CPT CODE S5140, T1019, S5100, H2011 with covered DX

Certified Family Home

HCPCS Description Place of Service S5140  

Certified Family Home – Daily One to two participants Foster Care – Adult; per diem 1 unit = 1 day T1019 Personal Care Service per 15 minutes

S5100 Adult Foster Care H2011 Crisis intervention per 15 minutes

12 Home

33 Custodial Care Facility

99 Other

HCPCS Modifier Description Diagnosis Place of Service

H2019 Therapeutic Behavioral Services 1 Unit = 15 minutes

H2019 HM Therapeutic Behavioral Services Limited to 96 units per calendar month. 1 Unit = 15 minutes

H2011 Community Crisis supports (1 unit = 15 minutes)

Based on dates of service, enter the ICD-9-CM code V60.4 or the ICD-10-CM code Z74.2 for the primary diagnosis.

For more information on which ICD version to use, refer to ICD-9 and ICD-10 Diagnosis Billing Requirements.

11 Office

12 Home

99 Other (Community)

Residential Habilitation and Respite Care CPT codes HCPCS Modifier Description 

H2011 Community Crisis Supports (1 unit = 15 min)

H2015 Comprehensive Community Support Services; per 15 minutes (24-hour/day unavailable under hourly services) for participants who live in their own home or apartment or live with a non-paid caregiver. 

This code requires PA.

1 Unit = 15 minutes

H2015 HQ Comprehensive Community Support Services; per 15 minutes Supported living for two or three participants who live in their own home or apartment or live with a non-paid caregiver. This code requires PA. 

1 Unit = 15 minutes 24 hour/day unavailable under hourly serviced.

H2022 Community Based Services, per diem 24 hours per day support and supervision. Provided through a blend of 1:1 and group staffing.

H2016 Comprehensive Community Support Services, per diem 24 hours per day support and supervision.

Typically requires 1:1 staffing but requests for blend of 1:1 and group staffing will be reviewed on a case-by-case basis.

Diagnosis Place of Service

Based on dates of service, enter the ICD-9-CM code V60.4 or ICD-10-CM code Z74.2 for the primary diagnosis. 12 Home (CFH, participant’s own home, or home of unpaid family) 99 Other (Community) This code should only be used when the participant receives hourly supported living to access the community. All other RES/HAB should be coded as Home.

HCPCS Modifier Description 

S5100 Day Care Services Adult; per 15 minutes

S5140  Certified Family Home Foster Care Adult; per diem

T2025 Agency - Certified Family Home Affiliation Fee DD Waiver Agency - Certified Family Home Affiliation Fee PA number must be billed on claim for payment consideration

Certified Family Home (CFH) - Agency Affiliation Fee

HCPCS Modifier Description Diagnosis Place of Service

T1005 Respite Care Services, up to 15 minutes 1 Unit = 15 minutes. (CFH, participant’s own home, or home of unpaid family) 99 Other (Community) . This code should only be used when the participant receives hourly supported living to access the community. All other RES/HAB should be coded as, Home.

S9125 Respite Care, In the Home, per diem 1 Unit = 1 day

Maximum of six hours per day or 24 units. Based on dates of service, enter the ICD-9-CM code V60.4 or ICD-10-CM code Z74.2 for the primary diagnosis.

For more information on which ICD version to use, refer to ICD-9 and ICD-10 Diagnosis Billing Requirements.

12 Home 

Billing CPT 97760 with covered diagnosis 

ORTHOTIC MANAGEMENT AND PROSTHETIC MANAGEMENT

Orthotic Training (CPT code 97760)

The draft LCD states that “usually less than 30 minutes is necessary for static orthotics training” and that typically “orthotic training can be completed in three (3) visits.” That may not be true for patients with complicated orthoses, or those whose activities require increasing use of the affected limb. AOTA requests that the time frequency limitations be removed as prohibited by “rule of thumb” restrictions. Documentation always should support the number of visits requested.

COVERAGE LIMITATIONS

AOTA takes exception to the definitive statement, “Medicare will cover no more than two re-evaluations per patient per course of injury/illness”. We understand that re-evaluation of a person occurs as part of every treatment session, and it would not be appropriate to bill 97004 each time. However, we do not agree that it is appropriate to initiate a seemingly incontrovertible coverage rule in an LCD. As stated above, we do not support “rule of thumb” frequency and duration numbers, but completely support the need for documentation when unusual circumstances arise. 

ICD 9 CM Code List

The draft LCD states that "it is the provider's responsibility to select the codes carried out to the highest level of specificity and selected from the ICD-9-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted." AOTA agrees with this statement and believes that Highmark should rely on the provider to choose the appropriate codes. 

For this reason, we believe that the code lists that follow the statement above should be deleted. Further, we are concerned that the list of ICD-9-CM codes in the draft LCD is missing codes that could be used to support medical necessity. 

