Skilled Home Health Care Nursing Services

Number: 0201

Policy

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 footnote 1* or hourly footnote 2** basis; and
  3. The skilled nursing service is not custodial footnote 3*** 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.

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, physician assistant, or nurse practitioner and are directly related to an active treatment plan of care established by the provider; 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 footnote 1*; 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.

footnote 1* Intermittent or part time skilled home care nursing is defined as a visit of up to 4 hours in duration.

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

footnote 3*** 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).

Custodial care can be prescribed by a physician or given by trained medical personnel. It may involve artificial methods such as feeding tubes, ventilators or catheters. Examples of custodial care include:

  • Routine patient care such as changing dressings, periodic turning and positioning in bed, administering oral medications;
  • Care of a stable tracheostomy (including intermittent suctioning);
  • Care of a stable colostomy/ileostomy;
  • Care of stable gastrostomy/jejunostomy/nasogastric tube (intermittent or continuous) feedings;
  • Care of a stable indwelling bladder catheter (including emptying/changing containers and clamping tubing);
  • Watching or protecting a member (examples include but not limited to pulse oximetry monitoring, monitoring of respiratory status, and seizure monitoring and observation in a person who is stable without cardiorespiratory compromise);
  • Respite care, adult (or child) day care, or convalescent care;
  • Institutional care, including room and board for rest cures, adult day care and convalescent care;
  • Help with the daily living activities, such as walking, grooming, bathing, dressing, getting in or out of bed, toileting, eating or preparing foods;
  • Any services that a person without medical or paramedical training could be trained to perform; and
  • Any service that can be performed by a person without any medical or paramedical training.

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.

Coverage of skilled home health care nursing services are limited to persons who are homebound. CMS guidelines state the following:

Any absence of an individual from the home attributable to the need to receive health care treatment, including regular absences for the purpose of participating in therapeutic, 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 in the State shall not disqualify an individual from being considered to be confined to his home. Any other absence of an individual from the home shall not so disqualify an individual if the absence is of infrequent or of relatively short duration. For purposes of the preceding sentence, any absence for the purpose of attending a religious service shall be deemed to be an absence of infrequent or short duration.

Table: CPT Codes / HCPCS Codes / ICD-10 Codes
Code Code Description

Information in the [brackets] below has been added for clarification purposes.   Codes requiring a 7th character are represented by "+":

CPT codes covered if selection criteria are met:

99500 Home visit for prenatal monitoring and assessment to include fetal heart rate, non-stress test, uterine monitoring, and gestational diabetes monitoring
99501 Home 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 cystostomy
99506 Home 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 administration
99512 Home visit for hemodialysis

Other CPT codes related to the CPB:

99509 Home visit for assistance with activities of daily living and personal care
99510 Home visit for individual, family, or marriage counseling

HCPCS codes covered if selection criteria are met:

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)
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 license practical nurse (LPN) in the home health or hospice setting, each 15 minutes
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
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
S5100 - S5105 Day care services
S5120 - S5121 Chore services
S5125- - S5126 Attendant care services
S5130 - S5131 Homemaker service
S5135 - S5136 Companion care, adult
S5140 - S5141 Foster care, adult
S5150 - S5151 Unskilled respite care
S5170 Home delivered meals, including preparation; per meal
S5175 Laundry service, external, professional; per order
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. American Medical Association, Council on Scientific Affairs. Home care in the 1990s. JAMA. 1990;263(9):1241-1244.
  2. Bernstein LH, et al. Primary Care in the Home. New York, NY: J.B. Lippincott Company; 1987.
  3. Birmingham J. Understanding the Medicare "Extended Care Benefit" a.k.a. the 3-midnight rule. Prof Case Manag. 2008;13(1):7-16.
  4. 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.
  5. Corkery E. Discharge planning and home health care: What every staff nurse should know. Orthopaed Nurs. 1989;8(6):18-27.
  6. Kadushin G. Home health care utilization: A review of the research for social work. Health Soc Work. 2004;29(3):219-244.
  7. Maguire GH, ed. Care of the Elderly: A Health Team Approach. Boston, MA: Little, Brown and Co.; 1985.
  8. Martinson IM, et al. Home Health Care Nursing. Philadelphia, PA: W.B. Saunders Co.; 1989.
  9. 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.
  10. Olson HH. Home health nursing. Caring. 1986;Aug:53-61.
  11. Stein J. Medicare and long-term care. Issue Brief Cent Medicare Educ. 2003;4(4):1-6.
  12. Suddarth DS. Lippincott Manual of Nursing Practice. Philadelphia, PA: J.B. Lippincott Co.; 1991.
  13. 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.
  14. 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.