Return to Billing & Payment Policies

 

Professional Services -

Home Health Services

Home nursing services includes attendant care, home health, home infusion and hospice. All of these services require prior authorization. The insurer will only pay for services specifically authorized. Services and supplies must be proper and necessary because of physical restrictions caused by the industrial injury or disease.

ATTENDANT CARE SERVICES

Attendant care services provide assistance in the home for personal care and activities of daily living. Attendant care services must be provided by an agency that is licensed, certified or registered to provide home health or home care services. Attendant care agencies must have RN supervision of care givers providing care to a worker. In addition to prior authorization attendant care agencies must obtain a provider account number and bill with the appropriate code(s) in order to be reimbursed for services. RN supervision services are not paid separately and are included in the hourly fee as business overhead. Attendants for workers may be:

• Registered aides
• Certified nurse‘s aides
• Licensed practical nurses
• Registered nurses

The agency providing services must be able to provide the type of attendant and supervision necessary to address the workers medical and safety needs. Agency services can be terminated if the agency cannot provide the necessary care. The agency cannot bill for more than 12 hours per day for any one caregiver. The agency cannot bill for care during the time
the caregiver is sleeping.

All RN evaluation reports must be submitted to the insurer within 15 days of the initial evaluation and then annually or when the worker‘s condition changes and necessitates a new evaluation. The insurer will notify the provider in writing if current approved hours are modified or changed. Refer to WAC 296-20-091 and WAC 296-23-246 for additional information.

The insurer will determine the maximum hours and type of authorized attendant care based on the nursing assessment of the worker‘s personal care needs that are proper and necessary and related to the worker‘s industrial injury. Personal care may include but is not limited to:

• Administration of medication
• Bathing
• Personal hygiene and skin care
• Bowel and bladder incontinence
• Feeding assistance
• Mobility assistance
• Turning and positioning,
• Transfers or walking
• Supervision due to cognitive impairment, behavior or blindness.
• Range of motion exercises
• Ostomy care

Attendant care services may be terminated or not authorized if:

• Behavior of worker or others at the place of residence is threatening or abusive,
• Worker is engaged in criminal or illegal activities,
• Worker does not have the cognitive ability to supervise attendant and there is no adult family member or guardian available to supervise the attendant,
• Residence is unsafe or unsanitary and places attendant at risk.

Attendant Service Codes

Code	Description	Fee
S9122	Attendant in the home provided by a certified or registered aide per hour	$26.01
S9123	Attendant in the home provided by a registered nurse per hour	$56.57
S9124	Attendant in the home provided by licensed practical nurse per hour	$41.29

Bundled Codes and DME

Attendant care agencies may bill for wound care and medical treatment supplies. Covered HCPCS codes which are listed as bundled in the fee schedule are separately payable to home attendant care service providers for supplies used in the worker‘s home.

Attendant care agencies may bill HCPCS code S8301 for infection control supplies when caregivers are providing care to a worker with an infectious wound. Prior authorization and prescription from the treating physician is required. An invoice for the supplies must be submitted with the bill.

Noncovered Services

Social work and chore services are not covered, except as part of home hospice care. Chore services and other services that are only needed to meet the worker‘s environmental needs are not covered. The following services are examples of chore services.

• Childcare
• Laundry and other housekeeping activities
• Meal planning and preparation
• Other everyday environmental needs unrelated to the medical care of the worker
• Recreational activities
• Shopping and errands for the worker
• Transportation of the worker
• Yard work
• Work associated activities

Workers must not be left unattended during approved service hours. Attendant care providers may not bill for services the attendant performs in the home while the worker is away from the home. Attendant care services will not be covered when a worker is in the hospital or a nursing facility unless the worker‘s industrial injury causes a special need that the hospital or nursing facility cannot provide and is specifically authorized. The agency can bill workers for hours not approved by the insurer if the worker is notified in advance they are responsible for payment.

Spouse Attendant Care

Spouses who are not employed by an agency, who provided insurer approved attendant services to their spouse prior to October 1, 2001 and who met criteria in the year 2002 may continue to bill for spouse attendant care. Spouses are limited to 70 hours per week. Spouse attendant will not be paid during sleeping time. Exemptions from this limit will be made based on insurer review. The insurer will determine the maximum hours of approved attendant care based on an independent nurse evaluation which will be performed yearly. If the worker requires more than 70 hours per week of attendant care the insurer can approve a qualified agency to provide the additional hours of care. The insurer will determine the maximum amount of additional care based on an RN evaluation.