For example, the code 438.9 Unspecified late effects of cerebrovascular disease is not listed in the draft LCD, yet is specifically included in CMS Transmittal 14144 among the ICD 9 codes "that are likely to quality for the automatic process therapy cap exception based on clinical condition or complexity." 

Billing Bariatric Surgery Procedures CPT 43770, 43644,43845 - covered DX

Effective for services on or after February 21, 2006, Medicare has determined that the following bariatric surgery procedures are reasonable and necessary under certain conditions for the treatment of morbid obesity. The patient must have a body-mass index (BMI) ≥35, have at least one co-morbidity related to obesity, and have been previously unsuccessful with medical treatment for obesity. This medical information must be documented in the patient's medical record. In addition, the procedure must be performed at an approved facility.

Covered HCPCS Procedure Codes

For services on or after February 21, 2006, the following HCPCS procedure codes are covered for bariatric surgery:

• 43770 - Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric band (gastric band and subcutaneous port components).

• 43644 - Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy (roux limb 150 cm or less).

• 43645 - Laparoscopy with gastric bypass and small intestine reconstruction to limit absorption. (Do not report 43645 in conjunction with 49320, 43847.)

• 43845 - Gastric restrictive procedure with partial gastrectomy, pylorus-preserving duodenoileostomy and ileoieostomy (50 to 100 cm common channel) to limit absorption (biliopancreatic diversion with duodenal switch).

• 43846 - Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb (150 cm or less Roux-en-Y gastroenterostomy. (For greater than 150 cm, use 43847.) (For laparoscopic procedure, use 43644.)

• 43847 - With small intestine reconstruction to limit absorption.

Noncovered HCPCS Procedure Codes

For services on or after February 21, 2006, the following HCPCS procedure codes are non-covered for bariatric surgery:

• 43842 - Gastric restrictive procedure, without gastric bypass, for morbid obesity; vertical banded gastroplasty.

• NOC code 43999 used to bill for:

• Laparoscopic vertical banded gastroplasty.

• Open sleeve gastrectomy.

• Laparoscopic sleeve gastrectomy.

• Open adjustable gastric banding.

ICD-9 Diagnosis Codes for Bariatric Surgery

278.01 - Morbid obesity; severe obesity

The following ICD-9 diagnosis codes identify BMI ≥35:

• V85.35 - Body Mass Index 35.0-35.9, adult.

• V85.36 - Body Mass Index 36.0-36.9, adult.

• V85.37 - Body Mass Index 37.0-37.9, adult.

• V85.38 - Body Mass Index 38.0-38.9, adult.

• V85.39 - Body Mass Index 39.0-39.9, adult.

• V85.4 - Body Mass Index 40 and over, adult.

Home Care Procedure Codes Table

ICS Service Provided HCPCS Modifier 1 Modifier 2 Modifier 3 Notes Home Health Aide S5125 

Housekeeper - Hourly T1019 1A Housekeeper - One

Time Only T1019 1A 1D 1D Modifier used to distinguish one time cleaning

Housekeeper - One Time Only T1019 1A 1D 1J 1D Modifier used to distinguish

one time cleaning 1J Modifier used to distinguish heavy duty cleaning

Personal Assistant T1019 1B 1B Modifier used to support PA rate Personal Assistant -

Mutual T1019 1B 1B Modifier used to support PA rate

Personal Assistant - Sleep In

T1019 1B 1B Modifier used to support PA rate

Personal Assistant - Sleep In Mutual T1019 1B 1M

1B Modifier used to support PA rate

1M Modifier used to support reduced (half) daily rate Personal Care Aide T1019

Personal Care Aide - Mutual T1019

Personal Care Aide - Sleep In

T1019 Personal Care Aide -

Sleep In Mutual T1019 1M 1M Modifier used to support reduced (half) daily rate

Personal Care Aide BFL Cluster T1019 1I

1I Modifier used to support different rate (CHCA contract only)

* Please use hourly rate: Please convert all 15 minute increments into an hourly rate (i.e. If you are billing one unit, we will process it as one hour, not as a 15 minute increment).

1. All mutual cases shall be billed at the hourly rate multiplied by the number of hours spent caring for each members

2. All sleep-in cases for dates of service of 5/1/2014 and later will require HCPCS code T1020 to be billed instead of HCPCS code T1019. The rate billed should be the hourly rate multiplied by 12 hours. The total amount (hourly rate X 12) should be billed as one unit.

3. All sleep-in mutual cases for dates of service as of 5/1/2014 and later will require HCPCS code T1020 to be billed instead of HCPCS code T1019. The rate billed should be the hourly rate multiplied by six hours. The total amount (hourly rate X six hours per member) should be billed as one unit.

Procedure Description Notes

T1019 Personal Care

Assistant, 15 min

Requires applicable modifiers per DHS guidelines. Modifier Description Notes

T1019.UA Supervision of Personal Care

Assistance, 15 min To bill Medica:

• The PCA Agency should bill with the Agency’s name and not an individual PCA.

