UTILIZATION MANAGEMENT GUIDELINE

POLICY
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POLICY GUIDELINES
DESCRIPTION
SCOPE
BENEFIT APPLICATION
RATIONALE
REFERENCES
CODING
APPENDIX
HISTORY

Skilled Home Health Care Services

Number 11.01.508*

Effective Date December 22, 2014

Revision Date(s) 12/22/14; 05/02/14; 04/14/14; 07/08/13; 09/11/12; 12/13/11; 02/09/10; 02/10/09; 06/10/08; 07/10/07; 07/11/06; 07/12/05; 07/13/04; 12/10/02; 09/21/00; 07/25; 11/02/99

Replaces N/A

*Medicare has a policy.

Policy

Skilled medical care in the home setting may be considered medically necessary when ALL of the following criteria are met:

  • The patient must be confined to the home also called homebound. (e.g. This means the patient’s physical condition makes it difficult to complete activities of daily living (ADLs) including getting in/out of their home without help from at least one other person, in most cases). (See Policy Guidelines – Definition of Terms)
  • The patient’s condition and care needs must meet skilled care criteria.(See Policy Guidelines)
  • Skilled home health care services are required for the patient to regain or partially regain a basic level of function for ADLs.
  • Skilled home health care services of one discipline or agency may not duplicate those provided by another.
  • Skilled home health care services must be ordered by a physician/clinician and directly related to an active treatment plan of care established by the home health care agency in collaboration with the physician/clinician.

Non-skilled care in the home setting may be considered not medically necessary. (See Policy Guidelines)

Maintenance therapy programs in the home setting are not covered. (See Policy Guidelines)

Related Policies

8.03.502

Physical Medicine and Rehabilitation – Physical Therapy and Medical Massage Therapy

8.03.503

Occupational Therapy

8.03.505

Speech Therapy

11.01.501

Inpatient Rehabilitation (IPR) Care: Guideline for Admission and Transition of Care

Policy Guidelines

The term skilled home health care, which is intermittent skilled medical care with a specified frequency and duration, is often used to separate it from non-medical care, custodial care, companion/caregiver care or private duty care which is usually hourly, long-term and may not be covered by health plan benefits.

Skilled medical home care is provided in two ways:

  1. Skilled home health care is provided by personnel from a licensed home health agency and may include but is not limited to, intermittent services by a registered nurse (RN), licensed practical nurse (LPN), home health aide (HHA), certified nursing assistant (CNA), physical therapist (PT), occupational therapist (OT), speech therapist (ST), and medical social worker(MSW).
  2. Private Duty Nursing for hourly care may be provided under an individual contract between the nurse and patient/family or through an agency. Private Duty Nursing for hourly care includes RN and LPN services only.

    Note:
    Private duty nursing may not be covered by health plan benefits.

Skilled Nursing, Medical Social Work and Rehabilitation Services in the Home

Skilled Nursing Services in the Home

Skilled nursing care is provided in the home setting by a registered nurse (RN) or Licensed Practical Nurse (LPN).

The care must require the technical proficiency, scientific skills, and knowledge of an RN or LPN.

Criteria for skilled nursing services in the home setting are:

