G0155 — Services of clinical social worker in home health or hospice settings, each 15 minutes
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without 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.
- HH clinical notes must document the patient's homebound status, relevant mental status findings, clinical condition, and the rationale that specialized RN skills are necessary for care.
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.
- Skilled nursing psychiatric services are covered when the patient has a diagnosed psychiatric disorder requiring active treatment by a psychiatrically trained registered nurse (RN) and all other home health (HH) eligibility requirements are met.
- The patient must be homebound per CMS definition; supported examples include agoraphobia, paranoia, panic disorder, severe thought disorders with delusions/hallucinations/agitation, acute depression with severe vegetative symptoms, or psychiatric problems associated with medical conditions that render the patient homebound.
- Services must be provided under a home health Plan of Care (POC) that is approved and signed by the treating physician prior to agency billing.
- Nursing services must meet the part-time or intermittent HH requirement (generally met when the patient requires a skilled nursing service at least every 60 days).
- Services are covered when they are reasonable and necessary for treating the patient's psychiatric diagnosis and/or symptoms with a reasonable expectation that stated goals will be achieved.
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
L34561 — Home Health - Psychiatric Care
Related Codes
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