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Florida Blue defines home health care services as those services rendered to an individual in the home by health care professionals (e.g., nurses, therapists) or paraprofessionals (e.g., home health aides, physical therapy assistants) to achieve and sustain an optimum state of health and independence for that individual. For purposes of coverage, home health care is provided on a per visit basis, generally for no more than two hours at a time.

Home Health Covered Services

These services are payable, provided they are covered in the member’s health insurance contract and the individual receiving the care meets criteria A or B and; C (i.e., A and C or B and C) below:
  1. The member is considered to be homebound due to medical condition based on physician documentation; or
  2. The physician documents the member is able to receive care in the home as a safe, appropriate alternate level of care; and
  3. The services being rendered in the home are:
    • prescribed by a licensed physician as part of a formal written treatment plan which is reviewed and validated by the prescribing physician every 62-days;
    • skilled in nature (nursing, infusion therapy, occupational therapy, physical therapy, or speech therapy);
    • necessary for the treatment of the member's condition;
    • producing continued measurable progress in the member toward the desired response to the plan of treatment;
    • supported by face-to-face clinical progress notes; and
    • non-custodial in nature.
Home health/home infusion services are payable, provided they are covered under the member’s benefits and when the provider administering the care:
  • Holds an active Florida home health license and employs or contracts with licensed professionals and para-professional within the scope of Florida regulations.
  • PTA services are covered when they are performed by a licensed PTA, and must be performed under the direction and supervision a licensed physical therapist.
  • Follows and updates the licensed physician’s executed plan of treatment every 62-days or upon request.
  • Certifies services for members based on the member’s contract benefits.
  • Receives required prior approvals on designated services for non-HMO subscribers.
  • Submits claims according to standard, contracted coding methodology.
  • Provides all visits in the member’s home. All reimbursable services must be documented and provided face-to-face. Visits and services provided by any other method (e.g., computer, fax, telephone, etc.) are non-reimbursable.
  • Complies with requests for audits and the sharing of clinical documentation with BCBSF.
Note: Medical policies (medical coverage guidelines) for home health are available on our website at www.bcbsfl.com. State of Florida Group Accounts and BlueCard home plans may require plan of treatment and supporting medical information for claim payment. Some groups (e.g., FEP and State of Florida) and other Blue Plans may also have specific medical coverage guidelines.   

Exclusions and Limitations

  • Plans and groups may have a limited number of visits or dollar allowance per benefit period.
  • Admission and assessment visits, without a skill performed during the same visit, are non-reimbursable.
  • Certified home health aide visits are limited to one per day and reimbursable in conjunction with the provision of skilled care.
  • Skilled and paraprofessional services are reimbursed per visit, per day.
  • All private duty nursing is non-covered, unless covered under the member’s benefits.
  • All custodial care is non-covered.
  • Routine venipunctures for collection of blood specimens are not separately reimbursable.
  • IV therapy billed with revenue codes 0260-0269 are included in other services and are not separately reimbursable.
  • Nutritional guidance provided at the same time as nursing services is included in the nursing reimbursement.

