Anthem Blue Cross and Blue Shield Virginia policy
CG-MED-23 Home Health
CG-MED-23 Home Health is a public Anthem Blue Cross and Blue Shield Virginia policy (policy CG-MED-23). It lists 128 CPT or HCPCS codes, 127 of them on the Anthem Blue Cross and Blue Shield Virginia prior authorization list. Not a coverage decision; the payer's own document governs.
- Policy number
- CG-MED-23
- Line of business
- Commercial
- Source
- www.anthem.com
Codes in this policy
The CPT and HCPCS codes the policy names. A policy can name a code it excludes. Prior authorization status is from the Anthem Blue Cross and Blue Shield Virginia prior authorization list.
| Code | Prior authorization | Description on the prior authorization list | Other Anthem Blue Cross and Blue Shield Virginia policies |
|---|---|---|---|
| 99500 | On the list | Home Visit, Prenat Monitor Assess, Fetal Heart Rate, Non-Stress Test, Uterine, Gestat Diabet Monitor | Policies naming 99500 |
| 99503 | On the list | Home Visit, Respiratory Therapy Care (Bronchodilator, Oxygen Therapy, Resp Assess, Apnea Eval) | Policies naming 99503 |
| 99504 | On the list | Home Visit, Mechanical Ventilation Care | Policies naming 99504 |
| 99505 | On the list | Home Visit, Stoma Care & Maintenance, Colostomy, Cystostomy | Policies naming 99505 |
| 99506 | On the list | Home Visit, Im Injections | Policies naming 99506 |
| 99507 | On the list | Home Visit, Care & Maintenance Catheter(S) (Therapy, Drainage, Enteral) | Policies naming 99507 |
| 99509 | On the list | Home Visit, Assistance W/Activities Daily Living & Personal Care | Policies naming 99509 |
| 99511 | On the list | Home Visit, Fecal Impaction Management & Enema Administration | Policies naming 99511 |
| 99512 | On the list | Home Visit, Hemodialysis | Policies naming 99512 |
| 99600 | On the list | Unlisted Home Visit Service/Procedure | Policies naming 99600 |
| 99601 | On the list | Home infusion/specialty drug administration, per visit (up to 2 hours) | Policies naming 99601 |
| 99602 | On the list | Home infusion/specialty drug administration, per visit (up to 2 hours); each additional hour (List separately in additio | Policies naming 99602 |
| G0068 | On the list | Professional services for the administration of anti-infective, pain management, chelation, pulmonary hypertension, and/or inotropic infusion drug(s) for each infusion drug ad | Policies naming G0068 |
| G0069 | On the list | Professional services for the administration of subcutaneous immunotherapy for each infusion drug administration calendar day in the individual's home, each 15 minutes | Policies naming G0069 |
| G0070 | On the list | Professional services for the administration of chemotherapy for each infusion drug administration calendar day in the individual's home, each 15 minutes | Policies naming G0070 |
| G0088 | On the list | Professional services, initial visit, for the administration of anti-infective, pain management, chelation, pulmonary hypertension, inotropic, or other intravenous infusion dr | Policies naming G0088 |
| G0089 | On the list | Professional services, initial visit, for the administration of subcutaneous immunotherapy or other subcutaneous infusion drug or biological for each infusion drug administrat | Policies naming G0089 |
| G0090 | On the list | Professional services, initial visit, for the administration of intravenous chemotherapy or other highly complex infusion drug or biological for each infusion drug administrat | Policies naming G0090 |
| G0151 | On the list | Services performed by a qualified physical therapist in the home health or hospice setting, each 15 minutes | Policies naming G0151 |
| G0152 | On the list | Services performed by a qualified occupational therapist in the home health or hospice setting, each 15 minutes | Policies naming G0152 |
| G0153 | On the list | Services performed by a qualified speech-language pathologist in the home health or hospice setting, each 15 minutes | Policies naming G0153 |
| G0155 | On the list | Services Of Clinical Social Worker In Home Health Or Hospice Settings, Each 15 Minutes | Policies naming G0155 |
| G0156 | On the list | Services Of Home Health/Hospice Aide In Home Health Or Hospice Settings, Each 15 Minutes | Policies naming G0156 |
| G0157 | On the list | Services performed by a qualified physical therapist assistant in the home health or hospice setting, each 15 minutes | Policies naming G0157 |
