Change In Prior Authorization Requirements

www.aetnabetterhealth.com/ohio

November 21, 2018

Change In Prior Authorization Requirements

Dear Provider,

Aetna Better Health of Ohio would like to notify you that effective January 1, 2019, Aetna Better Health of Ohio will not require prior authorization for the following Home Healthcare services for Medicare/Medicaid Plan members.

Home dialysis
Home health aide or certified nursing assistant
Home infusion/injectable therapy
Home nursing care by registered or licensed nurse
Home physical/occupational, respiratory and/or speech therapy

Please note:

Private duty nursing still requires precertification
Home infusion\supply codes associated with drugs\medical injectables still require precertification for all products

Example: HCPCS code S9345 Home infusion therapy, anti-hemophilic agent infusion therapy (e.g. factor viii); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem requires precertification
Please review all pages in this document for any additional information

The following is the list of codes that will no longer require prior authorization:

CODE	DESCRIPTION
99503	Home visit for respiratory therapy care (eg, bronchodilator, oxygen therapy, respiratory assessment, apnea evaluation)
99504	Home visit for mechanical ventilation care
99505	Home visit for stoma care and maintenance including colostomy and cystostomy
99506	Home visit for intramuscular injections
99507	Home visit for care and maintenance of catheter(s) (eg, urinary, drainage, and enteral)
99509	Home visit for assistance with activities of daily living and personal care
99511	Home visit for fecal impaction management and enema administration
99512	Home visit for hemodialysis
99600	Unlisted home visit service or procedure
99601	Home infusion/specialty drug administration, per visit (up to 2 hours)
99602	Home infusion/specialty drug administration, per visit (up to 2 hours); each additional hour (List separately in addition to code for primary procedure)
G0151	Services performed by a qualified physical therapist in the home health or hospice setting, each 15 minutes
G0152	Services performed by a qualified occupational therapist in the home health or hospice setting, each 15 minutes
G0153	Services performed by a qualified speech-language pathologist in the home health or hospice setting, each 15 minutes
G0156	Services of home health/hospice aide in home health or hospice settings, each 15 minutes
G0157	Services performed by a qualified physical therapist assistant in the home health or hospice setting, each 15 minutes
G0158	Services performed by a qualified occupational therapist assistant in the home health or hospice setting, each 15 minutes
G0159	Services performed by a qualified physical therapist, in the home health setting, in the establishment or delivery of a safe and effective therapy maintenance program, each 15 minutes
G0160	Services performed by a qualified occupational therapist, in the home health setting, in the establishment or delivery of a safe and effective occupational therapy maintenance program, each 15 minutes
G0161	Services performed by a qualified speech-language pathologist, in the home health setting, in the establishment or delivery of a safe and effective speech-language pathology maintenance program, each 15 minutes
G0162	Skilled services by a registered nurse (RN) for management and evaluation of the plan of care; each 15 minutes (the patient's underlying condition or complication requires an RN to ensure that essential non-skilled care achieves its purpose in the home health or hospice setting)
G0299	Direct skilled nursing services of a registered nurse (rn) in the home health or hospice setting, each 15 minutes
G0300	Direct skilled nursing services of a license practical nurse (lpn) in the home health or hospice setting, each 15 minutes
G0493	Skilled services of a registered nurse (rn) for the observation and assessment of the patient's condition, each 15 minutes (the change in the patient's condition requires skilled nursing personnel to identify and evaluate the patient's need for possible modification of treatment in the home health or hospice setting)
G0494	Skilled services of a licensed practical nurse (lpn) for the observation and assessment of the patient's condition, each 15 minutes (the change in the patient's condition requires skilled nursing personnel to identify and evaluate the patient's need for possible modification of treatment in the home health or hospice setting)
G0495	Skilled services of a registered nurse (rn), in the training and/or education of a patient or family member, in the home health or hospice setting, each 15 minutes
G0496	Skilled services of a licensed practical nurse (lpn), in the training and/or education of a patient or family member, in the home health or hospice setting, each 15 minutes
Q5001	Hospice Or Home Health Care Provided In Patient's Home/Residence
S9061	Home administration of aerosolized drug therapy (e.g., pentamidine); administrative services, professional pharmacy services, care coordination, all necessary supplies and equipment (drugs and nursing visits coded separately), per diem
S9098	Home visit, phototherapy services (e.g. bili-lite), including equipment rental, nursing services, blood draw, supplies, and other services, per diem
S9122	Home health aide or certified nurse assistant, providing care in the home; per hour
S9128	Speech therapy, in the home, per diem
S9129	Occupational therapy, in the home, per diem
S9131	Physical therapy; in the home, per diem
S9325	Home infusion therapy, pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment, (drugs and nursing visits coded separately), per diem (do not use this code with s9326, s9327 or s9328)
S9326	Home infusion therapy, continuous (twenty-four hours or more) pain management infusion; administrative services, professional pharmacy services, care coordination and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem
S9327	Home infusion therapy, intermittent (less than twenty-four hours) pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem
S9328	Home infusion therapy, implanted pump pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem
