DAL-Universal Billing Codes for Home and Community LTC
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December 21, 2016
Subject: Universal Billing Codes for Home Care and Adult Day Health Care Services
Dear Providers and Plans:
The New York State Public Health Law has been amended to require universal standards for coding of payment for home and community based long term care services claims. Specifically, it requires these codes to be based on universal billing codes approved by the Health Department and be consistent with any codes developed as part of the uniform assessment system for long term care established by the Department. Any claims under contracts or agreements between any long term care providers and managed long term care plans or manqged care plans are required to be processed using the universal standards for coding of payments. In addition, the Public Health Law has been amended to require electronic payments of claims under contracts or agreements between any long term care providers and managed long term care plans or managed care plans. These payments are required to be paid via electronic funds transfer.
Attached are a final set of universal codes for Long Term Care Services with respective modifiers (Attachment A) and Adult Day Health Care with respective modifiers (Attachment B).
The Department is requiring the implementation of billing codes by May 1, 2017 and will request status updates on March 1, 2017 and April 3, via email.
If there are questions regarding the implementation deadline of these billing codes, please notify the Department immediately by email to nfrates@health.ny.gov with the subject heading: Home Care Billing Codes.
Sincerely,
John E. Ulberg Jr.Medicaid Chief Financial Officer
Division of Finance and Rate Setting
Office of Health Insurance Programs
Attachment A
HOME CARE BILLING CODES AND MODIFIERS
| Service Type | Unit of Measurement | Billing Code | Modifier |
|---|---|---|---|
| HOME CARE SERVICES | |||
| Personal Care Aide Level I (Homemaker/Housekeeper) | |||
| PCS Level I –15 Minutes | Per 15 minutes | S5130 | NONE |
| PCS Level I – 1Hour | Per hour | S5130 w/ modifier | U1 |
| PCS Level ITwo Client | Per 15 minutes | S5130 w/modifier | U2 |
| PCS Level I Multiple Client | Per 15 minutes | S5130 w/modifier | U3 |
| PCS Level IWeekend/Holiday | Per 15 minutes | 55130 w/ modifier | U4 |
| Personal Care Aide Level II | |||
| PCS Level II Basic – 15 Minutes | Per 15 minutes | T1019 | NONE |
| PCS Level II Basic – 1Hour | Per hour | T1019 w/ modifier | U1 |
| PCS Level II Basic Two Client | Per 15 minutes | T1019 w/ modifier | U2 |
| PCS Level II Multiple Client | Per 15 minutes | T1019 w/ modifier | U3 |
| PCS Level II Weekend/Holiday | Per 15 minutes | T1019 w/ modifier | U4 |
| PCS Level II Hard to Serve | Per 15 minutes | T1019 w/ modifier | US |
| PCS Level IITwo Client Hard to Serve | Per 15 minutes | T1019 w/ modifier | U7 |
| PCS Level II Live in | Per diem (13 hours) | T1020 * | NONE |
| PCS Level II Live in Two Client | Per diem (13 hours) | T1020 w/ modifier * | U2 |
| PCS Level 11 Live in Weekend/Holiday | Per diem (13 hours) | T1020 w/ modifier * | U4 |
| PCS Level II Live in Two Client Hard to Serve | Per diem (13 hours) | T1020 w/ modifier * | U7 |
| Home Health Aide | |||
| HHA – 15 minutes | Per 15 minutes | S9122 S5125 | NONE |
| HHA | Per hour | S9122 w/ modifier | U1 |
| HHA Two Client | Per 15 minutes | S9122 w/ modifier S5125 w/ modifier | U2 |
| HHA – Live in | Per diem (13 hours) | T1021 S5126 |
NONE |
| HHA Live in Two Client | Per diem (13 hours) | T1021. w/ modifier S5126 w/ modifier | U2 |
| Advanced Home Health Aide | Per hour | S9122 w/modifier | A1 |
| Nursing Services | |||
| Nursing Assessment/Evaluation | Per visit | T1001 | |
| UAS Assessment | Per visit | T1001 T2024 |
|
| UAS Reassessment | Per visit | T1001 T2024 |
|
| Nursing Care in Home (RN) | Per diem (13 hours) | S9123 | |
| RN | Per hour | S9123 | |
| RN – 15 minutes | Per 15 minutes | T1002 | |
| Nursing Care in Home (LPN) | Per diem (13 hours) | ||
| LPN | Per hour | S9124 | |
| LPN – 15 minutes | Per 15 minutes | T1003 | |
| CONSUMER DIRECTED | |||
| Consumer Directed Personal Assistant | |||
| CDPA Basic – 15 Minutes | Per 15 minutes | T1019 w/ modifier | C6 |
| CDPA Basic – Hourly | Per hour | T1019 w/ modifier | C1 |
| CDPA Enhanced | Per 15 minutes | T1019 w/ modifier | C5 |
| CDPA Two Consumer | Per 15 minutes | T1019 w/ modifier | C2 |
| CDPA Two Consumer Enhanced | Per 15 minutes | T1019 w/ modifier | C7 |
