Original Issue Date (Created): 7/1/2002 Most Recent Review Date (Revised): 1/27/2015 Effective Date: 6/1/2015 POLICY PRODUCT VARIATIONS DESCRIPTION/BACKGROUND RATIONALE DEFINITIONS BENEFIT VARIATIONS DISCLAIMER CODING INFORMATION REFERENCES POLICY HISTORY I. POLICY **Please Note: This policy only applies to SeniorBlue HMO and SeniorBlue PPO products. Commercial product determinations are made in accordance with InterQual Guidelines. Determinations of the medical necessity and appropriateness of providing in-home services such as skilled nursing, skilled therapy services, home health aide services and medical social services will be made following the guidelines set forth in this policy and further described in the Centers for Medicare and Medicaid Services (CMS) guidelines as documented in the Medicare Benefit Policy Manual (Publication 100-2), Chapter 7- Home Health Services (as may be amended from time to time). In order for home health services to be considered medically necessary, the home environment must be safe, and all of the following general requirements must be met: The patient must be homebound. (See definitions). The patient's homebound status must be documented by the physician in the medical record, supported by the nursing assessment and documented in subsequent progress notes. The patient does not leave home for other services that can be provided in the home setting. The services requested must be medically appropriate for delivery in the home setting. The services must be intermittent in nature. (See definitions). The care must be provided under a plan of treatment established by and periodically reviewed by a licensed physician. The services must require the skills of a registered nurse, licensed practical (vocational) nurse under the supervision of a registered nurse, licensed physical therapist, or speech therapist; or the patient has a continuing need for occupational therapy. Page 1
Exception to the above criteria: Nursing visits for the sole purpose of venipuncture to obtain a blood sample may be considered medically necessary when the member is homebound and no mobile lab services are available. Skilled Nursing Services Skilled nursing serves may be considered medically necessary including but are not limited for the following: (Refer to Medicare Benefit Policy Manual (Publication 100-2), Chapter 7 Section 40 Skilled Nursing Care for a full description of skilled nursing services.) Observation and assessment of an unstable condition where there is a reasonable potential for change in order to identify and evaluate the need for possible modification of treatment or initiation of additional medical procedures. Management and evaluation of a care plan when the complexity of maintaining the unskilled plan of care depends upon the skilled oversight of a registered nurse to ensure that the unskilled plan of care is adhered to and adjusted so as to prevent complications and thereby, re-hospitalizations. Teaching and training activities to instruct the member, the member s family, or caregivers how to manage the treatment regimen where the teaching and training is appropriate to the member s functional loss, illness, or injury. Administration of medications when the service of a nurse is required to administer the medications safely and effectively. Nasogastric tube, and percutaneous tube feedings (including gastrostomy and jejunostomy tubes), and replacement, adjustment, stabilization and suctioning of the tubes. This includes the feedings and replacement or adjustment of the tubes. Nasopharyngeal and tracheostomy aspiration. Insertion and sterile irrigation and replacement of catheters, care of a suprapubic catheter, urethral catheters where the urethral catheter is necessitated by a permanent or temporary loss of bladder control, Care of wounds, (including, but not limited to, ulcers, burns, pressure sores, open surgical sites, fistulas, tube sites, and tumor erosion sites) when the skills of a licensed nurse are needed to provide safely and effectively the services necessary to treat the illness or injury, Ostomy care during the post-operative period and in the presence of associated complications where the need for skilled nursing care is clearly documented. Teaching ostomy care remains skilled nursing care regardless of the presence of complications. Page 2
Heat treatments that have been specifically ordered by a physician as part of active treatment of an illness or injury and require observation by a licensed nurse to adequately evaluate the patient's progress Administration of medical gases during the initial phases of a regimen that are necessary to the treatment of illness or injury in order to provide observation and evaluation of the patient's reaction to the gases, and to teach the family when and how to properly manage the administration of the gases. Rehabilitation nursing procedures, including the related teaching and adaptive aspects of nursing that are part of active treatment (e.g., the institution and supervision of bowel and bladder training programs) Home Health Aide Services Home health aide services are covered where the patient meets the qualifying criteria specified for home health services, and: Skilled (licensed nurse or therapist) home health services being provided; and The reason for the visits is to provide hands-on personal care of the patient or services needed to maintain the patient s