 Home Infusion Therapy

Home health agencies may provide and be reimbursed for nursing care related to home infusion therapy. Agencies that also own and operate a special parenteral/enteral pharmacy may be eligible for infusion reimbursement when initiated and conducted in the residence. Utilization of subcontracted services is not permitted, unless prior written approval has been received.
Home infusion therapy services are a covered benefit when the member has adequate venous access and who are capable of learning self-care, or have a care partner capable of learning to administer the therapy are eligible for home infusion therapy. The per diem allowance for infusion therapy includes administrative services; professional pharmacy services; care coordination and all necessary supplies and equipment such as pumps, tubing and flushes. These services are identified with the HCPCS codes and are reimbursed in addition to the nursing codes and the primary drugs, which are coded separately.
Note: Primary medication(s) ordered are reimbursable and should be coded with the appropriate J code. All solutions, flushes and diluents (such as heparin and normal saline) necessary to administer the primary medication are inclusive in this rate and will not be reimbursed separately.
Certain drugs are not payable under home infusion therapy or the member’s contract. Drugs that are classified as investigational or used in a research study are not covered.
Products and Services included in the Per Diem Payment Administrative Costs
  • Office procedures to determine eligibility, benefits and billing information
  • Deliveries and set-up
  • Costs associated with the start up of care or initial visit at the residence
  • Pharmacy Professional Services
    • Sterile procedures including intravenous admixtures, clean room upkeep, vertical and horizontal laminar flow hood certification, and all other biomedical procedures necessary for a safe environment
    • Compounding of medications
    • Medication profile set-up and drug utilization review
    • Monitoring for potential drug interactions
    • Pharmacy patient assessment and clinical monitoring
    • Development and implementation of pharmaceutical care plans
    • Pharmacokinetic dosing
    • Comprehensive knowledge of vascular access systems
    • Services of a Registered Dietician to routinely review medical records for patients receiving total parenteral nutrition
    • Review and interpretation of patient test results
    • Recommendation of dosage or medication changes based on clinical findings
    • Pumps used to administer the drugs are included in the per-diem and should not be billed separately
  • Care Coordination
    • Coordination of care with physicians, nurses, patients, patient’s family, other providers, and caregivers
    • Patient discharge services, including communication with other medical professionals and closing of the medical record
  • Infusion Therapy Related Supplies
    • Flushes, diluents and solutions i.e. heparin and normal saline
    • Durable, reusable infusion pumps
    • Elastomeric, disposable infusion pumps
    • Short peripheral vascular access devices (e.g., angiocaths)
    • Needles, gauze, sterile tubing, catheters, dressing kits and other supplies necessary for the effective administration of infusion therapy
    • Anaphylactic kits, when ordered and indicated
    • The pumps and IV poles used to administer drugs are part of the per-diem and should not be billed separately
The provider will be entitled to receive a per diem fee for each covered calendar day the patient receives a dose of pharmaceutical products under the physician’s order. Refills on infusion pumps are eligible for a per diem fee on the day of instillation only.
Non-Covered Infusion Therapy Services
Self-administered (non-infused) drugs delivered without nursing services and self-injectable drugs must be obtained from a participating retail pharmacy or specialty pharmacy, which are listed in BCBSF’s online provider directory. Refer to the Medication Guide for those medications that are considered to be self-administered. Intramuscular and subcutaneous injections are permitted for teaching purposes only and must be rendered by a professional licensed nurse. Other injections (intramuscular, subcutaneous) are permitted only when the injectable drug replacement program (HMO) or an injectable drug supplier program (PPO and Traditional) is not available to the member. S codes for intramuscular or subcutaneous injections (S9542) and catheter care flushes (S5498) are not reimbursed separately. Reimbursement is included in the allowance for the primary injectable drug.

Medical/Surgical Supplies

Medical supplies are classified as:
  • Routine because such services are essential and used in small quantities for patients during the usual course of most home visits; or
  • Non-routine because they are durable in nature or used in larger quantities to treat a patient’s specific illness or injury in accordance with the physician’s overall plan of treatment and often not included in the home plan of treatment. Non-routine medical supplies include specialty dressings, ostomy supplies, etc.
Necessary supplies (e.g., tape, gauze, non-sterile gloves, saline, alcohol wipes) to provide prescribed care during the visit are considered incidental to and reimbursed as part of the professional service rendered. These are often referred to as routine or “bag” supplies that are essential in enabling professionals to effective carry out the physician’s ordered plan of treatment for that home visit.
Routine medical supplies are included in the allowance for the nursing visit. Non-routine medical supplies are reimbursed separately and should be obtained through a participating DME or medical supplier.

Billing Requirements

CareCentrix Participating Providers:

 

For Home Health or Home Infusion services, providers participating in the CareCentrix network should follow billing guidelines as instructed by CareCentrix. Contact CareCentrix via their website at www.carecentrix.com, or by phone at 877-725-6525.
 Billing for Home Health Providers NOT participating in the CareCentrix Network:
  • Effective for home health episodes beginning on or after October 1, 2013, Original Medicare will no longer accept institutional claims submitted with Type of Bill 033X.  After October 1, 2013 home health will need to bill with Type of Bill 032X.
  • Home health providers with several provider numbers should submit the provider number of the agency that provided the care.  This will ensure claims are reimbursed correctly.
  • Submit both revenue and CPT/HCPCS Codes.  Claims submitted without both revenue and CPT/HCPCS codes or with invalid codes will be rejected at the claim or line level.

 