Spouse Attendant Code

Code	Description	Fee
8901H	Spouse attendant in the home per hour	$12.78

Travel Not Related To Medical Care

Workers, who qualify for attendant care and are planning a long distance trip, must inform the insurer of the plans and request specific authorization for coverage during the trip. The insurer will not cover travel expenses of the attendant or additional care hours. The worker must coordinate the trip with the appropriate attendant care agencies. Mileage, parking or other travel expenses when transporting a worker are the responsibility of the worker.

Temporary or Respite Attendant Care

The insurer can approve short term agency attendant care services for workers who qualify for attendant care and who have a spouse attendant or a non-paid care giver who is temporarily unable to provide the worker‘s care. The insurer will determine the maximum hours of authorized care and type of care based on the RN evaluation. Temporary or respite care requires prior authorization. The agency providing the care must meet the criteria for L&I approval as a provider. If a qualified attendant care agency cannot be found to provide care in the home, the worker can be approved to stay in a residential care facility.

The insurer will notify the provider in writing if current approved hours are modified or changed. Spouses will not be paid for respite care.

Nursing Evaluations

Independent nursing evaluation, when requested by the insurer, may be billed under Nurse Case Manager or Home Health Agency RN codes, using their respective codes.

HOSPICE SERVICES

In-home hospice services must be preauthorized and may include chore services. The following code applies to in-home hospice care:

Code	Description	Fee
Q5001	Hospice care, in the home, per diem	By report

For hospice services performed in a facility, please refer to Nursing Home, Residential and Hospice Care Services in the Facility Section.

HOME HEALTH SERVICES

The insurer will pay for aide, RN, physical therapy, occupational therapy and speech therapy services provided by a licensed home health agency when services become proper and necessary to treat a worker‘s accepted condition. Home health services require prior authorization. Home health services are for intermittent or short term treatment or therapy for a medical condition. Home health services must be requested by a physician. Services require an initial evaluation by the RN or therapist and a written report must be submitted to the insurer within 15 days of the evaluation.

Payment for continued treatment will require documentation of the worker‘s needs and progress and renewed authorization at the end of an approved treatment period. The worker is expected to be present and ready for the home health nurse or therapist and non-cooperation can result in termination of services. Home health services may be terminated or denied when the worker‘s medical condition and situation allows for outpatient treatment.

Documentation

Home nursing care providers must submit the initial assessment, attending provider‘s treatment plan and /or orders and home care treatment plan within 15 days of beginning the service. Updated plans must be submitted every 30 days thereafter.

Home Health Codes

Code	Description	Fee
G0151	Services of Physical Therapist in the home. 15 min. units. Maximum of 4 units per day.	$37.32
G0152	Services of Occupational Therapist in the home. 15 min units. Maximum of 4 units per day.	$38.69
G0153	Services of Speech Therapist in the home. 15 min units. Maximum of 4 units per day.	$38.69
G0154	Services of skilled nurse RN/LPN in the home 15 min unit.	$38.69
G0156	Services of home health aide in the home 15 min unit. Maximum of 8 units per day	$6.50

Bundled Codes and DME

Home health and home infusion services may bill appropriate HCPCS codes for wound care and medical treatment supplies. Covered HCPCS codes listed as bundled in the fee schedule are separately payable to home health and home care providers for supplies used during the home health visit. See WAC 296-20-01002 for the definition of bundled services. Durable medical equipment may require specific authorization prior to purchase.

HOME INFUSION SERVICES

Home infusion services provide drug administration, parenteral hydration, and parenteral feeding to a worker in the home. Skilled nurses contracted by the home infusion service provide education of the worker and family, evaluation and management of the infusion therapy, and care for the infusion site. Home infusion skilled nurse services will only be authorized when infusion therapy is approved as treatment for the worker‘s allowed industrial condition. Prior authorization is required for home infusion nurse services, drugs and any supplies regardless of who is providing services Home infusion services can be authorized independently or in conjunction with home health services.

Infusion therapy drugs, including injectable drugs, are payable only to pharmacies. Drugs must be authorized and billed with National Drug Code (NDC) codes or Universal Product Code (UPC) codes if no NDC codes are available.

The rental or purchase of infusion pumps must be billed with the appropriate HCPCS codes.
See WAC 296-20-1102 for additional information.

NOTE: Home health agencies must have prior authorization and use the RN G0154 visit code when administering home injections or nutritional parenteral solutions only.

Medical Supply companies and home infusion pharmacies may use the appropriate HCPCS code to bill for parenteral solutions, (TPN), or enteral formula nutrition with prior authorization. Home infusion codes may be billed for initial establishment of nutritional therapy for the worker when services have been authorized.

Home Infusion Codes

Code	Description	Fee
99601	Skilled RN visit for infusion therapy in the home. First 2 hours per visit.	$149.32
99602	Skilled RN visit for each additional hour per visit.	$62.79