| CDPA Live in | Per diem (13 hours) | T1020 w/ modifier* | C8 |
| CDPA Live in Enhanced | Per diem (13 hours) | T1020 w/ modifier* | C5 |
| CDPA Live in Two Consumer | Per diem (13 hours) | T1020 w/ modifier* | C2 |
| CDPA Live in Two Consumer Enhanced | Per diem (13 hours) | T1020 w/ modifier* | C7 |
| Home Health Care Services | |||
| Occupational Therapy | Per visit | S9129 | NONE |
| Physical Therapy | Per visit | S9131 | NONE |
| Speech Therapy | Per visit | S9128 | NONE |
| Respiratory Therapy | Per 15 minutes | G0238 | NONE |
| Nutritional Counseling | Per visit | S9470 | NONE |
| Medical Social Services | Per visit | S9127 | NONE |
| Sign Language/Oral interpreter | Per 15 minutes | T1013 S9127 | NONE |
| Social and Environmental Supports –Home Modification | Per service | S5165 | NONE |
| Social and Environmental Supports –Assessment | Per service | T1028 | NONE |
| Telehealth | |||
| Installation | Per service | S9110 | NONE |
| Monitoring Type I | Monthly | S9110 | NONE |
| Monitoring Type II | Monthly | S9110 | NONE |
| Monitoring Type III | Monthly | S9110 | NONE |
| Medication Dispensers | |||
| Installation | One Time | T1505 | NONE |
| Monitoring | Monthly | S5185 | NONE |
| *T1020 Per diem rate code may not be used if a personal care aide or personal assistant is not able to meet the sleep requirements required in Fair Labor Standards Act (FLSA). | |||
HOME CARE RATE CODE DEFINITIONS
| Type of Service | Definition |
|---|---|
| PCS Level I | Personal Care Service (PCS) Level I is defined in 18 NYCRR 505.14 as housekeeper services. |
| PCS Level II | Personal Care Service (PCS) Level II is defined in 18 NYCRR 505.14 as home attendant services. |
| CDPA | Consumer Directed Personal Assistance (CDPA) means the provision of assistance with personal care services, home health aide services, and skilled nursing tasks by a consumer directed personal assistant and under the instruction, supervision and direction of a consumer or the consumer's designated representative, as defined in 18 NYCRR 505.28. |
| Live in | T1020 Per diem rate code may not be used if a personal care aide or personal assistant is not able to meet the sleep requirements required in FLSA. |
MODIFIERS
| Modifier | Description | |
|---|---|---|
| U1 | PCS Basic – Hourly | This rate code modifier will be used for the provision of personal care Level I or Level II services on an hourly basis. |
| U2 | PCS Two Client Basic | This rate code modifier will be used for the provision of personal care Level I or Level II services to one of two clients in the same household where both clients are receiving personal care services from the same aide. |
| U3 | PCS Multiple Client | This rate code modifier will be used for the provision of personal care Level I or Level II services for each personal care recipient who resides with other personal care recipients in a designated geographic area, such as in the same apartment building. |
| U4 | PCS Weekend/Holiday | This rate code modifier will be used for the provision of personal care Level I or Level II services on weekends (defined as between Saturday 8 a.m. to Monday 8 a.m.) and designated holidays. |
| U5 | PCS Hard to Serve | This rate code modifier will be used for the provision of personal care Level II services for clients who have exceptional needs and/or are in exceptional circumstances, such as the following situations: (1) a client is left alone in the community in a life–threatening situation, and services must be provided within four hours; (2) a client has severe mental or physical diagnosis or has several documented social and/or behavioral problems which make him or her extremely difficult to serve; or (3) a client resides in a problematic environment which may include housing or geography or be influenced by the behavior or problems of family members residing with the client. |
| U7 | PCS Two Client Hard to Serve | This rate code modifier will be used for the provision of personal care Level II care services to one of two clients in the same household where both clients are receiving personal care services from the same aide and where at least one of the clients has exceptional needs and/or is in exceptional circumstances, such as the following situations: (1) a client is left alone in the community in a life–threatening situation, and services must be provided within four hours; (2) a client has severe mental or physical diagnosis or has several documented social and/or behavioral problems which make him or her extremely difficult to serve; or (3) a client resides in a problematic environment which may include housing or geography or be influenced by the behavior or problems of family members residing with the client. |
