G0155, Services of clinical social worker in home health or hospice settings, each 15
HCPCS/CPT
Prior Authorization
Prior Auth Required
Code explicitly requires prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- The DSM-5 diagnosis must be fully documented and available in the medical record.
- The documented DSM-5 diagnosis must match the diagnosis the ordering physician is treating and/or the diagnosis for which the patient was hospitalized.
- Clinicians should document medical conditions important to understanding or managing the individual's mental disorder (medical comorbidities) in the record.
Key Coverage Criteria
- Patient has a DSM-5 mental disorder diagnosis that is the reason for the ordering physician's treatment or for which the patient was hospitalized.
- I. Home health services are consideredmedically necessarywhenallof the followingcriteriaA through Dare met:
- The individual is confined to the home:The individual’s overall physical/medical condition poses a serious and significant impediment to receiving intermittent or occasional, skilled, medically necessary services outside the home setting. In general, the condition of these individuals should be such that there exists a normal inability to leave home and, consequently, leaving home would require a considerable and taxing effort;andIf the individual does in fact leave the home, the absences from t [...]
- The individual’s overall physical/medical condition poses a serious and significant impediment to receiving intermittent or occasional, skilled, medically necessary services outside the home setting. In general, the condition of these individuals should be such that there exists a normal inability to leave home and, consequently, leaving home would require a considerable and taxing effort;and
- If the individual does in fact leave the home, the absences from the home are infrequent or for periods of relatively short duration, or are attributable to the need to receive health care treatment. The following are examples of acceptable medical and non-medical absences (these examples are not all-inclusive and are provided as a means to illustrate the kinds of infrequent or unique events an individual may attend):Medical absences to receive health care treatment, including but not limited to [...]
- Medical absences to receive health care treatment, including but not limited to:Ongoing receipt of outpatient kidney dialysis;orReceipt of outpatient chemotherapy or radiation therapy;orParticipation in psychosocial or medical treatment in an adult day-care program that is licensed or certified by a state, or accredited, to furnish adult day-care services;or
4 Active Policies
ANTHEM-CG-MED-23, CG-MED-23 Home Health
ANTHEM-CG-MED-101, CG-MED-101 Home Hospice
A56756, Billing and Coding: Home Health - Psychiatric Care
EVICORE-HPLAN-AETNA-EEDE1D947485, Aetna Home Health Code List - Effective 01/01/2026
Related Codes
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