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Clinical Policy Bulletin:
Skilled Home Health Care Nursing Services
Number: 0201


Policy

  1. Skilled nursing care consists of those services that must be performed by a registered nurse or licensed practical (vocational) nurse, and meet all of the following criteria for skilled nursing services:

    1. Pursuant to physician orders, the service(s) is so inherently complex that it can be safely and effectively performed only by, or under the supervision of, a licensed nurse to achieve the medically desired result; and
    2. The skilled nursing care must be provided on an intermittent* or hourly** basis; and
    3. The skilled nursing service is not custodial*** in nature; and
    4. The skilled nursing service(s) must be reasonable and necessary for the treatment of the illness or injury, that is, the services must be consistent with the unique nature and severity of the member's illness or injury, his or her particular medical needs, and accepted standards of medical and nursing practice, without regard to whether the illness or injury is acute, chronic, terminal, or expected to last a long time.
  2. Skilled home health nursing care is the provision of intermittent skilled services to a member in the home for the purpose of restoring and maintaining his or her maximal level of function and health.  These services are rendered in lieu of hospitalization, confinement in an extended care facility, or going outside of the home for the service.

Subject to applicable benefit plan terms and limitations, Aetna considers skilled home health nursing services medically necessary when all of the following criteria are met:

  1. The member is homebound because of illness or injury (i.e., the member leaves home only with considerable and taxing effort and absences from home are infrequent, or of short duration, or to receive medical care); and
  2. The nursing services provided are not primarily for the comfort or convenience of the member or custodial in nature; and
  3. The services are ordered by a physician and are directly related to an active treatment plan of care established by the physician; and
  4. The services are provided in lieu of a continued hospitalization, confinement in a skilled nursing facility (SNF), or receiving outpatient services outside of the home; and
  5. The skilled nursing care is appropriate for the active treatment of a condition, illness, disease, or injury to avoid placing the member at risk for serious medical complications; and
  6. The skilled nursing care is intermittent or hourly in nature*; and
  7. The treatment provided is appropriate for the member's condition including the amount of time spent providing the service as well as the frequency and duration of the services.

* Intermittent or part time skilled home care nursing is defined as a visit of up to 4 hours in duration.

** Home health skilled nursing care is defined as a consecutive 4-hour period of time (i.e., an 8-hour shift equals 2 visits).

*** Custodial care is defined as services and supplies furnished to a person mainly to help him or her with activities of daily life.  Custodial care includes services and supplies:

  1. Furnished mainly to train or assist the insured family member in personal hygiene and other activities of daily living rather then to provide therapeutic treatment;
  2. That can be safely and adequately provided by persons without the technical skills of a health care provider (e.g., nurse).

Note: Benefit plan documents may include a more specific definition of custodial care that would supersede the general definition of custodial care provided in this CPB.  Please check benefit plan descriptions for details.

Notes:

This CPB does not pertain to home infusion services.  Home infusion services, including the related nursing service, are not considered to be part of the Home Health Care or Skilled Home Health Care Nursing Services benefit and do not accumulate toward any associated Home or Skilled Nursing benefit limits.

Under traditional (e.g., Managed Choice POS, PPO, and indemnity) plans and out-of-network care in QPOS plans, additional benefits for nursing services beyond those that are provided for under the home health care benefit (outlined above) may be available through the visiting or private duty nursing benefit.  Please check benefit plans for details.  See CPB 0136 - Skilled Home Private Duty Nursing Care for information on criteria and limitations for the visiting or private duty nursing benefit.



Background

Skilled nursing care is health care given when a person needs skilled nursing staff (registered nurse (RN) or licensed practical nurse (LPN)) to manage, observe, and evaluate care.  Skilled nursing care requires the involvement of skilled nursing staff in order to be given safely and effectively.  Care that can be given by non-professional staff is not considered skilled nursing care.  The goal of skilled nursing care is to help improve the patient's condition or to maintain the patient's condition and prevent it from getting worse.

Custodial care is care that helps persons with usual daily activities like walking, eating, or bathing.  It may also include care that most people do themselves, like using eye drops, oxygen, and taking care of colostomy or bladder catheters.

