Does S9213 require prior authorization?

No, S9213 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for S9213?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.00.

Verity

`S9213` — Home management of preeclampsia, includes administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing services coded separately); per diem (do not use this code with any home infusion per diem code)

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

No specific documentation requirements are specified in this Clinical Policy Bulletin itself.
For ambulatory blood pressure monitoring and home blood pressure monitors, the policy refers to related policies for medical necessity and coverage: CPB 0025 - Automated Ambulatory Blood Pressure Monitoring (for medical necessity criteria for ambulatory blood pressure monitoring) and CPB 0548 - Cardiovascular Monitoring Equipment for Home Use: Pulse, Blood Pressure, Telemonitors, and Pacemaker Monitors (for coverage of blood pressure monitors for home use). Documentation requirements for those services should follow the referenced CPBs.

Conservative management of mild preeclampsia should include clinical monitoring records as described by ACOG: blood pressure measurements, proteinuria assessment, renal and hepatic function tests, platelet counts, and serial sonography for fetal growth (as appropriate to gestational age and clinical circumstance).

Record that home visits take place during the same period the infusion therapy is ordered/being administered.

Documentation of failed conservative treatments (oral and/or rectal medications and/or non‑pharmacological therapies).

For reauthorization requests, documentation by the ordering provider showing reassessment of the member and rationale/clinical need for continued infusion therapy.

Key Coverage Criteria

Management of hypertensive disorders of pregnancy (general subject of this Clinical Policy Bulletin).
Home blood pressure monitoring for pregnant women with hypertension: ACOG Practice Bulletin (2019) recommends that pregnant women with hypertension be instructed on measuring blood pressure monitoring at home (procedures emphasize patient training, use of appropriately validated devices, and clear instructions).
Conservative management of mild preeclampsia for any woman not undergoing delivery, which involves monitoring the patient's blood pressure, proteinuria, renal and hepatic function, platelet counts, and serial sonography for fetal growth; inpatient or outpatient management may be appropriate.
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

3 Active Policies

AMBETTER-CP.MP.91 — Obstetrical Home Care Programs

AETNA-CPB-0368 — Hypertensive Disorders of Pregnancy

ANTHEM-CG-MED-23 — CG-MED-23 Home Health

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S9213 — Home management of preeclampsia, includes administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing services coded separately); per diem (do not use this code with any home infusion per diem code)