Billing Codes
T1001: Nursing Assessment/Initial Evaluation: A physician’s written report and a Claims Examiner’s prior authorization is required before the in-home assessment is conducted. Typically only one (1) in-home initial evaluation is authorized for a claimant. Once an authorization is approved by the DEEOIC, an assessment can be performed.
T1017: Targeted Case Management (15 minutes = 1 Unit): This service requires prior authorization from the DEEOIC Claims Examiner for a Registered Nurse to perform targeted case management. This is limited to the clinical impact of a claimant’s accepted work-related condition on his/her current medical status. The skill level of a Registered Nurse is required for this targeted case management activity. The Claims Examiner’s authorization will specify the number of hours authorized for a case management visit. Each unit of a T1017 code is equal to 15 minutes; therefore, if a nurse case manager is at the claimant’s home for an assessment for one hour, the proper number of units to bill for this T1017 code is 4 units.
T1019: Personal Care Attendant (PCA) (15 Minutes = 1 Unit): This service requires prior authorization from the Claims Examiner. Attendant services are non-skilled services routinely provided in an in-home setting. These services assist claimants with activities of daily living (i.e. bathing, feeding, dressing, etc.) Attendant services must be provided by a home health aide, licensed practical nurse, or similarly trained individual. A family member who is also a trained personal care attendant can only be approved for up to 12 hours of care per day.
An attendant can only be approved for care if there is sufficient medical rationale from a physician stipulating the specific need for personal care services related to the accepted work related condition that requires an attendant.
Each unit of a T1019 code is equal to 15 minutes; therefore, if an attendant provides services for one hour, the proper number of units to bill for this T1019 code is 4 units. Under no circumstances should this code be authorized for more than 7 hours and 45 minutes (31 units) of care per day.
T1020: Personal Care Services (PCA) Per Diem (8 hrs.): This service requires prior authorization from the DEEOIC Claims Examiner. Attendant services are non-skilled services routinely provided in an in-home setting. These services assist claimants with activities of daily living (i.e. bathing, feeding, dressing, etc.) Attendant services must be provided by a home health aide, licensed practical nurse, or similarly trained individual. A family member who is also a trained personal care attendant can only be approved for up to 12 hours of care per day.
An attendant can only be approved for care if there is sufficient medical rationale from a physician stipulating the specific need for personal care services related to the accepted work related condition that requires an attendant.
12-hour care: For personal care services approved for 12 hour care, the bill must be submitted with one unit of a T1020 code, which covers the 8-hour period of provided services, and 16 units T1019 which cover the 4-hour period of provided services.
Under no circumstance should a per diem code be used for less than 8 hours of care.
T1030: Nursing Care, in-home, by Registered Nurse (RN), Per Diem (8 Hours): This service requires prior authorization from the DEEIOC Claims Examiner for a Registered Nurse to perform in home health care (per 8 hour shift). An RN can only be approved for ongoing care if there is sufficient medical rationale from a physician stipulating the specific medical services related to the accepted work-related condition that require an RN for an 8 hour shift(s).
24-hour care: If this code is approved for 24 hour care, the bill must be submitted with 3 units of a T1030 code which covers the 24 hour period of provided services, regardless of the number of RNs assigned. For example, if two nurses are utilized for two 12 hour shifts, the bill must reflect three units of the authorized T1030 code.
Under no circumstances should a per diem code be used for less than 8 hours of care.
T1031: Nursing Care, in-home, by Licensed Practical Nurse (LPN) Per Diem (8 Hours): This service requires prior authorization from the DEEOIC Claims Examiner for a Licensed Practical Nurse to perform in-home health care (per 8 hour shift). An LPN can only be approved for ongoing care if there is sufficient medical rationale from a physician stipulating the specific medical services related to the accepted work-related condition that require an LPN for an 8 hour shift(s).
24-hour care: If this CPT code is approved for 24 hour care, the bill must be submitted with 3 units of a T1031 code which covers the 24 hour period of provided services, regardless of the number of LPNs assigned. For example, if two nurses are utilized for two 12 hour shifts, the bill must reflect three units of the authorized T1031 code.
Under no circumstances should a per diem code be used for less than 8 hours of care.
S5126: Attendant: Home Health Aide (HHA), Certified Nurse Assistant (CNA), Per Diem (8 Hours): This service requires prior authorization from the DEEIOC Claims Examiner. A HHA/CNA can only be authorized for care if there is sufficient medical rationale from a physician documenting the medical necessity of the service for the accepted work-related condition. If a HHA/CNA is authorized and a RN/LPN is utilized, bills should be submitted with the S5126 code.
24-hour care: If this CPT code is approved for 24 hour care and the care is provided, the bill must be submitted for 3 units which cover the 24 hour period of provided services, regardless of the number of HHA/CNAs assigned. For example, if two HHA/CNAs are utilized for two 12 hour shifts, the service provided still covers the authorized three 8 hour shifts and the bill should reflect 3 units of the authorized S5126 code.
Under no circumstances should a per diem code be used for less than 8 hours of care.
S9122: Home Health Aide (HHA) or Certified Nurse Assistant (CNA) Hourly Code (less than 8 hour care): This service requires prior authorization from the DEEOIC Claims Examiner for a HHA or CNA to perform in home health care (per hour code only). A HHA or CNA can be approved if there is sufficient medical rationale from a physician stipulating the specific medical services related to the accepted work-related condition that requires a HHA or CNA. Under no circumstances should an hourly code be authorized for more than 7 hours (units) of care per day.
S9123: Nursing Care in-home Registered Nurse (RN) Hourly Code (less than 8 hour care): This service requires prior authorization from the DEEOIC Claims Examiner for a RN to perform in home care (per hour code only). A RN can only be approved for ongoing care if there is sufficient medical rationale from a physician stipulating the specific medical services related to the accepted work-related condition that requires a RN. Under no circumstances should an hourly code be authorized for more than 7 hours (units) of care per day.
S9124: Nursing Care in-home License Practical Nurse (LPN) Hourly Rate (less than 8 hour care): This service requires prior authorization from the Claims Examiner for a LPN to perform in home care (per hour code only). A LPN can only be approved for ongoing care if there is sufficient medical rationale from a physician stipulating the specific medical services related to the accepted work-related condition that requires a LPN. Under no circumstances should an hourly code be authorized for more than 7 hours (units) of care per day.
S9126: Hospice Care, in the home, Per Diem (8 Hour Shifts): This service requires prior authorization from the DEEOIC Claims Examiner. Hospice care is generally requested and authorized when an employee is determined to be terminally ill.