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December 2016 Texas Medicaid Provider Procedures Manual

Home Health Nursing and Private Duty Nursing Services Handbook : 3 Home Health Skilled Nursing and Home Health Aide Services : 3.5 * Home Health SN and HHA Procedure Billing and Limitations

3.5
Home Health SN or HHA visits provided by home health agencies enrolled in Texas Medicaid must be billed using procedure codes G0299 (SN), G0300 (SN), and G0156 (HHA) and will be reimbursed per visit of up to 2.5 hours; not to exceed a combined total of three visits per day (7.5 hours total).
The reimbursement methodology for professional services delivered by home health agencies is a statewide visit rate calculated in accordance with 1 TAC §355.8021(a).
When services are provided to more than one client in the same setting, only the units directly provided to each client at distinct, separate time periods will be reimbursed. Provider documentation must support the services were delivered at distinct, separate time periods. Total home health services billed for all clients cannot exceed the individual provider’s total number of hours spent at the place of service.
One as needed (PRN) SN visit may be reimbursed every 30 days outside of the prior authorized visits when SN visits have been authorized for the particular client.
For reimbursement purposes, Home Health SN or HHA services are always billed as place of service 2 (home) regardless of the setting in which the services are actually provided. SN or HHA services provided in the day care or school setting will not be reimbursed.
For all clients, SN visits may be provided in the following locations:
For all clients, HHA visits may be provided in the following locations:
An immediate relative, parent or guardian, primary caregiver, or alternate care giver may not be reimbursed for HHA services even if he or she is an enrolled provider or employed by an enrolled provider.
SN and/or HHA services may be billed on the same day as PPECC services, but they may not be billed simultaneously with PPECC services. SN and/or HHA services may be billed before or after PPECC services.
Note:
SN and/or HHA services are subject to retrospective review and possible recoupment when the medical record does not document the provision of SN and/or HHA services are medically necessary based on the client’s situation and needs. The service provider’s record must explain all discrepancies between the service hours approved and the service hours provided. For example: the parents released the provider from all responsibility for the service hours or the agency was not able to staff the service hours. The release of provider responsibility does not indicate the client does not have a medical need for the services during those time periods.

Texas Medicaid & Healthcare Partnership
CPT only copyright 2014 American Medical Association. All rights reserved.