DAL-Universal Billing Codes for Home and Community LTC

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September 22, 2017

Subject: Revision to Universal Billing Codes for Home Care and Adult Day Health Care Services

Dear Providers and Plans:

This is to advise providers and plans of the revision of billing codes as set forth in the original release date of January 3, 2017 by the Department of Health. As you are aware, 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. Claims under contracts or agreements between long term care providers and managed long term care plans or managed 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 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 is 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 January 1, 2018.

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 Procedure Code Procedure Code Description Modifier
Personal Care Aide Level I (Homemaker/Housekeeper)
PCS Level I – 15 Minutes Per 15 minutes S5130 Homemaker service, NOS; per 15 minutes Ul
PCS Level I Two Client Per 15 minutes S5130 Homemaker service, NOS; per 15 minutes U2
PCS Level I Multiple Client Per 15 minutes S5130 Homemaker service, NOS; per 15 minutes U3
PCS Level I Weekend/Holiday Per 15 minutes S5130 Homemaker service, NOS; per 15 minutes TV
Personal Care Aide Level II
PCS Level II Basic – 15 Minutes Per 15 minutes T1019 Personal care services, per 15 minutes, not for an inpatient or resident of a hospital, nursing facility, ICF/MR or IMD, part of the individualized plan of treatment {code may not be used to identify services provided by home health aide or certified nurse assistant) Ul
PCS Level II Basic Two Client Per 15 minutes T1019 Personal care services, per 15 minutes, not for an inpatient or resident of a hospital, nursing facility, ICF/MR or IMD, part of the individualized plan of treatment {code may not be used to identify services provided by home health aide or certified nurse assistant) U2
PCS Level II Multiple Client Per 15 minutes T1019 Personal care services, per 15 minutes, not for an inpatient or resident of a hospital, nursing facility, ICF/MR or IMD, part of the individualized plan of treatment {code may not be used to identify services provided by home health aide or certified nurse assistant) U3
PCS Level II Weekend/Holiday Per 15 minutes T1019 Personal care services, per 15 minutes, not for an inpatient or resident of a hospital, nursing facility, ICF/MR or IMD, part of the individualized plan of treatment {code may not be used to identify services provided by home health aide or certified nurse assistant) TV
PCS Level II Hard to Serve Per 15 minutes T1019 Personal care services, per 15 minutes, not for an inpatient or resident of a hospital, nursing facility, ICF/MR or IMD, part of the individualized plan of treatment {code may not be used to identify services provided by home health aide or certified nurse assistant) U4
PCS Level IITwo Client Hard to Serve Per 15 minutes T1019 Personal care services, per 15 minutes, not for an inpatient or resident of a hospital, nursing facility, ICF/MR or IMD, part of the individualized plan of treatment {code may not be used to identify services provided by home health aide or certified nurse assistant) U5
PCS Level II Live in Per diem {13 hours) T1020 * Personal care services, per diem, not for an inpatient or resident of a hospital, nursing facility, JCF/MR or IMD, part of the individualized plan of treatment {code may not be used to identify services provided by home health aide or certified nurse assistant) NONE
PCS Level II Live in Two Client Per diem {13 hours) T1020 * Personal care services, per diem, not for an inpatient or resident of a hospital, nursing facility, JCF/MR or IMD, part of the individualized plan of treatment {code may not be used to identify services provided by home health aide or certified nurse assistant\ U2
PCS Level II Live in Weekend/Holiday Per diem {13 hours) T1020 * Personal care services, per diem, not for an inpatient or resident of a hospital, nursing facility, ICF/MR or IMD, part of the individualized plan of treatment {code may not be used to identify services provided by home health aide or certified nurse assistant! TV
PCS Level II Live in Two Client Hard to Serve Per diem (13 hours) T1020 * Personal care services, per diem, not for an inpatient or resident of a hospital, nursing facility, ICF/MR or !MD, part of the individualized plan of treatment (code may not be used to identify services provided by home health aide or certified nurse assistant\ U5
Consumer Directed Personal Assistant
CDPA Basic – 15 Minutes Per 15 minutes T1019 Personal care services, per 15 minutes, not for an inpatient or resident of a hospital, nursing facility, ICF/MR or IMD, part of the individualized plan of treatment (code may not be used to identify services provided by home health aide or certified nurse assistant) U6
CDPA Enhanced Per 15 minutes T1019 Personal care services, per 15 minutes, not for an inpatient or resident of a hospital, nursing facility, ICF/MR or IMD, part of the individualized plan of treatment (code may not be used to identify services provided by home health aide or certified nurse assistant) U8
