Home Behavioral Healthcare Services

Number: 0730

Policy

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

• The services are ordered by a physician and are directly related to an active treatment plan of care established by the physician; and 
• The skilled behavioral health care is appropriate for the active treatment of a condition, illness or disease; and 
• The skilled behavioral health care is intermittent or hourly in natureFootnotes for Intermittent or part-time skilled home behavioral health care^*; and
• The services are provided in lieu of a continued hospitalization, confinement in a residential treatment facility (RTF), or receiving outpatient services outside of the home; and 
• The treatment provided is appropriate for the member's condition including the amount of time spent providing the service as well as the frequency, type and duration of the services; and 
• 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
• The behavioral health services provided are not primarily for the comfort or convenience of the member or custodial in natureFootnotes for Custodial care ^**. 

Footnotes for Intermittent or part-time skilled home behavioral health care ^* Intermittent or part-time skilled home behavioral health care is defined as a visit of up to 1 hour in duration.

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

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

Note: Skilled home behavioral healthcare services are covered under the member’s behavioral healthcare benefit.  Please check benefit plan descriptions.

See also CPB 0201 - Skilled Home Health Care Nursing Services.

Background

Skilled home behavioral health care is the provision of intermittent skilled services for treatment of behavioral disorders in the home.  These services are rendered in lieu of hospitalization, confinement in an extended care facility, or going outside of the home for the service.

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 "+":
Other CPT codes related to the CPB:
99341	Home visit for the evaluation and management of a new patient, which requires these three key components: - A problem focused history; - A problem focused examination; and - Straightforward medical decision making.
99342	Home visit for the evaluation and management of a new patient, which requires these three key components: - An expanded problem focused history; An expanded problem focused examination; and - Medical decision making of low complexity.
99343	Home visit for the evaluation and management of a new patient, which requires these three key components: - A detailed history; A detailed examination; and - Medical decision making of moderate complexity.
99344	Home visit for the evaluation and management of a new patient, which requires these three key components: - A comprehensive history; A comprehensive examination; and - Medical decision making of moderate complexity.
99345	Home visit for the evaluation and management of a new patient, which requires these three key components: - A comprehensive history; A comprehensive examination; and - Medical decision making of high complexity.
99347	Home visit for the evaluation and management of an established patient, which requires these three key components: - A problem focused interval history; - A problem focused examination; and - Straightforward medical decision making.
99348	Home visit for the evaluation and management of an established patient, which requires these three key components: - An expanded problem focused interval history; An expanded problem focused examination; and - Medical decision making of low complexity.
99349	Home visit for the evaluation and management of an established patient, which requires these three key components: - A detailed interval history; A detailed examination; and - Medical decision making of moderate complexity.
99350	Home visit for the evaluation and management of an established patient, which requires these three key components: - A detailed interval history; A detailed examination; and - Medical decision making of high complexity.
Other HCPCS codes related to the CPB:
G0155	Services of clinical social worker in home health or hospice settings, each 15 minutes
G0177	Training and educational services related to the care and treatment of patients disabling mental health problems per session (45 minutes or more)
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
H0002	Behavioral health screening to determine eligibility for admission to treatment program
H0004	Behavioral health counseling and therapy, per 15 minutes
H0023	Behavioral health outreach service (planned approach to reach a targeted population)
H0031	Mental health assessment, by non-physician
H0032	Mental health service plan development by non-physician
H0036	Community psychiatric supportive treatment, face-to-face, per 15 minutes
H0037	Community psychiatric supportive treatment program, per diem
H0046	Mental health services, not otherwise specified
H2019	Therapeutic behavioral services, per 15 minutes
H2020	Therapeutic behavioral services, per diem
H2021	Community-based wrap-around services, per 15 minutes
H2022	Community-based wrap-around services, per diem
H2030	Mental health clubhouse services, per 15 minutes
H2031	Mental health clubhouse services, per diem
S0273	Physician visit at member's home, outside of a capitation arrangement
S0274	Nurse practitioner visit at member's home, outside of a capitation arrangement
S9127	Social work visit, in the home, per diem
S9482	Family stabilization services, per 15 minutes
S9484	Crisis intervention mental health services, per hour
S9485	Crisis intervention mental health services, per diem
ICD-10 codes covered if selection criteria are met:
F01.50 - F99	Mental and behavioral disorders

The above policy is based on the following references: