Chapter 11: Home Health Services
Billing & Payment Policies for Healthcare Services provided to Injured Workers and Crime Victims
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Effective July 1, 2011 |
 Complete Chapter for printing (Republished February 1, 2012) |
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Table of contents
Payment policies:
Attendant care services
Home health services
Home infusion services
In-home hospice services
More info:
Related topics
Definitions
Attendant care services:
Attendant care services provide assistance in the home for personal care and activities of daily living. (See definition of personal care, below.)
Bundled:
A bundled procedure code isn’t payable separately because its value is accounted for and included in the payment for other services. Bundled codes are identified in the fee schedules.
Pharmacy and DME providers can bill HCPCS codes listed as bundled in the fee schedules. This is because, for these provider types, there isn’t an office visit or a procedure into which supplies can be bundled.
Link: For the legal definition of “bundled,” see WAC 296-20-01002 .
By report (BR):
A code listed in the fee schedule as “BR” doesn’t have an established fee because the service is too unusual, variable, or new. When billing for the code, the provider must provide a report that defines or describes the services or procedures. The insurer will determine an appropriate fee based on the report.
Link: For more information, see WAC 296-20-01002 .
Chore services: Examples of chore services include:
- Childcare, or
- Laundry and other housekeeping activities, or
- Meal planning and preparation, or
- Other everyday environmental needs unrelated to the medical care of the worker, or
- Recreational activities, or
- Shopping and running errands for the worker, or
- Transportation of the worker, or
- Yard work, or
- Work associated activities.
Home health services:
Home health services are for intermittent or short term treatment or therapy for a medical condition, and include attendant care, home health, home care, infusion therapy, and hospice.
Note: In this chapter, payment policies for “Attendant care services,” “Home infusion services,” and “In-home hospice services” are detailed in distinct payment policy sections.
Home infusion services:
Home health services provide drug administration, parenteral hydration, and parenteral feeding to a worker in the home.
Personal care:
Personal care may include, but isn’t limited to:
- Administration of medication, or
- Bathing, or
- Personal hygiene and skin care, or
- Bowel and bladder incontinence, or
- Feeding assistance, or
- Mobility assistance, or
- Turning and positioning, or
- Transfers or walking, or
- Supervision due to cognitive impairment, behavior, or blindness, or
- Range of motion exercises, or
- Ostomy care.
Payment policy: Attendant care services
(See definition of attendant care services in “Definitions” at the beginning of this chapter.)
Prior authorization
All attendant care
All attendant care services require prior authorization.
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.
Note: For a definition of personal care, see “Definitions” at the beginning of this chapter.
Attendant care services may be terminated or not authorized if:
- Behavior of worker or others at the place of residence is threatening or abusive, or
- Worker is engaged in criminal or illegal activities, or
- Worker doesn’t have the cognitive ability to supervise attendant and there isn’t an adult family member or guardian available to supervise the attendant, or
- Residence is unsafe or unsanitary and places the attendant or worker at risk, or
- Worker is left unattended during approved service hours by the approved provider.
The insurer will notify the provider in writing if current approved hours are modified or changed.
Wound care
When attendant care agencies are providing care to a worker with an infectious wound, prior authorization and prescription from the treating physician is required.
Worker travel
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.
Temporary or respite care
Temporary or respite care requires prior authorization. The agency providing respite care must meet L&I criteria as a provider of home health services.
The insurer can approve short term agency attendant care services for a spouse or family member who provides either paid or unpaid attendant care when respite (relief) is required.
Note: Spouses won’t be paid for respite care.
If a current nursing assessment isn’t available, a nursing evaluation will be conducted to determine the level of care and the maximum hours of service required. (Also see “Independent nurse evaluation reports” under “Services that can be billed,” below.)
If in-home attendant care can’t be arranged with an agency, the insurer can approve a temporary stay in a residential care facility.
The insurer will notify the agency in writing when services are approved.
The insurer will notify the provider in writing if current approved hours are modified or changed.
Who must perform these services to qualify for payment
Attendant care agency requirements
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 registered nurse (RN) supervision of caregivers providing care to a worker.
The agency providing services must be able to provide the type of attendant care and supervision necessary to address the worker’s medical and safety needs. Agency services can be terminated if the agency can’t provide the necessary care.
Attendant requirements
Workers must not be left unattended during approved service hours.
Attendants for workers may be:
- Registered aides, or
- Certified nurse’s aides, or
- Licensed practical nurses, or
- RNs.
Respite care
The agency providing respite care must meet L&I criteria as a provider of home health services.
Spouse attendant care
Spouses may continue to bill for spouse attendant care if they:
- Aren’t employed by an agency, and
- Provided insurer approved attendant services to the worker prior to October 1, 2001, and
- Met criteria in the year 2002.