health or to facilitate treatment of the patient s illness or injury. Medical Social Services Medical social services that are provided by a qualified medical social worker or a social work assistant under the supervision of a qualified medical social worker may be covered as home health services where the patient meets the qualifying criteria specified for home health services, and: The services of these professionals are necessary to assist the patient or primary caregiver with social or emotional issues that may be an impediment to the effective treatment of the patient's medical condition or rate of recovery; and The plan of care indicates how the services which are required necessitate the skills of a qualified social worker or a social work assistant under the supervision of a qualified medical social worker. According to the Medicare Benefit Policy Manual, Chapter 7, Home Health Services, the following are non-covered services: Drugs and Biologicals are excluded under the Medicare home health benefit (except covered osteoporosis drugs as described in 50.4.3 of the Medicare Benefit Policy Manual Publication 100-2, Chapter 7- Home Health Services); Page 3
Meals delivered to the home; Homemaker services such as shopping, cleaning, and laundry; Personal care given by home health aides (including help with basic activities of daily living) when there are no skilled (licensed nurse or therapist) home health services being provided. Visits for observation of a medically stable patient (except as described in 40.1.2.1 of the Medicare Benefit Policy Manual, Publication 100-2, Chapter 7- Home Health Services). Nursing visits for the sole purpose of completing an assessment; Social services for the family members (except as described in 50.3 of the Medicare Benefit Policy Manual, Publication 100-2, Chapter 7- Home Health Services). Services of a dietician. Home Health Care and services are no longer considered medically necessary when: The care and services being provided no longer meet the definition of skilled nursing or therapy services; or The required care and services can be provided in an outpatient setting and the patient is no longer confined to home; or Rehabilitation or teaching goals are achieved. Cross-references: MP-3.008 Parenteral Home Infusion Therapy (including total parenteral nutrition) MP- 8.001 Physical Medicine and Specialized Physical Medicine Treatments (Outpatient) MP- 8.004 Occupational Therapy (Outpatient) Page 4
II. PRODUCT VARIATIONS [N] = No product variation, policy applies as stated [Y] = Standard product coverage varies from application of this policy, see below [Y] Capital Cares 4 Kids* [Y] Indemnity* [Y] PPO* [Y SpecialCare* [Y] HMO* [N] SeniorBlue HMO [N] SeniorBlue PPO [Y] POS* [Y] FEP PPO* *Commercial product determinations are made in accordance with InterQual III. DESCRIPTION/BACKGROUND Home health care is medically necessary skilled care provided to the homebound patient for treatment of an acute illness, an acute exacerbation of a chronic illness, or to provide rehabilitative services. Skilled care may be provided in the home setting by a registered nurse (RN), Licensed Practical Nurse (LPN), physical therapist (PT), occupational therapist (OT), or speech therapist (ST). Medical social services may also be covered as home health services. Home Health Aide (HHA) services may be provided for hands-on personal care (e.g. hygiene care, skin care, foot care, feeding and assistance with elimination) of the patient when skilled services are being provided. The care is generally coordinated through a Medicare Certified Home Health Care Agency, home infusion agency, or health care provider. IV. RATIONALE NA V. DEFINITIONS BASIC ACTIVITIES OF DAILY LIVING includes and is limited to walking in the home, eating, bathing, dressing, and homemaking. Page 5
HOMEBOUND: For purposes of this policy, an individual is considered confined to the home (homebound) if the following two criteria are met: Criteria-One: The patient must either: Because of illness or injury, need the aid of supportive devices such as crutches, canes, wheelchairs, and walkers; the use of special transportation; or the assistance of another person in order to leave their place of residence OR Have a condition such that leaving his or her home is medically contraindicated. If the patient meets one of the Criteria-One conditions, then the patient must ALSO meet two additional requirements defined in Criteria-Two below. Criteria-Two: There must exist a normal inability to leave home; AND Leaving home must require a considerable and taxing effort. HOME HEALTH AGENCY is a provider licensed and approved by the appropriate governmental agency which: Provides skilled nursing and other services on an intermittent basis in the member s home; Is responsible for supervising the delivery of such services under a plan prescribed by the attending physician. To qualify as a home health agency, the organization must meet all of the following criteria at a minimum: Current licensure under state law as a home health agency; Medicare certification; Proof of malpractice/liability insurance; and Accreditation by the Joint Accreditation of Hospital Associations (JCAHO) or similar accrediting agency approved by the Plan. INTERMITTENT SERVICES refers to skilled nursing care that is needed or given on fewer than seven days each week or less than eight (8) hours each day over a period of twenty-one (21) days (or less). VI. BENEFIT VARIATIONS The existence of this medical policy does not mean that this service is a covered benefit under the member's contract. Benefit determinations should be based in all cases on the applicable Page 6
