90961
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
5.52
Facility
$310.63
Non-Facility
$310.63
Documentation Required
- Assessment documenting specific ADL deficits (bathing, dressing, toileting, transferring, eating)
- Documentation of communication ability, cognitive status, and behavioral concerns necessitating supervision
- Documentation that the member is unable to self-administer medications when medication administration is cited as a reason for care
- Clinical documentation of the qualifying diagnosis (dementia, Alzheimer’s, organic brain syndrome, or other cognitive-impairing diagnosis such as TBI).
Key Coverage Criteria
- Long term residential care for members who require basic custodial care.
- Long term care for members who require more intense care due to dementia or other complex medical needs.
- Placement when skilled services are required that necessitate qualified technical or professional health personnel (e.g., RNs, LVNs, PT, OT, speech pathologists, audiologists).
- Custodial/non-skilled care: maintenance care provided by family members, health aides, or other unlicensed individuals when an individual has reached maximum level of physical or mental function and still requires assistance.
- Policy addresses the following specialized care categories: Dementia/Wandering Care; Dementia with Behaviors Care; Dialysis Care; Respiratory Care; Ventilator Care; Bariatric Care.
- Need for hands-on assistance or supervision with activities of daily living (ADLs) including bathing, dressing, toileting, transferring, and eating
1 Active Policy
AMBETTER-CP.MP.71 — Long Term Care Placement
Related Codes
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