Tuesday, June 20, 2017

Home Health revenue codes 0420, 0430, 0424, 0421

Revenue Code Description

Home Health Care Visits

0642 Home iv therapy services-iv site care, central line

0643 Home iv therapy services- IV start/change, peripheral line

0644 Home iv therapy services-non-routine nursing, peripheral line

0645 Home iv therapy services-training patient/caregiver, central line

0646 Home iv therapy services-training, disabled patient, central line

0647 Home iv therapy services-training, patient/caregiver, peripheral line

0648 Home iv therapy services-training, disabled patient, peripheral line

0649 Home iv therapy services-other iv therapy services

Therapy by a Home Health Care Agency/Facility

Coding Clarification: These codes apply to the Home Health Care Visit limit with the following Bill Type:

• 032x : Home health - Home Health Services under a plan of treatment

* 034x : Home health - Home Health Services not under a plan of treatment

0420 Physical therapy-general

0421 Physical therapy-visit charge

0422 Physical therapy-hourly charge

0423 Physical therapy-group rate

0424 Physical therapy-evaluation or reevaluation

0429 Physical therapy-other physical therapy

0430 Occupational therapy-general

0431 Occupational therapy-visit charge

0432 Occupational therapy-hourly charge

0433 Occupational therapy-group rate

0434 Occupational therapy-evaluation or reevaluation

0439 Occupational therapy-other occupational therapy

0440 Speech therapy-language pathology-general

0441 Speech therapy-language pathology-visit charge

0442 Speech therapy-language pathology-hourly charge

0443 Speech therapy-language pathology-group rate

0444 Speech therapy-language pathology-evaluation or reevaluation

0449 Speech therapy-language pathology-other speech-language pathology


For coverage of assisted administration of clotting factors and coagulant blood products, refer to the policy titled Assisted Administration of Clotting Factors and Coagulant Blood Products. For coverage of clotting factor and coagulant blood products, refer to the policy titled Clotting Factors and Coagulant Blood Products.

Essential Health Benefits for Individual and Small Group

For plan years beginning on or after January 1, 2014, the Affordable Care Act of 2010 (ACA) requires fully insured non-grandfathered individual and small group plans (inside and outside of Exchanges) to provide coverage for ten categories of Essential Health Benefits (“EHBs”). Large group plans (both self-funded and fully insured), and small group ASO plans, are not subject to the requirement to offer coverage for EHBs. However, if such plans choose to provide coverage for benefits which are deemed EHBs, the ACA requires all dollar limits on those benefits to be removed on all Grandfathered and Non-Grandfathered plans. The determination of which benefits constitute EHBs is made on a state by state basis. As such, when using this policy, it is important to refer to the member specific benefit plan document to determine benefit coverage.


Indications for Coverage

The services being requested must meet all of the following:

** Be ordered and directed by a treating practitioner or specialist (M.D., D.O., P.A. or N.P); and

** The care must be delivered or supervised by a licensed professional in order to obtain a specified medical outcome; and

** Services must be skilled care in nature (refer to the policy titled Skilled Care and Custodial Care Services and the Definitions section below); and

** Services must be intermittent and part time (typically provided for less than 4 hours per day; refer to the member specific benefit plan document for intermittent definitions, if provided); and

** Services are provided in the home in lieu of skilled care in another setting (such as but not limited to a nursing facility, acute inpatient rehabilitation or a hospital); and

** Services must be clinically appropriate and not more costly than an alternative health services; and

** A written treatment plan must be submitted with the request for specific services and supplies’ periodic review of the written treatment plan may be required for continued Skilled Care needs and progress toward goals; and

** Services are not provided for the comfort and convenience of the member or the member’s family; and

** Services are not custodial care in nature. Medical Necessity Plans

Use the criteria above where applicable.

Additional Information

** Medical supplies and medications that are used in conjunction with a home health care visit are covered as part of
that visit. Some examples are, but not limited to, surgical dressing, catheters, syringes, irrigation devices.

Reimbursement for home health care visits and supplies are contractually determined. ** Eligible physical, occupational and speech therapy received in the home from a Home Health Agency is covered under the Home Health Care section of the member’s certificate of coverage and/or summary of benefits. The Home Health Care section only applies to services that are rendered by a Home Health Agency.

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