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Clinical Policy Bulletin:
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 to avoid placing the member at risk for serious complications; and 
  • The skilled behavioral health care is intermittent or hourly in nature*; 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 nature**. 

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

** 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.

 
CPT Codes / HCPCS Codes / ICD-9 Codes
Other CPT codes related to the CPB:
99341
99342
99343
99344
99345
99347
99348
99349
99350
Other HCPCS codes related to the CPB:
G0154 Direct skilled nursing services of a licensed nurse (LPN or RN) in the home health or hospice settings, each 15 minutes
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)
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-9 codes covered if selection criteria are met:
290.0 - 319 Mental disorders


The above policy is based on the following references:
  1. Burns T, Knapp M, Catty J, et al. Home treatment for mental health problems: A systematic review. Health Technol Assess. 2001;5(15):1-139.
  2. Zeltzer BB, Kohn R. Mental health services for homebound elders from home health nursing agencies and home care agencies. Psychiatr Serv. 2006;57(4):567-569.
  3. Malaysian Health Technology Assessment Unit (MHTAU). Home care nursing. Systematic review. Kuala Lumpur, Malaysia: Malaysian Health Technology Assessment Unit (MHTAU); 2001.
  4. Kohn R, Goldsmith E, Sedgwick TW. Treatment of homebound mentally ill elderly patients: The multidisciplinary psychiatric mobile team. Am J Geriatr Psychiatry. 2002;10(4):469-475.
  5. Farran CJ, Horton-Deutsch SL, Fiedler R, Scott C. Psychiatric home care for the elderly. Home Health Care Serv Q. 1997;16(1-2):77-92.
  6. Bruce ML, Van Citters AD, Bartels SJ. Evidence-based mental health services for home and community. Psychiatr Clin North Am. 2005;28(4):1039-1060.


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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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