  • The need for skilled nursing is determined by the condition of the patient, the nature of the services required and the complexity or technical aspects of the services provided. Nursing care is not skilled simply because an RN or LPN delivers it or because a physician orders it.
  • The following treatments, procedures, or services require the skills and technical expertise of an RN or LPN and home visits to provide them may be considered medically necessary. The patient must require at least one of the following to qualify for home skilled nursing visits. In conjunction with delivering these services, the nurse is expected to provide teaching and training to the patient, available family members and/or caregiver(s). The goal of this teaching is to facilitate participation in and/or assumption of the patient’s care.
  • Skilled supervision and management is required due to a high probability, as opposed to a possibility, that complications would arise without oversight of the treatment program by a licensed nurse.
  • Skilled observation, assessment, and monitoring of the patient are required due to a complicated condition.
  • Teaching
  • The activity or procedure being taught may or may not be skilled; the teaching is the skilled service.
  • Documentation must state the reason why teaching was not completed in the prior treatment setting, if any, and the patient’s capability to understand and be compliant.
  • Visit frequency depends on the complexity of the procedure being taught and the learning ability of the caregiver and/or patient.
  • In general, up to three visits for teaching may be medically necessary. If more than three visits are needed, there must be documentation of learning barriers or unusual circumstances.
  • Once a procedure is mastered by the patient and/or caregiver, further visits to reiterate previous teaching are considered not medically necessary.
  • If a caregiver changes, additional visits may be medically necessary for the purpose of training the new caregiver.
  • Catheter care may be medically necessary for the following services:
  • Insertion of urinary catheters, visit frequency should be every 3-6 weeks unless unusual circumstances are documented.
  • Irrigation of indwelling catheters.
  • Straight catheterization for residual, or to obtain a specimen for a urinary analysis (UA). Ongoing intermittent straight catheterization would be considered non-skilled.
  • Teaching of catheter care
  • Catheter removal
  • Feeding tubes (nasogastric, jejunostomy, gastrostomy) may be medically necessary for the following services:
  • Feeding tube insertion
  • Feeding tube irrigation, depending on the severity of the patient’s condition
  • Teaching feeding tube management and care
  • Non-routine subcutaneous (SQ), intramuscular (IM), or intravenous (IV) medication administration may be medically necessary if the drug is the appropriate treatment for the condition and there is a medical reason for not administering the oral form of the drug if one is available. Teaching subcutaneous administration management should be accomplished in 1 to 3 visits.
  • Complex medication management
  • Home visits may be medically necessary for management of a complex range of newly prescribed medications (including oral) where there is a high probability of adverse reactions and/or a change in the dosage or type of medication. Up to 3 visits may be necessary unless the patient’s condition changes and a new treatment plan must be made.
  • Wound care may be medically necessary when the following criteria are met:
  • Extensive wound care is needed (i.e., packing, debridement, irrigation, using sterile technique)
  • Occasional nursing visits for assessment of wound healing may be necessary in complicated cases (e.g., diabetics). Visits solely for observation in uncomplicated cases that do not include extensive wound care are not considered medically necessary.
  • Stoma dilation for colostomy care
  • Manual removal of a fecal impaction
  • Blood draws if portable lab service is not available
  • Ventilator or continuous positive airway pressure (CPAP) monitoring for respiratory insufficiency in the home is considered medically necessary when all the following criteria are met:
  • For patients on a ventilator up to 24 hours per day for up to three weeks upon initial discharge from an inpatient setting as a transition to home may be medically necessary. Thereafter up to 16 hours of home nursing care per day is considered medically necessary.
  • If 24 hours per day of nursing care is being requested for an indefinite period of time, skilled nursing facility (SNF) placement should be considered. If a SNF bed is not available, home nursing care for up to 24 hours may be medically necessary until a SNF bed is available.

Skilled Medical Social Worker Services in the Home

Skilled medical social workers’ (MSW) interventions provided in the home may be indicated to assist with acute emotional issues, short-term and/or long-term planning arrangements and referrals to community services. The MSW must be working in conjunction with the skilled RN or rehabilitation therapist. MSW interventions should be completed in 1-2 visits.

Criteria for skilled medical social worker services in the home are:

  • The patient/family has social and/or emotional factors that impact their response to treatment and assistance with coping skills (crisis intervention) is needed in order to adjust to the change in health status; or
  • The patient/family needs help finding community resources (e.g. financial assistance for medications, transportation, food/housing, setting up Durable Power of Attorney/Health Care Proxy, SSI application); or
  • There are barriers to care (e.g. patient lacks an external support system; known or suspected substance abuse or chemical dependency; known or suspected physical/mental abuse)

Note: An MSW cannot be the only skilled service provided in the home.

Skilled Rehabilitation Services in the Home

Skilled physical/occupational/speech therapy services in the home setting may be needed to help a patient regain or partially regain a prior level of function. The therapy services are addressed in separate medical policies. (See Related Policies).

An essential factor when considering home based health care is the availability of willing and able family members or other people who can participate in direct care of the patient. If family or other sources of care are not available or are not willing to assume significant caregiver duties after a reasonable period of training, home based health care should not be considered for the member. In these cases the member or family should be informed about and guided to appropriate facilities for the level of care needed by the patient.

Non-Skilled Services in the Home

Examples of non-skilled services include but are not limited to:

  • Administration and/or set up of oral medications
  • Administration of oxygen, IPPB treatments and nebulizer treatments
  • Administration of suppositories and/or enema
  • Application of eye drops or ointments or topical medications
  • Custodial care: activities of daily living that can be provided by non-medical people for example help in bathing, eating, dressing, and preventing a person from self-harm
  • Heat treatments such as whirlpool, paraffin baths and heat lamps that can be self-administered
  • Home health aides and supervisory visits for observation of home health aides
  • Ongoing intermittent straight catheterization for chronic conditions
  • Preparation of plans, records, or programs involved in care is considered an administrative function and not direct patient care.
  • Routine administration of maintenance medications including insulin. This applies to oral (PO), subcutaneous (SQ), intramuscular (IM) and intravenous (IV) medications
  • Routine colostomy care
  • Routine enteral feedings
  • Routine foot and nail care
  • Routine services directed toward the prevention of injury or illness
  • Simple dressing changes
  • Suctioning of the nasopharynx
  • Visits for administrative purposes only, such as recertification assessments

NOTE: Documentation of extraordinary comorbidities and complications may require review and consideration on a case-by-case basis for some of the non-skilled care listed above.