| G0158 | On the list | Services performed by a qualified occupational therapist assistant in the home health or hospice setting, each 15 minutes | Policies naming G0158 |
| G0159 | On the list | Services performed by a qualified physical therapist, in the home health setting, in the establishment or delivery of a safe and effective physical therapy maintenance program | Policies naming G0159 |
| G0160 | On the list | 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 | Policies naming G0160 |
| G0161 | On the list | 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 m | Policies naming G0161 |
| G0162 | On the list | Skilled services by a registered nurse (RN) for management & evaluation of the plan of care; each 15 minutes (the patient's underlying condition or complication requires an RN | Policies naming G0162 |
| G0299 | On the list | Direct skilled nursing services of a registered nurse (RN) in the home health or hospice setting, each 15 minutes | Policies naming G0299 |
| G0300 | On the list | Direct skilled nursing services of a license practical nurse (LPN) in the home health or hospice setting, each 15 minutes | Policies naming G0300 |
| G0320 | On the list | Home health services furnished using synchronous telemedicine rendered via a real-time two- way audio and video telecommunications system | Policies naming G0320 |
| G0321 | On the list | Home health services furnished using synchronous telemedicine rendered via telephone or other real-time interactive audio-only telecommunications system | Policies naming G0321 |
| G0322 | On the list | The collection of physiologic data digitally stored and/or transmitted by the patient to the home health agency (i.e., remote patient monitoring) | Policies naming G0322 |
| G0493 | Not listed | Policies naming G0493 | |
| G0494 | On the list | 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 requ | Policies naming G0494 |
| G0495 | On the list | 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 | Policies naming G0495 |
| G0496 | On the list | 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 | Policies naming G0496 |
| G2168 | On the list | Services performed by a physical therapist assistant in the home health setting in the delivery of a safe and effective physical therapy maintenance program, each 15 minutes | Policies naming G2168 |
| G2169 | On the list | Services performed by an occupational therapist assistant in the home health setting in the delivery of a safe and effective occupational therapy maintenance program, each 15 | Policies naming G2169 |
| Q5001 | On the list | Hospice or home health care provided in patient's home/residence | Policies naming Q5001 |
| Q5002 | On the list | Hospice or home health care provided in assisted living facility | Policies naming Q5002 |
| Q5009 | On the list | Hospice or home health care provided in place not otherwise specified (nos) | Policies naming Q5009 |
| S5035 | On the list | Home infusion therapy, routine service of infusion device (e.g., pump maintenance) | Policies naming S5035 |
| S5036 | On the list | Home infusion therapy, repair of infusion device (e.g., pump repair) | Policies naming S5036 |
| S5108 | On the list | Home care training to home care client, per 15 minutes | Policies naming S5108 |
| S5109 | On the list | Home care training to home care client, per 15 minutes per session | Policies naming S5109 |
| S5110 | On the list | Home Care Training, Family, Per 15 Minutes | Policies naming S5110 |
| S5111 | On the list | Home Care Training, Family, Per Session | Policies naming S5111 |
| S5115 | On the list | Home Care Training, Non-Family, Per 15 Minutes | Policies naming S5115 |
| S5116 | On the list | Home Care Training, Non-Family, Per Session | Policies naming S5116 |
| S5180 | On the list | Home Health Respiratory Therapy, Initial Evaluation | Policies naming S5180 |
| S5181 | On the list | Home Health Respiratory Therapy, NOS, Per Diem | Policies naming S5181 |
| S5497 | On the list | Home infusion therapy, catheter care/maintenance, not otherwise classified | Policies naming S5497 |
| S5498 | On the list | Home infusion therapy, catheter care/maintenance, simple (single lumen) | Policies naming S5498 |
| S5501 | On the list | Home infusion therapy, catheter care/maintenance, complex (more than one lumen) | Policies naming S5501 |
| S5502 | On the list | Home infusion therapy, catheter care/maintenance, implanted access device | Policies naming S5502 |
