaker services unrelated to Member's care or home meal delivery services (e.g.,
Meals-on-Wheels) or transportation services (e.g., Dial-a-Ride).
6. Private Duty Nursing (there may be a specific benefit related to the Member's benefit
package. Refer to the Member's health benefit plan/summary of benefits as well as the
Private Duty Nursing policy for additional information.
7. Home Health Services beyond benefit limits, e.g. visits.
DEFINITIONS
Home Health Agency: a program or organization authorized by law to provide health care
services in the home.
Home Health Visit:. Up to 4 hours of Skilled Care Services received from a Home Health Agency
that are both of the following:
•
•
Ordered by a Physician.
Provided in the home by a registered nurse, or provided by either a home health aide or
licensed practical nurse and supervised by a registered nurse.
Benefits are available only when the Home Health Agency services are provided on a part-time,
Intermittent Care schedule and when skilled care is required.
Skilled care is skilled nursing, skilled teaching, and skilled rehabilitation services when all of the
following are true:
•
•
•
•
•
It must be delivered or supervised by licensed technical or professional medical
personnel in order to obtain the specified medical outcome, and provide for the safety of
the patient.
It is ordered by a Physician.
It is not delivered for the purpose of assisting with activities of daily living, including but
not limited to dressing, feeding, bathing or transferring from a bed to a chair.
It requires clinical training in order to be delivered safely and effectively.
It is not Custodial Care.
Oxford 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.
Exception: For NJ Small and Individual plan coverage, refer to the NJ Small and Individual
plans section above.
Home Health Care: Clinical Policy (Effective 05/01/2014)
©1996-2014, Oxford Health Plans, LLC
6
Intermittent- Part-time Home Health Services (CMS): Where a patient is eligible for coverage
of home health services, Medicare covers either part-time or intermittent home health aide
services or skilled nursing services subject to the limits below. The law at §1861(m) of the Act
clarified: "the term "part-time or intermittent services" means skilled nursing and home health aide
services furnished any number of days per week as long as they are furnished (combined) less
than 8 hours each day and 28 or fewer hours each week (or, subject to review on a case-by-case
basis as to the need for care, less than 8 hours each day and 35 or fewer hours each week).
Extensions are for exceptional circumstances when the need for additional care is finite and
predictable).
Intermittent Visit (s) (CMS): "intermittent" means skilled nursing care that is either provided or
needed on fewer than 7 days each week or less than 8 hours of each day for periods of 21 days
or less (with extensions in exceptional circumstances when the need for additional care is finite
and predictable).
Place of Residence: Wherever the patient makes his/her home. This may be his/her dwelling, an
apartment, a relative's home, home for the aged, a custodial care facility, or some other type of
institution.
Skilled Care (CMS): Skilled nursing and/or skilled rehabilitation services are those services,
furnished pursuant to physician orders, that:
•
•
Require the skills of qualified technical or professional health personnel such as
registered nurses, licensed practical (vocational) nurses, physical therapists,
occupational therapists, and speech-language pathologists or audiologists; and
Must be provided directly by or under the general supervision of these skilled nursing or
skilled rehabilitation personnel to assure the safety of the patient and to achieve the
medically desired result.
APPLICABLE CODES
The codes listed in this policy are for reference purposes only. Listing of a service or device code
in this policy does not imply that the service described by this code is a covered or non-covered
health service. Coverage is determined by the Member’s plan of benefits or Certificate of
Coverage. This list of codes may not be all inclusive.
Applicable CPT Codes:
CPT® Code
99500
99501
99502
99503
99504
99505
99506
99507
99511
99512
Description
Home visit for prenatal monitoring and assessment to include fetal heart rate,
non stress test, uterine monitoring and gestational diabetes monitoring
Home visit for postnatal assessment and follow-up care
Home visit for newborn care and assessment
Home visit for respiratory therapy care (e.g., bronchodilator, oxygen therapy,
respiratory assessment, apnea evaluation)
Home visit for mechanical ventilation care
Home visit for stoma care and maintenance including colostomy and
cystostomy
Home visit for intramuscular injections
Home visit for care and maintenance of catheter(s) (e.g., urinary, drainage, and
enteral)
Home visit for fecal impaction management and enema administration
Home visit for hemodialysis, per diem
®
CPT is a registered trademark of the American Medical Association.