CDPA Two Consumer Per 15 minutes T1019 Personal care services, per 15 minutes, not for an inpatient or resident of a hospital, nursing facility, ICF/MR or IMD, part of the individualized plan of treatment (code may not be used to identify services provided by home health aide or certified nurse assistant) U7
CDPA Two Consumer Enhanced Per 15 minutes T1019 Personal care services, per 15 minutes, not for an inpatient or resident of a hospital, nursing facility, ICF/MR or IMD, part of the individualized plan of treatment (code may not be used to identify services provided by home health aide or certified nurse assistant) U9
CDPA Live in Per diem (13 hours) T1020 * Personal care services, per diem, not for an inpatient or resident of a hospital, nursing facility, ICF/MR or IMD, part of the individualized plan of treatment (code may not be used to identify services provided by home health aide or certified nurse assistant\ U6
CDPA Live in Enhanced Per diem (13 hours) T1020 * Personal care services, per diem, not for an inpatient or resident of a hospital, nursing facility, ICF/MR or IMD, part of the individualized plan of treatment (code may not be used to identify services provided by home health aide or certified nurse assistant\ U8
CDPA Live in Two Consumer Per diem (13 hours) T1020 * Personal care services, per diem, not for an inpatient or resident of a hospital, nursing facility, ICF/MR or IMD, part of the individualized plan of treatment (code may not be used to identify services provided by home health aide or certified nurse assistant) U7
CDPA Live in Two Consumer Enhanced Per diem (13 hours) T1020 * Personal care services, per diem, not for an inpatient or resident of a hospital, nursing facility, ICF/MR or IMD, part of the individualized plan of treatment (code may not be used to identify services provided by home health aide or certified nurse assistant) U9
*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 Health Aide
HHA – 15 minutes Per 15 minutes S5125 Attendant care services; per 15 minutes NONE
HHA Per hour S9122 Home health aide or certified nurse assistant, providing care in the home; per hour NONE
HHA Two Client Per 15 minutes S5125 Attendant care services; per 15 minutes U2
HHA – Live in Per diem {13 hours) S5126 Attendant care services; per diem NONE
HHA Live in Two Client Per diem (13 hours) S5126 Attendant care services; per diem U2
Advanced Home Health Aide Per hour S9122 Home health aide or certified nurse assistant, providing care in the home; per hour Ul
Nursing Services
Nursing Assessment/Evaluation Per visit T1001 Nursing Assessment/evaluation NONE
UAS Assessment Per visit T2024 T1001–Nursing Assessment/evaluation. T2024–Service Assessment/plan of care development. NONE
UAS Reassessment Per visit T2024 T1001–Nursing Assessment/evaluation. T2024–Service Assessment/plan of care development. NONE
Nursing Care in Home (RN) Per diem (13 hours) T1030 Nursing care, in the home, by registered nurse, per diem NONE
RN Per hour S9123 Nursing care, in the home; by registered nurse, per hour (use for general nursing care only, not to be used when CPT codes 99500–99602 can be used) NONE
RN – 15 minutes Per 15 minutes T1002 RN services, up to 15 minutes NONE
Nursing Care in Home (LPN) Per diem (13 hours) T1031 Nursing care, in the home, by licensed practical nurse, per diem NONE
LPN Per hour S9124 Nursing Care, in the home; by licensed practical nurse, per hour NONE
LPN – 15 minutes Per 15 minutes T1003 LPN/LVN services, up to 15 minutes NONE
Home Health Care Services
Occupational Therapy Per visit S9129 Occupational therapy, in the home, per diem NONE
Physical Therapy Per visit S9131 Physical therapy, in the home, per diem NONE
Speech Therapy Per visit S9128 Speech therapy, in the home, per diem NONE
Respiratory Therapy Per 15 minutes G0237 Therapeutic procedures to increase strength or endurance of respiratory muscles, one–on–one, face–to–face, per 15 minutes (includes monitoring) NONE
Respiratory Therapy Per 15 minutes G0238 Therapeutic procedures to improve respiratory function, other than described by G0237, one–on–one, face–to–face, per 15 minutes (includes monitoring) NONE
Nutritional Counseling Per visit S9470 Nutritional counseling, dietician visit NONE
Medical Social Services Per visit S9127 Social work visit, in the home, per diem NONE
Sign Language/Oral interpreter Per 15 minutes T1013 Sign language or oral interpretive services, per 15 minutes NONE
Social and Environmental Supports –Home Modification Per service S5165 Home modifications; per service NONE
Social and Environmental Supports –Assessment Per service T1028 Assessment of home, physical and family environment, to determine suitability to meet patients medical needs NONE
Telehealth
Installation Per service 59110 Telemonitoring of patient in their home, including all necessary equipment; computer system, connections, and software; maintenance; patient education and support; per month NONE
Monitoring Monthly 59110 Telemonitoring of patient in their home, including all necessary equipment; computer system, connections, and software; maintenance; patient education and support; per month U1
Medication Dispensers
Installation One Time Tl505 Electronic medication compliance management device, includes all components and accessories, not otherwise classified NONE
Monitoring Monthly 55185 Medication reminder service, nonface–to–face; per month NONE