S9329	Home infusion therapy, chemotherapy infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem (do not use this code with s9330 or s9331)
S9330	Home infusion therapy, continuous (twenty-four hours or more) chemotherapy infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem
S9331	Home infusion therapy, intermittent (less than twenty-four hours) chemotherapy infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem
S9336	Home infusion therapy, continuous anticoagulant infusion therapy (e.g. heparin), administrative services, professional pharmacy services, care coordination and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem
S9338	Home infusion therapy, immunotherapy, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem
S9340	Home therapy; enteral nutrition; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (enteral formula and nursing visits coded separately), per diem
S9341	Home therapy; enteral nutrition via gravity; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (enteral formula and nursing visits coded separately), per diem
S9342	Home therapy; enteral nutrition via pump; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (enteral formula and nursing visits coded separately), per diem
S9343	Home therapy; enteral nutrition via bolus; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (enteral formula and nursing visits coded separately), per diem
S9347	Home infusion therapy, uninterrupted, long-term, controlled rate intravenous or subcutaneous infusion therapy (e.g. epoprostenol); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem
S9348	Home infusion therapy, sympathomimetic/inotropic agent infusion therapy (e.g., dobutamine); administrative services, professional pharmacy services, care coordination, all necessary supplies and equipment (drugs and nursing visits coded separately), per diem
S9351	Home infusion therapy, continuous or intermittent anti-emetic infusion therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and visits coded separately), per diem
S9353	Home infusion therapy, continuous insulin infusion therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem
S9355	Home infusion therapy, chelation therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem
S9359	Home infusion therapy, anti-tumor necrosis factor intravenous therapy; (e.g. infliximab); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem
S9361	Home infusion therapy, diuretic intravenous therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem
S9363	Home infusion therapy, anti-spasmotic therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem
S9364	Home infusion therapy, total parenteral nutrition (tpn); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment including standard tpn formula (lipids, specialty amino acid formulas, drugs other than in standard formula and nursing visits coded separately), per diem
S9365	Home infusion therapy, total parenteral nutrition (tpn); one liter per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment including standard tpn formula (lipids, specialty amino acid formulas, drugs other than in standard formula and nursing visits coded separately), per diem
S9366	Home infusion therapy, total parenteral nutrition (tpn); one liter per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment including standard tpn formula (lipids, specialty amino acid formulas, drugs other than in standard formula and nursing visits coded separately), per diem
S9367	Home infusion therapy, total parenteral nutrition (tpn); more than two liters but no more than three liters per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment including standard tpn formula (lipids, specialty amino acid formulas, drugs other than in standard formula and nursing visits coded separately), per diem
S9368	Home infusion therapy, total parenteral nutrition (tpn); more than three liters per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment including standard tpn formula (lipids, specialty amino acid formulas, drugs other than in standard formula and nursing visits coded separately), per diem
S9370	Home therapy, intermittent anti-emetic injection therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem
S9372	Home therapy; intermittent anticoagulant injection therapy (e.g. heparin); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem (do not use this code for flushing of infusion devices with heparin to maintain patency)
S9373	Home infusion therapy, hydration therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem (do not use with hydration therapy codes s9374-s9377 using daily volume scales)
S9374	Home infusion therapy, hydration therapy; one liter per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem
S9375	Home infusion therapy, hydration therapy; more than one liter but no more than two liters per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem
S9376	Home infusion therapy, hydration therapy; more than two liters but no more than three liters per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem
S9377	Home infusion therapy, hydration therapy; more than three liters per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies (drugs and nursing visits coded separately), per diem
S9490	Home infusion therapy, corticosteroid infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem
S9559	Home injectable therapy, interferon, including administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem
S9560	Home injectable therapy; hormonal therapy (e.g.; leuprolide, goserelin), including administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem
T1001	Nursing assessment / evaluation
T1002	Rn services, up to 15 minutes
T1003	Lpn/lvn services, up to 15 minutes
T1004	Services of a qualified nursing aide, up to 15 minutes
T1005	Respite care services, up to 15 minutes
T1021	Home health aide or certified nurse assistant, per visit
T1022	Contracted home health agency services, all services provided under contract, per day
T1502	Administration of oral, intramuscular and/or subcutaneous medication by health care agency/professional, per visit
T1503	Administration of medication, other than oral and/or injectable, by a health care agency/professional, per visit

