[Billing Codes]

 

T1001:  Nursing Assessment In-Home Initial Evaluation:  Typically only one (1) in-home initial evaluation is authorized for a claimant.  Once an authorization is approved by the DEEOIC, an assessment can be performed.  Given that this code is used for “initial” nursing assessments, if the provider or physician request more than one, additional justification is required.

   

S5126:  Home Health Aide (HHA), Certified Nurse Assistant (CNA), Per Diem (8 Hour Shift):  A HHA/CNA can only be authorized if there is sufficient medical rationale from a physician documenting the medical necessity of the service for the accepted condition.  If a HHA/CNA is authorized and a RN/LPN is utilized, bills will be paid only at the authorized HHA level.  Only the HHA/CNA is authorized for reimbursement. 

 

24-hour care:  If this code is approved for 24 hour care and the care is provided, the bills must be submitted for 3 units which cover the 24 hour period of provided services, regardless of the number of HHA/CNAs assigned.  For example, if two HHA/CNAs are utilized for two 12 hour shifts, the service provided still covers the authorized three 8 hour shifts and the bill should reflect 3 units of the authorized S5126 code. Under no circumstances should a per diem code be used for less than 8 hours of care.

 

T1030:  Nursing Care, in home, by Registered Nurse (RN), Per Diem (8 Hour Shift):  An RN can only be approved for ongoing care if there is sufficient medical rationale from a physician stipulating the specific medical services related to the accepted condition that require an RN for an 8 hour shift(s). 

 

24-hour care:  If this code is approved for 24 hour care, the bill must be submitted with 3 units of T1030 which cover the 24 hour period of provided services, not by the number of RNs assigned.  For example, if two nurses are utilized for two 12 hour shifts, the bill must reflect


three units of the authorized T1030 code.  Under no circumstances should a per diem code be used for less than 8 hours of care.

 

 T1031:  Nursing Care, in the home, by Licensed Practical Nurse (LPN) Per Diem (8 Hour Shifts):  An LPN can only be approved for ongoing care if there is sufficient medical rationale from a physician stipulating the specific medical services related to the accepted condition that require an LPN for an 8 hour shift(s). 

 

24-hour care:  If this code is approved for 24 hour care, the bill must be submitted with 3 units of T1031 which cover the 24 hour period of provided services, not by the number of LPNs assigned.  For example, if two nurses are utilized for two 12 hour shifts, the bill must reflect three units of the authorized T1031 code.  Under no circumstances should a per diem code be used for less than 8 hours of care.

 

S9122:  Home Health Aide (HHA) or Certified Nurse Assistant (CNA) Hourly Code (less than 8 hour care):  An HHA or CNA can be approved if there is sufficient medical rationale from a physician stipulating the specific medical services related to the accepted condition that require an HHA.

 

S9124:  Nursing Care In-Home License Practical Nurse (LPN) Hourly Rate (less than 8 hour care):  An LPN can only be approved for ongoing care if there is sufficient medical rationale from a physician stipulating the specific medical services related to the accepted condition that require an LPN. 

 

S9123:  Nursing Care in Home Registered Nurse (RN) Hourly Code (less than 8 hour care):  An RN can only be approved for ongoing care if there is sufficient medical rationale from a physician stipulating the specific medical services related to the accepted condition that require an RN. 


 

T1017:  Targeted Case Management each 15 minutes:  This service requires prior authorization from the Claims Examiner for a Registered Nurse to perform targeted case management.  This is limited to the clinical impact of a claimant’s accepted condition on his/her current medical status. The skill level of Registered Nurse is required for this targeted case management activity.  The claims examiner’s authorization will specify the number of hours authorized for a case management visit.  Each unit of a T1017 code is equal to 15 minutes; therefore if a nurse case manager is at the claimant’s home for an assessment for one hour, the proper number of units to bill for this T1017 code is 4 units.

 

 

 

***Note:  When authorizing a HHA, RN or LPN, both per diem (“T” codes) and hourly codes (“S” codes) are to be authorized in the authorization letter and in the email sent to the FO.  The threads from the FO to ACS must also contain these codes, along with the associated units