S9123, Nursing care, in the home; by registered nurse, per hour (use for general
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
- Documentation that the child meets an eligible condition per state-defined criteria for developmental delay (medical/diagnostic documentation of developmental delay or high risk).
- Individual Family Service Plan (IFSP) for any child recognized as having a disability that interferes with learning from infancy to age 3; IFSP must include specific early intervention services the family and child will receive and a projection of their duration (per Education of the Handicapped Act Amendments requirement).
- When applicable, standardized developmental screening and testing results with scoring and documentation (e.g., use of standardized instruments as described by CPT/HCPCS such as 96110, 96112/96113, G0451) including interpretation and report.
- Clinical records supporting the medical necessity of component services (e.g., assessments, therapy plan, progress notes, rationale for PT/OT/speech therapy or other services tied to the eligible condition).
Key Coverage Criteria
- Early intervention programs (coordinated multidisciplinary care) for children from infancy to 3 years of age who have developmental delays or have a high potential for developmental delay.
- Children with biological conditions that may predispose to a developmental delay (eligible for early intervention services).
- Children at risk of developing developmental delays attributable to environmental factors (eligible for early intervention services).
- Coverage of component services of early intervention programs (such as speech therapy, physical therapy, occupational therapy, psychological counseling for families, nursing care, and physical or social stimulation) when the child presents with an eligible condition.
- Provision of services described in an Individual Family Service Plan (IFSP) for a child recognized as having a disability that interferes with learning from infancy to age 3 (IFSP defines specific early intervention services and projected duration).
- None — Aetna considers planned deliveries at home and associated services not medically appropriate.
10 Active Policies
ANTHEM-CG-MED-71, CG-MED-71 Chronic Wound Care in the Home or Outpatient Setting
ANTHEM-CG-REHAB-08, CG-REHAB-08 Private Duty Nursing in the Home Setting
ANTHEM-CG-MED-23, CG-MED-23 Home Health
AETNA-CPB-0444, Early Intervention Programs
AETNA-CPB-0329, Home Births
Related Codes
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