contract language. Medical policies do not constitute a description of benefits. A member s individual or group customer benefits govern which services are covered, which are excluded, and which are subject to benefit limits and which require preauthorization. Members and providers should consult the member s benefit information or contact Capital for benefit information. VII. DISCLAIMER Capital s medical policies are developed to assist in administering a member s benefits, do not constitute medical advice and are subject to change. Treating providers are solely responsible for medical advice and treatment of members. Members should discuss any medical policy related to their coverage or condition with their provider and consult their benefit information to determine if the service is covered. If there is a discrepancy between this medical policy and a member s benefit information, the benefit information will govern. Capital considers the information contained in this medical policy to be proprietary and it may only be disseminated as permitted by law. VIII. CODING INFORMATION Note: This list of codes may not be all-inclusive, and codes are subject to change at any time. The identification of a code in this section does not denote coverage as coverage is determined by the terms of member benefit information. In addition, not all covered services are eligible for separate reimbursement. Covered when medically necessary: CPT Codes 94005 99374 99375 99500 99501 99502 99503 99504 99505 99506 99507 99509 99510 99511 99512 99600 Current Procedural Terminology (CPT) copyrighted by American Medical Association. All Rights Reserved. HCPCS Code G0151 G0152 G0153 G0154 G0155 G0156 G0162 G0163 Description Services of physical therapist in home health setting, each 15 minutes Services of occupational therapist in home health setting, each 15 minutes Services of speech and language pathologist in home health setting, each 15 minutes Services of skilled nurse in home health 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 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) for the observation and assessment of the patient's condition, each 15 minutes (the change in the patient's condition requires skilled nursing personnel Page 7
HCPCS Code G0164 G0179 G0180 G0181 Description 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 (LPN or RN), in the training and/or education of a patient or family member, in the home health or hospice setting, each 15 minutes Phys re-cert mcr-covr hom hlth srvc re-cert prd Phys cert mcr-covr hom hlth srvc per cert prd Phys supv pt recv mcr-covr srvc hom hlth agcy *Specific diagnosis coding does not apply to this policy IX. REFERENCES Centers for Medicare & Medicaid Services. Publication 100-2. Medicare Benefit Policy Manual. Rev. 37, 08-12-05. Chapter 7- Home Health Services [Website]: http://www.cms.hhs.gov/manuals/downloads/bp102c07.pdf. Accessed November 24, 2014. Kelly M, Penney E. Collaboration of hospital case managers and home care liaisons when transitioning patients. Professional Case Management [serial online]. May 2011; 16(3):128-138. Madigan EA, Curet OL. A data mining approach in home healthcare: outcomes and service use. BMC Health Serv Res 2006; 4; 6:18. Mattke S, Klautzer L, Mengistu T, et al. Health and well-being in the home. RAND Corporation Occasional Paper. 2010. [Website]: http://www.rand.org/pubs/occasional_papers/op323.html. Accessed November 24, 2014. Mosby's Medical, Nursing and Allied Health Dictionary, 6 th edition. Taber's Cyclopedic Medical Dictionary, 20 th edition. The Joint Commission, Home The Best Place for Health Care. 2011. [Website]: www.jointcommission.org/assets/1/18/home_care_position_paper_4_5_11.pdf Accessed November 24, 2014. Vasquez MS. Preventing Rehospitalization through effective home health nursing care. Prof Case Manag. 2009 Jan-Feb; 14(1):32-8. X. POLICY HISTORY MP 3.002 CAC 5/25/04 CAC 8/31/04 CAC 6/27/06 CAC 9/26/06 Page 8
CAC 2/27/07 CAC 1/29/08 Consensus CAC 1/27/09 Consensus CAC 9/29/09 Policy statement revised to include nursing visits for the sole purpose of venipuncture to obtain a blood sample medically necessary when the member is homebound and no mobile lab services are available. Statement removed from exclusions section. References updated. CAC 9/28/10 Policy statement clarified regarding home health aide and medical social services. CAC 10/25/11 Consensus Review CAC 10/30/12 Consensus Review, no change to policy statements. References updated. Codes reviewed 10/18/12 KLR CAC 1/28/14 Minor. Added the section on skilled nursing services. Updated references. Deleted the following statement from list of indications when home care is considered no longer medically necessary The patient no longer demonstrates progress towards established goals. Codes reviewed. 1/27/15 Minor. Added services of a dietician to the list of non-covered services. References updated. Top Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company, Capital Advantage Assurance Company and Keystone Health Plan Central. Independent licensees of the BlueCross BlueShield Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies. Page 9