Home Health Care: Clinical Policy (Effective 05/01/2014)
©1996-2014, Oxford Health Plans, LLC
7
Applicable HCPCS Codes:
HCPCS
Code
G0151
G0152
G0153
G0154
G0155
G0156
G0157
G0158
G0159
G0160
G0161
G0162
G0163
G0164
H1004
S5108
S5109
S5110
S5111
S5115
S5116
S5180
S5181
S9061
S9097
S9098
S9122
S9123
S9124
Description
Services performed by a qualified physical therapist in the home health or hospice
setting, each 15 minutes
Services performed by a qualified occupational therapist in the home health or
hospice setting, each 15 minutes
Services performed by a qualified speech-language pathologist in the home health
or hospice setting, each 15 minutes
Direct skilled nursing services of a licensed nurse (LPN or RN) in the home health
or hospice setting, each 15 minutes
Services of clinical social worker in home health setting, each 15 minutes
Services of home health aide in home health setting, each 15 minutes
Services performed by a qualified physical therapist assistant in the home health
or hospice setting, each 15 minutes
Services performed by a qualified occupational therapist assistant in the home
health or hospice setting, each 15 minutes
Services performed by a qualified physical therapist, in the home health setting, in
the establishment or delivery of a safe and effective therapy maintenance program,
each 15 minutes
Services performed by a qualified occupational therapist, in the home health
setting, in the establishment or delivery of a safe and effective therapy
maintenance program, each 15 minutes
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
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 nonskilled care achieves its purpose in the
home health or hospice setting)
Skilled services of a licensed nurse (lpn or rn) in the delivery of observation &
assessment of the patient's condition, each 15 minutes (when the likelihood of
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)
Skilled services of a licensed nurse, in the training and/or education of a patient or
family member, in the home health or hospice setting, each 15 minutes
Prenatal care, at-risk enhanced service; follow-up home visit
Home care training to home care client, per 15 minutes
Home care training to home care client, per session
Home care training, family; per 15 minutes
Home care training, family; per session
Home care training, non-family; per 15 minutes
Home care training, non-family; per session
Home health respiratory therapy, initial evaluation
Home health respiratory therapy, nos, per diem
Home administration of aerosolized drug therapy (e.g, pentamidine); administrative
services, professional pharmacy services, care coordination, all necessary
supplies and equipment (drugs and nursing visits coded separately), per diem
Home visit for wound care
Home visit, phototherapy services (e.g, bili-lite), including equipment rental,
nursing services, blood draw, supplies, and other services, per diem
Home health aide or certified nurse assistant, providing care in the home; per hour
Nursing care, in the home; by registered nurse, per hour (use for general nursing
care only, not to be used when CPT codes 99500-99602 can be used)
Nursing care, in the home; by licensed practical nurse, per hour
Home Health Care: Clinical Policy (Effective 05/01/2014)
©1996-2014, Oxford Health Plans, LLC
8
HCPCS
Code
S9127
S9128
S9129
S9131
Description
Social work visit, in the home, per diem
Speech therapy, in the home, per diem
Occupational therapy, in the home, per diem
Physical therapy; in the home, per diem
Home management of preterm labor, including administrative services,
professional pharmacy services, care coordination, and all necessary supplies or
S9208
equipment (drugs and nursing visits coded separately), per diem (do not use this
code with any home infusion per diem code)
Home management of preterm premature rupture of membranes (pprom),
including administrative services, professional pharmacy services, care
S9209
coordination, and all necessary supplies or equipment (drugs and nursing visits
coded separately), per diem (do not use this code with any home infusion per diem
code)
Home management of gestational hypertension, includes administrative services,
professional pharmacy services, care coordination, and all necessary supplies or
S9211
equipment (drugs and nursing visits coded separately), per diem (do not use this
code with any home infusion per diem code)
Home management of gestational hypertension, includes administrative services,
professional pharmacy services, care coordination, and all necessary supplies or
S9212
equipment (drugs and nursing visits coded separately), per diem (do not use this
code with any home infusion per diem code)
Home management of preeclampsia, includes administrative services, professional
pharmacy services, care coordination, and all necessary supplies and equipment
S9213
(drugs and nursing services coded separately); per diem (do not use this code with
any home infusion per diem code)
Home management of gestational diabetes, includes administrative services,
professional pharmacy services, care coordination, and all necessary supplies or