Definition of Terms

  • Activities of Daily Living (ADLs) - are self-care activities within a member’s place of residence that include dressing/bathing, eating, ambulating (walking), toileting, grooming and hygiene.
  • Homebound/Confined to Home - means a physician must certify that the member is confined to home. A member may be considered homebound if:
  • Their medical condition restricts the ability to leave their place of residence (except with the aid of supportive devices such as wheelchairs and walkers, the use of special transportation, and/or the assistance of another person); or
  • Leaving the home would require a taxing effort; or
  • Leaving home is medically contraindicated.
  • A member confined to home may leave the home for medical treatment such as chemotherapy
  • Homebound status may be applied to members with compromised immune status or who are in such poor health that reverse isolation precautions are recommended by their providers to avoid exposure to infection(s).
  • Examples of a poor resistance to disease may include but are not limited to:
  • Premature infants, or
  • Patients undergoing chemotherapy, or
  • Patients with a chronic disease that has lowered their immune status.
  • Homebound status applies to those members that require assistance when performing activities of daily living.

Note: Homebound status is not determined by the lack of available transportation or inability to drive.

  • Home health care - Includes skilled nursing, rehab and other therapies provided through a licensed home health agency. Home health care is intermittent or part-time skilled health care in a member’s place of residence.
  • Maintenance Program - Consists of activities that preserve the patient’s present level of function and prevent regression of that function. Maintenance begins when the therapeutic goals of a treatment plan have been achieved or when no further functional progress is apparent or expected to occur. This may apply to patients with chronic and stable conditions where skilled supervision is no longer required and clinical improvement is not expected.
  • Non-Skilled Services - Are services that could be done safely by the patient or a non-medical person without the supervision of a skilled nurse or therapist.

Description

Skilled medical services in the home setting may be medically necessary for the treatment of an illness, disease, condition or bodily injury for restoration of function and health. The skilled services are intermittent (part-time) and provided in place of a hospital or nursing home confinement or leaving the home for the skilled care.

Facility based treatment may be shortened and the transition to home made more safe and effective by providing medically necessary care in the home when it has been determined that the condition is medically stable but specific interventions are required to maintain that status and support continued improvement. This is short term, episodic care.

Examples of cases in this category are post-surgical delay or complication of wound healing, newly instituted regimes of care that require self-injected medications, new conditions that require training for self-care such as management of colostomy or ileostomy care, transition to home for members with motor impairments such as stroke or fractures that limit mobility or more severe limitation situations.

The goal of skilled home care is help the member/family reach a level of independence with medical treatments/therapy or home exercise programs so the skilled home visits can decrease then stop. When a member is assessed for home care services, a plan of care needs to be developed that clearly defines the anticipated time to achieve goals for improving functional ability either by the patient, or the caregiver and when home nursing care will cease.

Some medical conditions create the need for observation with possible need for intervention if self-care is compromised by the inability to perform critical functions. This may require long term care and benefits may not be available depending on the individual patient’s clinical needs.

Some examples of this category are:

  • Communication is severely impaired or non-existent
  • Management of secretions is severely impaired or non-existent
  • Nutritional needs must be managed by alternative methods
  • Voluntary movement is severely impaired or non-existent

NOTE: Other skilled services that may occur in the home setting are addressed in separate medical policies. (See Related Policies).

Scope

Medical policies are systematically developed guidelines that serve as a resource for Company staff when determining coverage for specific medical procedures, drugs or devices. Coverage for medical services is subject to the limits and conditions of the member benefit plan. Members and their providers should consult the member benefit booklet or contact a customer service representative to determine whether there are any benefit limitations. This medical policy does not apply to Medicare Advantage.

Benefit Application

Coverage for skilled medical care in the home is based on the member’s health plan contract benefits and medical necessity when criteria in this medical policy are met. In some plans, the available home health care benefit is defined by a specific number of skilled visits covered per year regardless of the member’s condition or number of visits/course of therapy ordered by the primary health care provider.

Private Duty Nursing is available in a limited number of contracts but may be used as an alternative to institutional care under the provisions of some member contracts.

The level of care is one element in the determination of availability of contract benefits. The criteria in the member’s contract for Rehabilitation and Home Health Care needs to be reviewed when making determinations regarding coverage. All member contracts describe Skilled Care as the level of care that is needed for benefits to be available. In addition to that requirement, it may be necessary to meet other criteria in order for benefits to be available.

Washington

Effective January 1, 1995, Washington state has a specific Washington Administrative Code (WAC 284-44-500) that mandates benefit coverage for alternative care that includes substitution of home health care, provided in lieu of hospitalization/institutionalization for Washington state residents. State specific information about the administrative criteria can be found at the source URL: http://apps.leg.wa.gov/WAC/default.aspx?cite=284-44-500. Last accessed November, 2014.