Note: Also see “Payment limits” for spouse attendant care, below.
Link: For more information on laws about spouse attendant care, see WAC 296-23-246 .
Services that can be billed
Attendant services
| HCPCS code | Description | Max fee |
| S9122 | Attendant in the home provided by a home health aide certified or certified nurse assistant 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 |
Agency care services
The agency can bill workers for hours that aren’t approved by the insurer if the worker is notified in advance that they are responsible for payment.
Independent nurse evaluation reports
An independent nurse evaluation requested by the insurer, may be billed under “Nurse Case Manager” or “Home Health Agency RN” codes, using their respective codes. (See more information about these reports under “Requirements for billing,” below.)
Wound care and medical treatment supplies
Attendant care agencies may bill for wound care and medical treatment supplies.
Covered HCPCS codes listed as bundled in the fee schedule are separately payable to home attendant care service providers for supplies used in the worker’s home.
Note: See definition of bundled in “Definitions” at the beginning of this chapter.
Spouse attendant care
| HCPCS code | Description | Max fee |
| 8901H | Spouse attendant in the home per hour | $12.78 |
Services that aren’t covered
Chore services
Chore services and other services that are only needed to meet the worker’s environmental needs aren’t covered.
Social work and chore services aren’t covered, except as part of home hospice care.
Notes: See definition of chore services in “Definitions” at the beginning of this chapter.
Attendant care services in hospitals or nursing facilities
Attendant care services won’t 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 can’t provide, and
- Attendant care is authorized specifically to be provided in the hospital or nursing facility.
Travel that isn’t related to medical care
The insurer won’t cover travel expenses of the attendant or authorized additional care hours.
Mileage, parking, and other travel expenses of the attendant when transporting a worker are the responsibility of the worker.
(Also see “Requirements for billing,” below.)
Requirements for billing
Agency care services
In addition to prior authorization, attendant care agencies must obtain a provider account number and bill with the appropriate code(s) to be reimbursed for services.
Independent nurse evaluation reports
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.
Daily chart notes
Documentation to support daily billing must be submitted to the insurer and include:
- Begin and end time of each caregiver’s shift, and
- Name, initials, and title of each caregiver, and
- Specific care provided and who provided the care.
Wound care
In addition to prior authorization, when caregivers are providing wound care a prescription from the treating provider is required to bill for infection control supplies (HCPCS code S8301).
An invoice for the supplies must be submitted with the bill.
Travel that isn’t related to medical care
A worker who qualifies for attendant care and is planning a long distance trip, must inform the insurer of the plans and request specific authorization for coverage during the trip.
The worker must coordinate the trip with the appropriate attendant care agencies. (Also see “Services that aren’t covered,” above.)
Payment limits
Attendant services
RN supervision services aren’t paid separately and are included in the hourly fee as business overhead.
Attendant care providers can’t bill for services the attendant performs in the home while the worker is away from the home.
Agency care services
The agency can’t bill for more than 12 hours per day for any one caregiver.
The agency can’t bill for care during the time the caregiver is sleeping.
Spouse attendant care
Spouse attendants may bill up to 70 hours per week. Also:
- Exemptions to 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 must be performed yearly, and
- 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, and
- The insurer will determine the maximum amount of additional care based on an RN evaluation.
Spouse attendants won’t be paid during sleeping time.
Payment policy: Home health services
(See definition of home health services in “Definitions” at the beginning of this chapter.)
Links: For additional information on home health services, see WAC 296-20-03001 (8) and WAC 296-23-246 .
Prior authorization
Home health services
All home health services require prior authorization and must be requested by a physician. The insurer will only pay for proper and necessary services required to address physical restrictions caused by the industrial injury or disease.
When services become proper and necessary to treat a worker’s accepted condition, the insurer will pay for aide, RN, physical therapy (PT), occupational therapy (OT), and speech therapy services provided by a licensed home health agency.
Home health services may be terminated or denied when the worker’s medical condition and situation allows for outpatient treatment.
Durable medical equipment (DME)
Durable medical equipment may require specific authorization prior to purchase. 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.
Link: To see which codes require prior authorization, see the HCPCS fee schedule at http://feeschedules.Lni.wa.gov . Codes that require prior authorization are noted with a “Y” in the “Prior auth” column.
Note: See definition of bundled in “Definitions” at the beginning of this chapter.
Worker responsibilities
The worker is expected to be present and ready for the home health nurse or therapist treatment.
Noncooperation can result in termination of services.
Who must perform these services to qualify for payment
Aide, RN, physical therapy (PT), occupational therapy (OT), and speech therapy services must be provided by a licensed home health agency.