S9214
equipment (drugs and nursing visits coded separately), per diem (do not use this
code with any home infusion per diem code)
Home therapy, hemodialysis; administrative services, professional pharmacy
S9335
services, care coordination, and all necessary supplies and equipment (drugs and
nursing services coded separately), per diem
Home therapy, peritoneal dialysis; administrative services, professional pharmacy
S9339
services, care coordination and all necessary supplies and equipment (drugs and
nursing visits coded separately), per diem
Home therapy; enteral nutrition; administrative services, professional pharmacy
S9340
services, care coordination, and all necessary supplies and equipment (enteral
formula and nursing visits coded separately), per diem
Home therapy; enteral nutrition via gravity; administrative services, professional
S9341
pharmacy services, care coordination, and all necessary supplies and equipment
(enteral formula and nursing visits coded separately), per diem
Home therapy; enteral nutrition via pump; administrative services, professional
S9342
pharmacy services, care coordination, and all necessary supplies and equipment
(enteral formula and nursing visits coded separately), per diem
Home therapy; enteral nutrition via bolus; administrative services, professional
S9343
pharmacy services, care coordination, and all necessary supplies and equipment
(enteral formula and nursing visits coded separately), per diem
Home therapy, intermittent anti-emetic injection therapy; administrative services,
S9370
professional pharmacy services, care coordination, and all necessary supplies and
equipment (drugs and nursing visits coded separately), per diem
Home therapy, intermittent anticoagulant injection therapy; administrative services,
professional pharmacy services, care coordination, and all necessary supplies and
S9372
equipment (drugs and nursing visits coded separately), per diem (do not use this
code for flushing of infusion devices with heparin to maintain patency)
Enterostomal therapy by a registered nurse certified in enterostomal therapy, per
S9474
diem
Home Health Care: Clinical Policy (Effective 05/01/2014)
9
©1996-2014, Oxford Health Plans, LLC
HCPCS
Code
S9537
S9542
S9559
S9560
S9562
S9590
T1001
T1002
T1003
T1004
T1021
T1022
T1028
T1030
T1031
T1502
Description
Home therapy, hematopoietic hormone injection therapy (e.g. erythropoietin, g-csf,
gm-csf); administrative services, professional pharmacy services, care
coordination, and all necessary supplies and equipment (drugs and nursing visits
coded separately); per diem
Home injectable therapy; not otherwise classified, including administrative
services, professional pharmacy services, coordination of care, and all necessary
supplies and equipment (drugs and nursing visits coded separately), per diem
home injectable therapy; interferon, including administrative services, professional
pharmacy services, coordination of care, and all necessary supplies and
equipment (drugs and nursing visits coded separately), per diem
home injectable therapy; hormonal therapy (e.g.; leuprolide, goserelin), including
administrative services, professional pharmacy services, care coordination, and all
necessary supplies and equipment (drugs and nursing visits coded separately),
per diem
Home injectable therapy, palivizumab, including administrative services,
professional pharmacy services, care coordination, and all necessary supplies and
equipment (drugs and nursing visits coded separately), per diem
home therapy, irrigation therapy (e.g. sterile irrigation of an organ or anatomical
cavity); including administrative services, professional pharmacy services, care
coordination, and all necessary supplies and equipment (drugs and nursing visits
coded separately), per diem
Nursing assessment/evaluation
RN services, up to 15 minutes
LPN/LVN services, up to 15 minutes
Services of a qualified nursing aide, up to 15 minutes
Home health aide or certified nurse assistant, per visit
Contracted home health agency services, all services provided under contract, per
day
Assessment of home, physical and family environment, to determine suitability to
meet patient's medical needs
Nursing care, in the home, by registered nurse, per diem
Nursing care, in the home, by licensed practical nurse, per diem
Administration of oral, intramuscular and/or subcutaneous medication by health
care agency/professional, per visit
Home IV Infusion
CPT® Code
99601
99602
HCPCS
Code
S5035
S5036
S5497
S5498
Description
Home infusion/specialty drug administration, per visit (up to 2 hours)
Home infusion/specialty drug administration, per visit each additional hour (list
separately in addition to primary procedure)
Description
Home infusion therapy, routine service of infusion device (e.g. pump maintenance)
Home infusion therapy, repair of infusion device (e.g. pump repair)
Home infusion therapy, catheter care/maintenance, not otherwise classified;
includes administrative services, professional pharmacy services, care
coordination, and all necessary supplies and equipment (drugs and nursing visits