Attachment A

Note: For modifiers that state "as defined by each state", please refer to the column labeled NYS Definition. Each program utilizes modifiers for their specific program. Modifiers may be utilized more than once and are unique based on individual program

Modifier Descriptions

Modifier Modifier Description NYS Definition Notes
Personal Care Aide Level I (Homemaker/Housekeeper)
U1 Medicaid level of care 1, as defined by each state This rate code modifier will be used for the provision of personal care Level I for basic services.  
U2 Medicaid level of care 2, as defined by each state This rate code modifier will be used for the provision of personal ca re Level I services to one of two clients in the same household where both clients are receiving personal care services from the sa me aide.  
U3 Medicaid level of care 3, as defined by each state This rate code modifier will be used for the provision of personal ca re Level I 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.  
TV Special payment rate, holidays/weekends   This rate code modifier will be used for the provision of personal care Level I services on weekends (defined as between Saturday 8 a.m. to Monday 8 a.m.) and designated holidays.
Personal Care Aide Level II
U1 Medicaid level of care 1, as defined by each state This rate code modifier will be used for the provision of personal care Level II for basic services.  
U2 Medicaid level of care 2, as defined by each state This rate code modifier will be used for the provision of personal care 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 Medicaid level of care 3, as defined by each state This rate code modifier will be used for the provision of personal care 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 Medicaid level of care 4, as defined by each state 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.  
U5 Medicaid level of care 5, as defined by each state 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.  
TV Special payment rate, holidays/weekends   This rate code modifier will be used for the provision of personal care Level I or Level II (defined as between Saturday 8 a.m. to Monday 8 a.m.) and designated holidays.
Consumer Directed Personal Assistant
U6 Medicaid level of care 6, as defined by each state This rate code modifier will be used for the provision of consumer directed personal assistance services for basic services.  
U7 Medicaid level of care 7, as defined by each state 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.  
U8 Medicaid level of care 8, as defined by each state 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.  
U9 Medicaid level of care 1, as defined by each state 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.  
Telehealth
U1 Medicaid level of care 1, as defined by each state This rate code modifier would be used for the monthly fee of telemonitoring of patient.  
Home Health Aide
U1 Medicaid level of care 1, as defined by each state This rate code modifier would be used for the provision of Advanced Home Health Aide services on an hourly basis.  
U2 Medicaid level of care 2, as defined by each state 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.  

Attachment B

ADULT DAY HEALTH CARE BILLING CODES AND MODIFIERS

Service Type Unit of Measurement Procedure Code Procedure Code Description Modifier
Adult Day Health Care – Basic Level Per Diem 55102 Day care services, adult; per diem U1
Adult Day Health Care – Standard Level Per Diem 55102 Day care services, adult; per diem U2
Adult Day Health Care – Intensive Level Per Diem 55102 Day care services, adult; per diem U3

Attachment B

Modifier Descriptions

ADULT DAV HEALTH CARE PROGRAM
Modifier Modifier Description NYS Definition
U1 Medicaid level of care 1, as defined by each state Services will include, personal care, supervision and monitoring, socialization, meals, therapeutic recreation activities.
U2 Medicaid level of care 2, as defined by each state All services in basic level and all ADHC core services listed under 425.5.
U3 Medicaid level of care 3, as defined by each state All 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.