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 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:

  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.