coded separately), per diem
Home infusion therapy, catheter care / maintenance, simple (single lumen),
includes administrative services, professional pharmacy services, care
coordination and all necessary supplies and equipment, (drugs and nursing visits
coded separately), per diem
Home Health Care: Clinical Policy (Effective 05/01/2014)
©1996-2014, Oxford Health Plans, LLC
10
HCPCS
Code
S5501
S5502
S5517
S5518
S5520
S5521
S5522
S5523
S9325
S9326
S9327
S9328
S9329
S9330
S9331
S9336
S9338
Description
Home infusion therapy, catheter care/maintenance, complex (more than one
lumen), includes administrative services, professional pharmacy services, care
coordination, and all necessary supplies and equipment (drugs and nursing visits
coded separately), per diem
Home infusion therapy, catheter care/maintenance, implanted access device,
includes administrative services, professional pharmacy services, care
coordination and all necessary supplies and equipment, (drugs and nursing visits
coded separately), per diem (use this code for interim maintenance of vascular
access not currently in use)
Home infusion therapy, all supplies necessary for restoration of catheter patency
or declotting
Home infusion therapy, all supplies necessary for catheter repair
Home infusion therapy, all supplies (including catheter) necessary for a
peripherally inserted central venous catheter (picc) line insertion
Home infusion therapy, all supplies (including catheter) necessary for a midline
catheter insertion
Home infusion therapy, insertion of peripherally inserted central venous catheter
(picc), nursing services only (no supplies or catheter included)
Home infusion therapy, insertion of midline central venous catheter, nursing
services only (no supplies or catheter included)
Home infusion therapy, pain management infusion; administrative services,
professional pharmacy services, care coordination, and all necessary supplies and
equipment, (drugs and nursing visits coded separately), per diem (do not use this
code with s9326, s9327, or s9328)
Home infusion therapy, continuous (twenty-fours hours or more) pain management
infusion; administrative services, professional pharmacy services, care
coordination, and all necessary supplies and equipment (drugs and nursing visits
coded separately), per diem
Home infusion therapy, intermittent (less than twenty-fours hours) pain
management infusion; administrative services, professional pharmacy services,
care coordination, and all necessary supplies and equipment (drugs and nursing
visits coded separately), per diem
Home infusion therapy, implanted pump pain management infusion; administrative
services, professional pharmacy services, care coordination and all necessary
supplies and equipment (drugs and nursing visits coded separately), per diem
Home infusion therapy, chemotherapy infusion; administrative services,
professional pharmacy services, care coordination and all necessary supplies and
equipment (drugs and nursing visits coded separately), per diem (do not use this
code with s9330 or s9331)
Home infusion therapy, continuous (twenty-four hours or more) chemotherapy
infusion; administrative services, professional pharmacy services, care
coordination and all necessary supplies and equipment (drugs and nursing visits
coded separately), per diem
Home infusion therapy, intermittent (less than twenty-four hours) chemotherapy
infusion; administrative services, professional pharmacy services, care
coordination, and all necessary supplies and equipment (drugs and nursing visits
coded separately), per diem
Home infusion therapy, continuous anticoagulant infusion therapy (e.g., heparin),
administrative services, professional pharmacy services, care coordination and all
necessary supplies and equipment (drugs and nursing visits coded separately),
per diem
Home infusion therapy, immunotherapy therapy; administrative services,
professional pharmacy services, care coordination and all necessary supplies and
equipment (drugs and nursing visits coded separately), per diem
Home Health Care: Clinical Policy (Effective 05/01/2014)
©1996-2014, Oxford Health Plans, LLC
11
HCPCS
Code
S9345
S9346
S9347
S9348
S9351
S9353
S9357
S9359
S9361
S9363
S9364
S9365
S9366
S9367
Description
Home infusion therapy, anti-hemophilic agent infusion therapy (e.g., factor viii);
administrative services, professional pharmacy services, care coordination and all
necessary supplies and equipment (drugs and nursing visits coded separately),
per diem
Home infusion therapy, alpha-1-proteinase inhibitor (e.g., prolastin); administrative
services, professional pharmacy services, care coordination, and all necessary
supplies and equipment (drugs and nursing visits coded separately), per diem
Home infusion therapy, uninterrupted, long-term, controlled rate intravenous or
subcutaneous infusion therapy (e.g. epoprostenol); administrative services,
professional pharmacy services, care coordination, and all necessary supplies and
equipment (drugs and nursing visits coded separately), per diem
Home infusion therapy, sympathomimetic/inotropic agent infusion therapy (e.g.