  • Bill according to CPT/HCPCS definitions to determine appropriate coding, inclusive supply and item sizing. Claim lines must be split unevenly when units exceed 999 to prevent duplicate denials.
    • Do not bill more than 15 lines or 31-days of services on the same claim. If billing for services over a span of dates, bill once for that span (after span is complete) to include all services for the dates of service on one claim. Overlapping or repeating span dates causes duplicate denials.
    • The home health agency should not submit a bill/claim for an inclusive period beginning in one calendar year and extending into the next calendar year.
    • If the agency does not bill on a calendar month basis, it prepares two bills. The first covers the period ending December 31 of the old year; the second, the period beginning January 1 of the New Year.
  • All services must be itemized by date of service. Enter the appropriate revenue code and date for each service rendered.
  • Physical therapy, speech therapy and occupational therapy services should be billed by the visit, not by the modality or hour, unless approved by Care Coordination.
  • Reimbursement for visits provided by a health care professional of differing specialties is limited to one per day for each specialty, unless documented as medically necessary.
  • Some plans, including BlueCard may require medical documentation for unlisted codes, such as 99600.
  • Utilization of specific codes is strongly recommended to facilitate easier claims processing.
    • Home Health Billing Requirements for Non-Contracted Medicare Advantage
      • Effective for home health episodes beginning on or after October 1, 2013, Original Medicare will no longer accept institutional claims submitted with Type of Bill 033X.  After October 1, 2013 home health will need to bill with Type of Bill 032X.
      • Bill type "322-329"
      • Health Insurance Prospective Payment System (HIPPS) code
      • Treatment Authorization Code
      • Core-Based Statistical Area (CBSA) must be included with value amount field for a value code 61
      Billing for Infusion Services For Providers NOT participating in the CareCentrix Network:
      • Classified drugs must be submitted with valid CPT/HCPCS codes and HCPCS quantity.
      • Unclassified drugs must be submitted with valid CPT/HCPCS codes NDC numbers with the NDC metric decimal quantity for medications administered.
      • Do not bill more than seven consecutive days on any claim line.
      • Bill only primary drugs and S per diem codes related to infusion when professional nursing services are provided.
      • Do not bill codes that are considered inclusive in the S per diem code.
      • Corrected claims; if billing for additional dates of service or additional items, not included on the original claim, a corrected claim is required.
      Some groups and other Blue Plans may have specific coding and/or billing requirements for home infusion. Call the appropriate Blue Plan with any questions prior to filing the claim.
      Billing Multiple Infusion Therapies
      • Multiple infusion therapies apply to patients who require multiple concurrent infusion treatments including, but not limited to, multiple antibiotics, hydration and chemotherapy.
      • BCBSF will not reimburse separately for each therapy. Instead, the provider must bill and will be reimbursed for the per diem service, plus the drug(s) administered. Do not report zero dollar charges for the remaining therapies.
      • The only exception to this is aerosolized AIDS drug therapy. It is the only therapy that must be billed in conjunction with another mode of home IV therapy administration. It is also the only drug therapy that, while provided as part of a multiple-therapy treatment, can be billed as a separate service
      • Use procedure code S9061 to report aerosolized AIDS drug therapy.
      Some groups and other Blue Plans may have specific coding and/or billing requirements for home infusion. Call the appropriate Blue Plan with any questions prior to filing the claim.
      When billing home health services to BCBSF, revenue codes and CPT/HCPCS should be reported using the most current publications. The matrix below indicates the commonly used the revenue codes to be used in billing home health/home infusion services.
       
      Description of Service Revenue Codes
      Home Health Aide 0571
      0572 - hourly
      Medical Social Services 0561
      Occupational Therapy 0434 – evaluation/re-evaluation
      0431 – visit charge
      Physical Therapy 0424 - evaluation/re-evaluation
      0421 - visit charge
      Speech Therapy 0444 - evaluation/re-evaluation
      0441 - visit charge
      Skilled Nursing 0551 – visit charge
      0552 - hourly
      General Classification Home IV Therapy 0640
      Non-routine nursing, central line 0641
      Site Care, central line 0642
      Start/Change, peripheral line 0643
      Routine Nursing, peripheral line 0644
      Drugs 0250-0252
      0630-0636
       
       

      Medical Review

      When claims are submitted for home health services, it is essential that the claims and required supporting documentation are accurate. If a claim does not meet the established edit criteria, it may require medical review. Edits may be selected based on diagnoses, revenue codes, HCPCS codes or provider specific reasons. Medical review may be performed by registered nurses to ensure that the rendered services are medically appropriate and to determine if the claim can be paid based on the documentation submitted.
       
        1/30/2012
        The Manual is not intended to be a complete statement of all BCBSF polices or procedures for providers. Other policies and procedures, not included in this Manual, may be posted on our website or published in special publications, including but not limited to, letters, bulletins, or newsletters. Any section of this Manual may be updated at any time. In the event of any inconsistency between information contained in this Manual and the agreement(s) between you or your facility and BCBSF or Health Options the terms of such agreement(s) shall govern.

        The Manual is not intended to be a complete statement of all Florida Blue polices or procedures for providers. Other policies and procedures, not included in this Manual, may be posted on our website or published in special publications, including but not limited to, letters, bulletins, or newsletters. Any section of this Manual may be updated at any time. In the event of any inconsistency between information contained in this Manual and the agreement(s) between you or your facility and Florida Blue or Health Options the terms of such agreement(s) shall govern.

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