Services that can be billed
Home health services
| HCPCS code | Description and notes | Max 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 and Language Pathologist 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 units | $38.69 |
| G0156 | Services of home health aide in the home 15 min units. Maximum of 96 units per day | $6.50 |
| G0162 | Services of skilled nurse (RN) evaluation and management of the plan of care, 15 min units | $38.69 |
Wound care and medical treatment supplies
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.
Note: See definition of bundled in “Definitions” at the beginning of this chapter.
Requirements for billing
Documentation
The following documentation is required to be submitted by the home health care provider within 15 days of beginning the services:
- Attending provider’s treatment plan and/or orders by the attending provider,
- An initial evaluation by the RN or PT/OT, and
- A home care treatment plan.
Updated plans must be submitted every 30 days thereafter.
Providers must submit documentation to the insurer to support daily billing that includes:
- Begin and end time of each caregiver’s shift,
- Name, initials, and title of each caregiver,
- Specific care provided and who provided the care.
Continued treatment
Payment for continued treatment requires:
- Documentation of the worker’s needs and progress, and
- Renewed authorization at the end of an approved treatment period.
Payment policy: Home infusion services
(See definition of home infusion services in “Definitions” at the beginning of this chapter.)
Links: For additional information on home infusion services, see WAC 296-20-1102 .
Prior authorization
Regardless of who is providing services, prior authorization is required for:
- Home infusion nurse services,
- Drugs, and
- Any supplies.
The insurer will only pay for proper and necessary services required to address physical restrictions caused by the industrial injury or disease.
Home infusion services can be authorized independently or in conjunction with home health services.
Home infusion skilled nurse services will only be authorized when infusion therapy is approved as treatment for the worker’s allowed industrial condition.
Who must perform these services to qualify for payment
Home infusion nurse services
Skilled nurses contracted by the home infusion service provide infusion therapy, as well as:
- Education of the worker and family,
- Evaluation and management of the infusion therapy, and
- Care for the infusion site.
Infusion therapy drugs
Infusion therapy drugs, including injectable drugs, are payable only to pharmacies.
Services that can be billed
Home infusion nurse services
These home infusion CPT® codes may be billed for initial establishment of nutritional therapy for the worker when services have been authorized:
| CPT® code | Description and notes | Max 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 |
Supplies
Medical supply companies and home infusion pharmacies may use the appropriate HCPCS code to bill for parenteral solutions, total parental nutrition (TPN), or enteral formula nutrition with prior authorization.
Wound care and medical treatment supplies
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.
Note: See definition of bundled in “Definitions” at the beginning of this chapter.
Requirements for billing
Home infusion nurse services
For administering home injections or nutritional parenteral solutions only, use the RN visit code G0154 (Services of skilled nurse in home health setting, each 15 minutes).
Infusion therapy drugs
Infusion therapy drugs, including injectable drugs, must be billed with National Drug Code (NDC) codes or Universal Product Code (UPC) codes if no NDC codes are available.
Supplies
The rental or purchase of infusion pumps must be billed with the appropriate HCPCS codes.
Payment policy: In-home hospice services
Link: For payment policies for hospice services performed in a facility, see the Nursing Home and Other Residential Care Services chapter.
Prior authorization
In-home hospice services must be preauthorized and may include chore services. The insurer will only pay for proper and necessary services required to address physical restrictions caused by the industrial injury or disease.
Services that can be billed
| HCPCS code | Description and notes | Max fee |
| Q5001 | Hospice care, in the home, per diem. Applies to in-home hospice care. | By report |
Note: See definition of by report in “Definitions” at the beginning of this chapter.
Links: Related topics
| If you’re looking for more information about… | Then go here: |
| Administrative rules for home health services |
Washington Administrative Code (WAC) 296-20-03001(8): http://apps.leg.wa.gov/WAC/default.aspx?cite=296-20-03001 WAC 296-20-1102: http://apps.leg.wa.gov/WAC/default.aspx?cite=296-20-1102 WAC 296-23-246: http://apps.leg.wa.gov/WAC/default.aspx?cite=296-23-246 |
| Becoming an L&I provider | L&I’s website: www.Lni.wa.gov/ClaimsIns/Providers/Becoming/default.asp |
| Billing instructions and forms | Chapter 1: Introduction |
| Fee schedules for all healthcare professional services (including home health) |
L&I’s website: http://feeschedules.Lni.wa.gov |
| Payment policies for durable medical equipment (DME) |
Chapter 9: Durable Medical Equipment |
| Payment policies for hospice services performed in a facility |
Chapter 36: Nursing Home and Other Residential Care Services |
| Payment policies for physical therapy and occupational therapy |
Chapter 24: Physical Medicine Services |
| Payment policies for supplies | Chapter 28: Supplies, Materials, and Bundled Services |
Need more help? Call L&I’s Provider Hotline at 1-800-848-0811.
CPT® codes and descriptions only are © 2010 American Medical Association