dobutamine); administrative services, professional pharmacy services, care
coordination, and all necessary supplies and equipment (drugs and nursing visits
coded separately), per diem
Home infusion therapy, continuous or intermittent anti-emetic infusion therapy;
administrative services, professional pharmacy services, care coordination, and all
necessary supplies and equipment (drugs and visits coded separately), per diem
Home infusion therapy, continuous insulin infusion therapy; administrative
services, professional pharmacy services, care coordination, and all necessary
supplies and equipment (drugs and nursing visits coded separately), per diem
Home infusion therapy, enzyme replacement intravenous therapy; (e.g.
imiglucerase); administrative services, professional pharmacy services, care
coordination, and all necessary supplies and equipment (drugs and nursing visits
coded separately), per diem
Home infusion therapy, anti-tumor necrosis factor intravenous therapy; (e.g,
infliximab); administrative services, professional pharmacy services, care
coordination, and all necessary supplies and equipment (drugs and nursing visits
coded separately), per diem
Home infusion therapy, diuretic intravenous therapy; administrative services,
professional pharmacy services, care coordination, and all necessary supplies and
equipment (drugs and nursing visits coded separately), per diem
Home infusion therapy, anti-spasmotic intravenous therapy; administrative
services, professional pharmacy services, care coordination, and all necessary
supplies and equipment (drugs and nursing visits coded separately), per diem
Home infusion therapy, total parenteral nutrition (tpn); administrative services,
professional pharmacy services, care coordination, and all necessary supplies and
equipment including standard tpn formula (lipids, specialty amino acid formulas,
drugs other than in standard formula and nursing visits coded separately), per
diem (do not use with home infusion codes s9365-s9368 using daily volume
scales)
Home infusion therapy, total parenteral nutrition (tpn); one liter per day,
administrative services, professional pharmacy services, care coordination, and all
necessary supplies and equipment including standard tpn formula (lipids, specialty
amino acid formulas, drugs other than in standard formula and nursing visits coded
separately), per diem
Home infusion therapy, total parenteral nutrition (tpn); more than one liter, but no
more than two liters per day, administrative services, professional pharmacy
services, care coordination, and all necessary supplies and equipment including
standard tpn
Home infusion therapy, total parenteral nutrition (tpn); more than two liters but no
more than three liters per day, administrative services, professional pharmacy
services, care coordination, and all necessary supplies and equipment including
standard tpn formula (lipids, specialty amino acid formulas, drugs other than in
standard formula and nursing visits coded separately), per diem
Home Health Care: Clinical Policy (Effective 05/01/2014)
©1996-2014, Oxford Health Plans, LLC
12
HCPCS
Code
S9368
S9373
S9374
S9375
S9376
S9377
S9379
S9490
S9494
S9497
S9500
S9501
S9502
S9503
Description
Home infusion therapy, total parenteral nutrition (tpn); more than two liters but no
more than three liters per day, administrative services, professional pharmacy
services, care coordination, and all necessary supplies and equipment including
standard tpn formula (lipids, specialty amino acid formulas, drugs other than in
standard formula and nursing visits coded separately), per diem
Home infusion therapy, hydration therapy; administrative services, professional
pharmacy services, care coordination, and all necessary supplies and equipment
(drugs and nursing visits coded separately), per diem (do not use with hydration
therapy codes s9374-s9377 using daily volume scales)
Home infusion therapy, hydration therapy; one liter per day, administrative
services, professional pharmacy services, care coordination, and all necessary
supplies and equipment (drugs and nursing visits coded separately), per diem
Home infusion therapy, hydration therapy; more than one liter but no more than
two liters per day, administrative services, professional pharmacy services, care
coordination, and all necessary supplies and equipment (drugs and nursing visits
coded separately), per diem
Home infusion therapy, hydration therapy; more than two liters but no more than
three liters per day, administrative services, professional pharmacy services, care
coordination, and all necessary supplies and equipment (drugs and nursing visits
