Clinical Policy Bulletin: Home Behavioral Healthcare Services
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.
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:
Other HCPCS codes related to the CPB:
Direct skilled nursing services of a licensed nurse (LPN or RN) in the home health or hospice settings, each 15 minutes
Services of clinical social worker in home health or hospice settings, each 15 minutes
Training and educational services related to the care and treatment of patients disabling mental health problems per session (45 minutes or more)
Behavioral health screening to determine eligibility for admission to treatment program
Behavioral health counseling and therapy, per 15 minutes
Behavioral health outreach service (planned approach to reach a targeted population)
Mental health assessment, by non-physician
Mental health service plan development by non-physician
Community psychiatric supportive treatment, face-to-face, per 15 minutes
Community psychiatric supportive treatment program, per diem
Mental health services, not otherwise specified
Therapeutic behavioral services, per 15 minutes
Therapeutic behavioral services, per diem
Community-based wrap-around services, per 15 minutes
Community-based wrap-around services, per diem
Mental health clubhouse services, per 15 minutes
Mental health clubhouse services, per diem
Physician visit at member's home, outside of a capitation arrangement
Nurse practitioner visit at member's home, outside of a capitation arrangement
Social work visit, in the home, per diem
Family stabilization services, per 15 minutes
Crisis intervention mental health services, per hour
Crisis intervention mental health services, per diem
ICD-9 codes covered if selection criteria are met:
290.0 - 319
The above policy is based on the following references:
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.
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.
Malaysian Health Technology Assessment Unit (MHTAU). Home care nursing. Systematic review. Kuala Lumpur, Malaysia: Malaysian Health Technology Assessment Unit (MHTAU); 2001.
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.
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.
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.
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.