Note that the following rules will apply:

1. Home Health/Home Infusion Procedures Place of Service Limitation

Per the AMA CPT and CMS HCPCS Manuals, the following Home Health/Home Infusion procedures should be limited to Place of Service 03 (School), 04 (Homeless shelter), 12 (Home), 13 (Assisted living facility), 14 (Group home), 16 (Temporary lodging), 33 (Custodial care facility), 54 (Intermediate care facility/individuals with intellectual disabilities) and 55 (Residential substance abuse treatment facility). Consequently, if one of the procedures listed below is billed in any other place of service, it will be denied.

Exception: Home health/home infusion service billed with modifier SS (Home infusion therapy in infusion suite).

Home Health/Home Infusion Procedures:

 99500-99600, S9097-S9098, S9122-S9127, S9208-S9214 (Home visit services)

 99601-99602 (Home infusion/specialty drug administration)

 S5035-S5036, S5497-S5523, S9325-S9379, S9490-S9504 (Home infusion therapy)

 S5180-S5181 (Home respiratory therapy)

 S9128-S9131 (Home speech, occupational and physical therapy)

2. Home Health Physician Certification or Re-certification

According to CMS policy, only a physician defined as a Doctor of Medicine, Osteopathy or Podiatric Medicine can certify or recertify a beneficiary for home health services. Therefore, G0179 (Physician re-certification for Medicare-covered home health services under a home health plan of care) and G0180 (Physician certification for Medicare-covered home health services under a home health plan of care) will be denied when billed by a Non-Physician Practitioner.

3. According to the National Home Infusion Association (NHIA), the national definition of per diem includes professional pharmacy services (i.e. dispensing, clinical monitoring, care coordination, supplies and equipment, multiple categories of pharmacy professional services), administrative services, and other support costs. Supplies and equipment are included in the per diem reimbursement as necessary for the effective administration of infusion, specialty drugs, nutrition and other special therapies.

4. According to the HCPCS Level II Manual, the description of modifier SH (Second concurrently administered infusion therapy) indicates the intended use of the modifier. Therefore, when an intravenous (IV) home infusion has not been billed previously without a modifier SH or SJ for the same date of service [i.e. to indicate the initial infusion], then the IV home infusion service with modifier SH will be denied. Similarly, the description of modifier SJ (Third or more concurrently administered infusion therapy) indicates the intended use of the modifier. Therefore, when an IV home infusion has not been billed previously with modifier SH (Second concurrently administered infusion therapy) for the same date of service, the IV home infusion service with modifier SJ will be denied.

IV home infusion service codes included in this policy:

 S9325-S9331, S9336, S9338, S9345-S9349, S9351, S9353, S9355, S9357, S9359, S9361, S9363-S9368, S9373-S9377, S9379, S9490, S9494, S9497, S9500-S9504, S9810

As always, don't hesitate to contact your Aetna Better Health of Ohio Provider Relations Representative with any questions or comments.

Thanks for all you do!

Sincerely,

Provider Services

Aetna Better Health of Ohio