coded separately), per diem
Home infusion therapy, hydration therapy; more than three liters per day,
administrative services, professional pharmacy services, care coordination, and all
necessary supplies (drugs and nursing visits coded separately), per diem
Home infusion therapy, infusion therapy, not otherwise classified; administrative
services, professional pharmacy services, care coordination, and all necessary
supplies and equipment (drugs and nursing visits coded separately), per diem
Home infusion therapy, corticosteroid infusion; administrative services,
professional pharmacy services, care coordination, and all necessary supplies and
equipment (drugs and nursing visits coded separately), per diem
Home infusion therapy, antibiotic, antiviral, or antifungal therapy; administrative
services, professional pharmacy services, care coordination, and all necessary
supplies and equipment (drugs and nursing visits coded separately, per diem) (do
not use with home infusion codes for hourly dosing schedules s9497 – s9504)
Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every three
hours; administrative services, professional pharmacy services, care coordination,
and all necessary supplies and equipment (drugs and nursing visits coded
separately), per diem
Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 24
hours; administrative services, professional pharmacy services, care coordination,
and all necessary supplies and equipment (drugs and nursing visits coded
separately), per diem
Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 12
hours; administrative services, professional pharmacy services, care coordination,
and all necessary supplies and equipment (drugs and nursing visits coded
separately), per diem
Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every eight
hours; administrative services, professional pharmacy services, care coordination,
and all necessary supplies and equipment (drugs and nursing visits coded
separately), per diem
Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every six
hours; administrative services, professional pharmacy services, care coordination,
and all necessary supplies and equipment (drugs and nursing visits coded
separately), per diem
Home Health Care: Clinical Policy (Effective 05/01/2014)
©1996-2014, Oxford Health Plans, LLC
13
HCPCS
Code
S9504
S9538
Description
Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every four
hours; administrative services, professional pharmacy services, care coordination,
and all necessary supplies and equipment (drugs and nursing visits coded
separately), per diem
Home transfusion of blood product(s); administrative services, professional
pharmacy services, care coordination, and all necessary supplies and equipment
(blood products, drugs, ad nursing visits coded separately), per diem
DESCRIPTION OF SERVICES
Home care is care provided in the Member's home by a home health service or agency licensed
by the state in which the Member resides. The care must be provided by physician-supervised
health professionals under the direction of a physician's written treatment plan and must be in lieu
of hospitalization or confinement in a skilled nursing facility.
REFERENCES
The foregoing policy has been adapted from an existing UnitedHealthcare coverage
determination guideline that was researched, developed and approved by the UnitedHealthcare
Coverage Determination Committee. [CDG-A-004, effective 05/01/2013]
CMS Medicare Benefit Policy Manual, Chapter 7 Home Health Services @
http://www.cms.hhs.gov/manuals/Downloads/bp102c07.pdf
POLICY HISTORY/REVISION INFORMATION
Date
•
05/01/2014
•
Action/Description
Revised coverage rationale for home treatment services for
bleeding episodes associated with hemophilia:
o For New Jersey Individual Plan Members: Added language
to indicate:
 Assisted administration of clotting factor drugs in the
home require pre-certification for the home care services
(not for the clotting factor drugs)
 Clotting factor drugs do not require pre-certification and
are covered under medical benefit
o For New Jersey Large and Small Group Plan Members:
Added reference links policies titled:
 Assisted Administration of Clotting Factors and
Coagulant Blood Products for information regarding
coverage of assisted administration of blood products
 Clotting Factors and Coagulant Blood Products for
information regarding coverage of clotting factor and
coagulant blood products
Archived previous policy version HOME 002.19 T1
Home Health Care: Clinical Policy (Effective 05/01/2014)
©1996-2014, Oxford Health Plans, LLC
14