Rationale

N/A

References

  1. Centers for Medicare and Medicaid Services (CMS). Medicare Benefit Policy Manual. Chapter 7 Home Health Services – Section 40.1.1 Skilled Nursing Care [electronic version]. Source URL: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c07.pdf. Accessed November, 2014.
  2. Centers for Medicare and Medicaid Services (CMS). Medicare Benefit Policy Manual. Chapter 7 Home Health Services – Section 50.3 Medical Social Services [electronic version]. Source URL: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c07.pdf. Accessed November, 2014.
  3. Centers for Medicare and Medicaid Services (CMS). Medicare Benefit Policy Manual. Chapter 7 Home Health Services – Section 40.2 Skilled Therapy Services [electronic version]. Source URL: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c07.pdf. Accessed November, 2014.
  4. Centers for Medicare and Medicaid Services (CMS). National Coverage Determination. Home nurses' visits to patients requiring heparin injection. NCD #290.2 [electronic version]. Source URL: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=210&ncdver=1&DocID=290.2&bc=gAAAAAgAAAAA&. Accessed November, 2014.

Coding

Codes

Number

Description

CPT

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)

 

99509

Home visit for assistance with activities of daily living and personal care

 

99510

Home visit for individual, family, or marriage counseling

 

99511

Home visit for fecal impaction management and enema administration

 

99512

Home visit for hemodialysis

 

99600

Unlisted home visit service or procedure

HCPCS

G0154

Direct skilled nursing services of a licensed nurse (LPN or RN) 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

by licensed practical nurse, per hour

Type of Service

Skilled Nursing

PT,OT,ST,MSW

 

Place of Service

Home

 

Appendix

N/A

History

Date

Reason

11/02/99

Add to Administrative Section - New Policy

07/25/00

Replace Policy - Proposed Care Management Guidelines/Medical Care Guidelines document addressing Hourly Skilled Nursing Care

09/21/02

Replace Policy - Additional clarification to wording provided by CTCA. No criteria changes.

12/10/02

Replace Policy - Scheduled review; no criteria changes.

07/13/04

Replace Policy - Scheduled review; no criteria changes; new review date only.

09/01/04

Replace Policy - Policy Renumbered from PR.10.01.500. No date changes.

07/12/05

Replace Policy - Policy re-written for ease of understanding. Title changed from Skilled Care, Expanded Nursing Care, Non-Skilled Care, and Custodial Care.

07/11/06

Replace Policy - Policy reviewed; no change to policy statement; Scope and Disclaimer updated.

07/10/07

Replace Policy - Policy updated with literature review; no change in policy statement.

10/09/07

Cross References Updated - No other changes.

05/13/08

Cross References Updated - No other changes.

06/10/08

Replace Policy - Policy updated with literature search; no change in policy statement.

08/12/08

Cross Reference Update - No other changes.

02/10/09

Replace Policy - Policy updated with literature search. Policy statement updated, minor edits did not change the intent of statement.

07/14/09

Code update - All CPT codes added, no other changes.

02/09/10

Replace Policy - Policy updated with literature search; no change in policy statement.

12/13/11

Replace Policy – Policy updated. Removed reference to Interqual criteria.

09/11/12

Replace policy. Policy updated with literature search; no change in policy statement.

10/16/12

Update Related Policies – Add 11.01.501.

07/24/13

Replace policy. Policy statement clarified to state that coverage determination is based on applicable MCG & additional criteria in the policy. Minor edits & format changes for readability. Policy statement unchanged.

05/02/14

Annual Review. Policy review. Title changed to Skilled Home Health Care Services. Added non-skilled care as not medically necessary and maintenance therapy as not covered to the policy statements. Added criteria for MSW and Definition of Terms to the Policy Guidelines. Added Washington state WAC for Alternative Care to Benefit Application section. A literature review through March 2014 did not prompt the addition of new references. Policy statement changed as noted.

06/06/14

Coding update. HCPCS code G0154 added to the policy; this code is listed on the RMN with reference to this policy. Updating the policy to align.

12/22/14

Interim Update. Policy reclassified, renumbered from 10.01.500 to 11.01.508 and moved from Medical Policy to UM Guideline. Reference to using MCG as a tool to guide determinations is removed from policy statement. Policy reviewed, minor edits done for readability. Reference 2 removed; new references 2-4 added. Policy statement changed as noted.


Disclaimer: This medical policy is a guide in evaluating the medical necessity of a particular service or treatment. The Company adopts policies after careful review of published peer-reviewed scientific literature, national guidelines and local standards of practice. Since medical technology is constantly changing, the Company reserves the right to review and update policies as appropriate. Member contracts differ in their benefits. Always consult the member benefit booklet or contact a member service representative to determine coverage for a specific medical service or supply. CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA).
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