• Must be billed on a CMS-1500 form. 

T1019.UC Extended Personal Care 1:1, 15 min

The UC modifier is used for Extended PCA services. 

T1019.TT Shared Personal Care 1:2, 15 min

The TT modifier is used for Shared PCA services. T1019.HQ Group Setting

Personal Care 1:3, 15 min

The HQ modifier is used for Group Setting PCA services.. T1019.TT.UC Shared/Extended/

Related/PCA More than two modifiers might be required; In this example the provider is billing for Shared and Extended  ervices. T1019.U5 Transitional Decrease in Units T1019.U6 Temporary Increase in Units Note: 

All PCA services require prior authorization. View Prior Authorization List & Request Form on medica.com. Medica can read all applicable modifiers, so be sure to correctly bill using all applicable modifiers,  including relationship modifiers.

34 Centers for Medicare & Medicaid Services. (2016). 2016 Alpha-Numeric HCPCS File [Excel Spreadsheet, codes G0156, T1019]. 

35 Definitions, 42 C.F.R. § 441.505. 

38 HIPAASpace. (n.d.). HCPCS 2016 Code: T1019. 

39 U.S. Department of Health and Human Services. Centers for Disease Control and Prevention. National Center for Health Statistics. (2013, December). Long-Term Care Services in the United States: 2013 Overview (p. 3). 

40 Paraprofessional Healthcare Institute. (2013, March). State Data Center. United States: Employment Projections. 


* S0105 HABILITATION ATTENDANT CARE SERVICES - DELEGATED NURSING 10A HC S5125 P A 01/01/1900 12/31/2199

* S0105 HABILITATION PERSONAL CARE SERVICES - NURSING 10A HC T1019 P A 01/01/1900 12/31/2199

* S0107 HABILITATION - PREVOCATIONAL 10B HC T2015 U4 P A 01/01/1900 12/31/2199

* G6085 CDS HABILITATION-TRAINING 10V HC T2016 P A 12/01/2013 12/31/2199

* G6086 CDS HABILITATION-ADL'S 10V HC T2016 U5 P A 12/01/2013 12/31/2199

* G6087 CDS HABILITATION- TAXES 10V HC T2016 UG P A 12/01/2013 12/31/2199

* G6088 CDS HABILITATION-ES/BENEFITS 10V HC T2016 UF P A 12/01/2013 12/31/2199

* G0128 RESPITE - OUT-OF-HOME 11A HC S5151 P A 01/01/1900 12/31/2199

* G0170 AGENCY ADMIN - OUT OF HOME RESPITE CDS 11A ER P A 01/01/1900 12/31/2199

* G0302 NURSING SERVICES BY LPN/LVN 13A HC T1003 P A 01/01/1900 12/31/2199

* G0303 NURSING SERVICES - RN 13B HC T1002 P A 01/01/1900 12/31/2199

* T1002 SPECIALIZED NURSING RN 13C HC T1002 TG TD P A 01/01/2008 12/31/2199

* T1003 SPECIALIZED NURSING LVN 13D HC T1003 TG TE P A 01/01/2008 12/31/2199

• Be sure to bill the units as appropriate for each type of service. For example:

— T1019 Level 2: Directed towards more physical support of the patient, e.g. bathing, dressing, etc. Service is billed in 15 minute increments. One hour of service equals 4 billed units.

— T1020 Level 2: Intended for individuals requiring up to 12 hours of assistance in a given day. Service is billed in daily (per diem) increments. One day of service equals 1 unit.

— S9124: LPN Services. Service is billed in hourly increments. One hour of service equals 1 unit.

— Q3014: Telehealth Installation Service. Service is billed by minute increments. One minute equals 1 unit.  

Attachment A – Revenue Code/HCPCS Combination examples This list is not complete and is subject to change.

CPT/HCPCS Code Description Units billed as Acceptable Place of Service (POS) Rev Code Bill Type S5102 Day care services, adult 1 unit = 1 day 99: Other Facility 0569 0231-0238 S5105 Center-based day care services 1 unit = 1 day 99: Other Facility 0560 0231-0238 S5130 Personal Care Services 1 unit = 15 min 12: Home 0580 0321-0328 T1019 1 unit = 15 min

T1020 1 unit = 1 day S9124 LPN per hour As indicated in description Inpatient: 21 Outpatient: 12

Inpatient: 0989 Outpatient: 0589 0321-0329 T1030 RN per diem T1031 LPN per diem

97802 Medical Nutrition/ Medical NutritionIndividual 1 unit = 1 service 22: outpatient 0942 0131-0138 97803

Q3014 Telehealth 1 unit = 1 minute 12: Home 0780 0321-0329 T1014 0969

Variable* Outpatient Rehabilitation

22: outpatient 0420-0449 0131-0138