| S5517 | On the list | Home infusion therapy, all supplies necessary for restoration of catheter potency or declotting | Policies naming S5517 |
| S5518 | On the list | Home infusion therapy, all supplies necessary for catheter repair | Policies naming S5518 |
| S5520 | On the list | Home infusion therapy, all supplies (including catheter) necessary for a peripherally inserted central venous catheter ( | Policies naming S5520 |
| S5521 | On the list | Home infusion therapy, all supplies (including catheter) necessary for midline catheter insertion | Policies naming S5521 |
| S5522 | On the list | Home infusion therapy, insertion of peripherally inserted central venous catheter (PICC), nursing services only (no supp | Policies naming S5522 |
| S5523 | On the list | Home infusion therapy, insertion of midline central venous catheter, nursing services only (no supplies or catheter incl | Policies naming S5523 |
| S9061 | On the list | Medical Supplies And Equipme | Policies naming S9061 |
| S9097 | On the list | Home Visit For Wound Care | Policies naming S9097 |
| S9122 | On the list | Home health aide or certified nurse assistant, providing care in the home; per hour | Policies naming S9122 |
| S9123 | On the list | Nursing care, in the home; by registered nurse, per hour (use for general nursing care only, not to be used when CPT cod | Policies naming S9123 |
| S9124 | On the list | Nursing care, in the home; by licensed practical nurse, per hour | Policies naming S9124 |
| S9127 | On the list | Social Work Visit, In The Ho | Policies naming S9127 |
| S9128 | On the list | Speech Therapy, In The Home | Policies naming S9128 |
| S9129 | On the list | Occupational Therapy, In The | Policies naming S9129 |
| S9131 | On the list | Physical therapy, in the home, per diem | Policies naming S9131 |
| S9209 | On the list | Home management of preterm premature rupture of membranes (pprom) | Policies naming S9209 |
| S9211 | On the list | Home management of gestational hypertension | Policies naming S9211 |
| S9212 | On the list | Home management of postpartum hypertension | Policies naming S9212 |
| S9213 | On the list | Home management of preeclampsia | Policies naming S9213 |
| S9214 | On the list | Home management of gestational diabetes | Policies naming S9214 |
| S9325 | On the list | Home infusion therapy, pain management infusion (do not use this code with S9326, S9327 or S9328) | Policies naming S9325 |
| S9326 | On the list | Home infusion therapy, continuous pain management infusion | Policies naming S9326 |
| S9327 | On the list | Home infusion therapy, intermittent pain management infusion | Policies naming S9327 |
| S9328 | On the list | Home infusion therapy, implanted pump pain management infusion | Policies naming S9328 |
| S9329 | On the list | Home infusion therapy, chemotherapy infusion (do not use this code with S9330 or S9331) | Policies naming S9329 |
| S9330 | On the list | Home infusion therapy, continuous chemotherapy infusion | Policies naming S9330 |
| S9331 | On the list | Home infusion therapy, intermittent chemotherapy infusion | Policies naming S9331 |
| S9336 | On the list | Home infusion therapy, continuous anticoagulant infusion therapy (e.g., Heparin) | Policies naming S9336 |
| S9338 | On the list | Home infusion therapy, immunotherapy therapy | Policies naming S9338 |
| S9345 | On the list | Home infusion therapy, anti-hemophilic agent infusion therapy (e.g., factor VIII) | Policies naming S9345 |
| S9346 | On the list | Home infusion therapy, alpha-1-proteinase inhibitor (e.g., Prolastin) | Policies naming S9346 |
| S9348 | On the list | Home infusion therapy, sympathomimetic/inotropic agent infusion therapy (e,g. Dobutamine) | Policies naming S9348 |
| S9351 | On the list | Home infusion therapy, continuous or intermittent anti-emetic infusion therapy; administrative services, professional ph | Policies naming S9351 |
| S9353 | On the list | Home infusion therapy, continuous insulin infusion therapy | Policies naming S9353 |
| S9357 | On the list | Home infusion therapy, enzyme replacement intravenous therapy; (e.g., Imiglucerase) | Policies naming S9357 |
| S9361 | On the list | Home infusion therapy, diuretic intravenous therapy | Policies naming S9361 |
| S9363 | On the list | Home infusion therapy, anti-spasmotic intravenous therapy | Policies naming S9363 |
| S9364 | On the list | Home infusion therapy, total parenteral nutrition (TPN) (do not use with home infusion codes S9365-S9368 using daily vol | Policies naming S9364 |