 
CPT Codes / HCPCS Codes / ICD-9 Codes
CPT codes covered if selection criteria are met:
99500
99501
99502
99503
99504
99505
99506
99507
99511
99512
Other CPT codes related to the CPB:
99509
99510
HCPCS codes covered if selection criteria are met:
G0154 Direct skilled nursing services of licensed nurse (LPN or RN) in the home health or hospice setting, each 15 minutes
G0162 Skilled services by a registered nurse (RN) in the delivery of management & 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 achieve its purpose in the home health or hospice setting)
G0163 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)
G0164 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
S9123 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)
S9124 Nursing care, in the home; by licensed practical nurse, per hour
S9474 Enterostomal therapy by a registered nurse certified in enterostomal therapy, per diem
T1000 Private duty/independent nursing service(s) - licensed, up to 15 minutes
T1001 Nursing assessment/evaluation
T1002 RN Services, up to 15 minutes
T1003 LPN/LVN services, up to 15 minutes
T1030 Nursing care, in the home, by registered nurse, per diem
T1031 Nursing care, in the home, by licensed practical nurse, per diem
HCPCS codes not covered for indications listed in the CPB:
S0320 Telephone calls by a registered nurse to a disease management program member for monitoring purposes, per month
T1019 Personal care services, per 15 minutes, not for an inpatient or resident of a hospital, nursing facility, ICF/MR or IMD, part of the individualized plan of treatment (code may not be used to identify services provided by a home health aide or certified nurse assistant)
T1020 Personal care services, per diem, not for an inpatient or resident of a hospital, nursing facility, ICF/MR or IMD, part of the individualized plan of treatment (code may not be used to identify services provided by a home health aide or certified nurse assistant)
Other HCPCS codes related to the CPB:
G0156 Services of a home health aide in home health setting, each 15 minutes
S5108 Home care training to home care client; per 15 minutes
S5109 Home care training to home care client; per session
S5110 Home care training, family; per 15 minutes
S5111 Home care training, family; per session
S5115 Home care training, nonfamily; per 15 minutes
S5116 Home care training, nonfamily; per session
S9098 Home visit, phototherapy services (e.g., Bili-lite) including equipment rental, nursing services, blood draw, supplies, and other services, per diem
S9122 Home health aide or certified nurse assistant, providing care in the home; per hour
T1004 Services of a qualified nursing aide, up to 15 minutes
T1021 Home health aide or certified nurse assistant, per visit


The above policy is based on the following references:
  1. U.S. Department of Health and Human Services, Health Care Financing Administration (HCFA). Skilled nursing care. Home Health Agency Manual §205.1. HCFA Pub. 11. Baltimore, MD: HCFA; 2000.
  2. Suddarth DS. Lippincott Manual of Nursing Practice. Philadelphia, PA: J.B. Lippincott Co.; 1991.
  3. Bernstein LH, et al. Primary Care in the Home. New York, NY: J.B. Lippincott Company; 1987.
  4. Corkery E. Discharge planning and home health care: What every staff nurse should know. Orthopaed Nurs. 1989;8(6):18-27.
  5. American Medical Association, Council on Scientific Affairs. Home care in the 1990s. JAMA. 1990;263(9):1241-1244.
  6. Maguire GH, ed. Care of the Elderly: A Health Team Approach. Boston, MA: Little, Brown and Co.; 1985.
  7. Martinson IM, et al. Home Health Care Nursing. Philadelphia, PA: W.B. Saunders Co.; 1989.
  8. Olson HH. Home health nursing. Caring. 1986;Aug:53-61.
  9. Cartier C. From home to hospital and back again: Economic restructuring, end of life, and the gendered problems of place-switching health services. Soc Sci Med. 2003;56(11):2289-2301.
  10. Stein J. Medicare and long-term care. Issue Brief Cent Medicare Educ. 2003;4(4):1-6.
  11. Kadushin G. Home health care utilization: A review of the research for social work. Health Soc Work. 2004;29(3):219-244.
  12. Office of the Secretary, Department of Defense. TRICARE; Sub-acute care program; Uniform skilled nursing facility benefit; Home health care benefit; Adopting Medicare payment methods for skilled nursing facilities and home health care providers. Final rule. Fed Regist. 2005;70(204):61368-61379.
  13. Vincent HK, Vincent KR. Functional and economic outcomes of cardiopulmonary patients: A preliminary comparison of the inpatient rehabilitation and skilled nursing facility environments. Am J Phys Med Rehabil. 2008;87(5):371-380.
  14. Birmingham J. Understanding the Medicare "Extended Care Benefit" a.k.a. the 3-midnight rule. Prof Case Manag. 2008;13(1):7-16.


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Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
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