| C1 | CDPA Basic – Hourly | This rate code modifier will be used for the provision of consumer directed personal assistance services on an hourly basis. |
| C2 | CDPA Two Consumer | This rate code modifier will be used for the provision of consumer directed personal assistance services to one of two consumers in the same household where both consumers are receiving personal assistance services from the same personal assistant. |
| C5 | CDPA Enhanced | This rate code modifier will be used for the provision of consumer directed personal care services for consumers who have exceptional needs and/or are in exceptional circumstances, such as the following situations: (1) a consumer has a documented inability to hire or retain sufficient staff, where the consumer can document that attempts have been made and that the wage rate is directly responsible for the inability to hire or retain staff and provided further that the consumer is at a nursing home level of care and therefore the lack of sufficient staff will result in institutionalization; (2) a consumer has severe mental and/or physical diagnosis or has several documented social and/or behavioral problems which make him or her extremely difficult to serve; or (3) a consumer resides in a problematic environment which may include housing or geography, or be influenced by the behavior or problems of family members residing with the consumer. |
| C6 | CDPA Basic – 15 Minutes | This rate code modifier will be used for the provision of consumer directed personal assistance services on a 15–minute basis. |
| C7 | CDPA Two Consumer Enhanced | This rate code modifier will be used for the provision of consumer directed personal assistance services to one of two consumers in the same household where both consumers are receiving personal assistance services from the same personal assistant and where at least one of the consumers has exceptional needs and/or is in exceptional circumstances, such as the following situations: (1) a consumer has a documented inability to hire or retain sufficient staff, where the consumer can document that attempts have been made and that the wage rate is directly responsible for the inability to hire or retain staff and provided further that the consumer is at a nursing home level of care and therefore the lack of sufficient staff will result in institutionalization; (2) a consumer has severe mental and/or physical diagnosis or has several documented social and/or behavioral problems which make him or her extremely difficult to serve; or (3) a consumer resides in a problematic environment which may include housing or geography, or be influenced by the behavior or problems of family members residing with the consumer. |
| C8 | CDPA Live in – Basic | This rate code modifier will be used for the provision of consumer directed personal assistance services on a per diem basis. |
| A1 | AHHA – Hourly | This rate code modifier would be used for the provision of Advanced Home Health Aide services on an hourly basis. |
Attachment B
Subject: Universal billing codes Adult Day Health Care services
ADHC Billing Codes for unbundled services payment: S5102 with Modifiers:
Ul – Basic Level
U2 – Standard Level
U3 – Intensive Level
The services listed under the following modifiers are considered suggestions. Nothing shall prohibit the plan and the ADHC program from developing or adjusting services under each level to meet the needs of the enrollee. In accordance with 425.23, nothing shall prohibit adult day health care programs and managed long term care plans from agreeing to reimbursement terms that reflect a registrant's receipt of less than the full range of adult day health care services.
S5102 (Ul) Basic level
Personal care
Supervision and monitoring Socialization
Meals
Therapeutic recreation and activities
Other services as needed and negotiated between the plan and the ADHC program
S5102 (U2) Standard level
All services in basic level and all ADHC core services listed under 425.5
Other services as needed and negotiated between the plan and the ADHC program
S5102 (U3) Intensive level
All services in basic and standard levels
Intensive skilled nursing including, but not limited to: Tube feeds
Wound care
Hoyer, Marisa or Sara lifts
TB screening and on–going follow–up Palliative care
Other services as needed and negotiated between the plan and ADHC program