| S9365 | On the list | Home infusion therapy, total parenteral nutrition (TPN); one liter per day | Policies naming S9365 |
| S9366 | On the list | Home infusion therapy, total parenteral nutrition (TPN); more than one liter but no more than two liters per day | Policies naming S9366 |
| S9367 | On the list | Home infusion therapy, total parenteral nutrition (TPN); more than two liter but no more than three liters per day | Policies naming S9367 |
| S9368 | On the list | Home infusion therapy, total parenteral nutrition (TPN); more than three liter per day | Policies naming S9368 |
| S9370 | On the list | Home therapy, intermittent anti-emetic injection therapy | Policies naming S9370 |
| S9372 | On the list | Home infusion therapy, intermittent anticoagulant injection therapy; (e.g., Heparin); (do not use this code for flushing | Policies naming S9372 |
| S9373 | On the list | Home infusion therapy, hydration therapy (do not use with hydration therapy codes S9374- S9377 using daily volume scales) | Policies naming S9373 |
| S9374 | On the list | Home infusion therapy, hydration therapy; one liter per day | Policies naming S9374 |
| S9375 | On the list | Home infusion therapy, hydration therapy; more than one liter but no more than two liters per day | Policies naming S9375 |
| S9376 | On the list | Home infusion therapy, hydration therapy; more than two liters but no more than three liters per day | Policies naming S9376 |
| S9377 | On the list | Home infusion therapy, hydration therapy; more than three liters per day | Policies naming S9377 |
| S9379 | On the list | Home infusion therapy, infusion therapy, not otherwise classified; administrative services, professional pharmacy servic | Policies naming S9379 |
| S9490 | On the list | Home infusion therapy, corticosteroid infusion; administrative services, professional pharmacy services, care coordinati | Policies naming S9490 |
| S9494 | On the list | Home infusion therapy, antibiotic, antiviral, or antifungal therapy (do not use with home infusion codes for hourly dosi | Policies naming S9494 |
| S9497 | On the list | Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every three hours | Policies naming S9497 |
| S9500 | On the list | Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 24 hours | Policies naming S9500 |
| S9501 | On the list | Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 12 hours | Policies naming S9501 |
| S9502 | On the list | Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 8 hours | Policies naming S9502 |
| S9503 | On the list | Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every six hours | Policies naming S9503 |
| S9504 | On the list | Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every four hours | Policies naming S9504 |
| S9538 | On the list | Home transfusion of blood product(s) (blood products, drugs and nursing visits coded separately), per diem | Policies naming S9538 |
| S9542 | On the list | Home injectable therapy; not otherwise classified | Policies naming S9542 |
| S9560 | On the list | Home injectable therapy; hormonal therapy (e.g., leuprolide, goserelin) (drugs and nursing visits coded separately), per | Policies naming S9560 |
| S9590 | On the list | Home Therpay, Irrigation Therpay (E.G. Sterile Irrigation Of An Organ | Policies naming S9590 |
| S9810 | On the list | Home therapy; professional pharmacy service for provision of infusion, specialty drug administration, and/or disease sta | Policies naming S9810 |
| T1001 | On the list | Nursing assessment/evaluation | Policies naming T1001 |
| T1002 | On the list | RN services, up to 15 minutes | Policies naming T1002 |
| T1003 | On the list | LPN/LVN services, up to 15 minutes | Policies naming T1003 |
| T1004 | On the list | Services of a qualified nursing aide, up to 15 minutes | Policies naming T1004 |
| T1021 | On the list | Home Health Aide Or Certified Nurse Assistant, Per Visit | Policies naming T1021 |
| T1022 | On the list | Contracted Home Health Agency Services, All Services Provided Under Co | Policies naming T1022 |
| T1030 | On the list | Nursing Care, In The Home, By Registered Nurse, Per Diem | Policies naming T1030 |
| T1031 | On the list | Nursing Care, In The Home, By Licensed Practical Nurse, Per Diem | Policies naming T1031 |
All Anthem Blue Cross and Blue Shield Virginia policies · Anthem Blue Cross and Blue Shield Virginia prior authorization CPT list