DAL–Universal Billing Codes for Home and Community LTC (2022)

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September 22, 2017

Subject: Revision to Universal Billing Codes for Home Care and Adult Day Health Care Services

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Dear Providers and Plans:

This is to advise providers and plans of the revision of billing codes as set forth in the original release date of January 3, 2017 by the Department of Health. As you are aware, the New York State Public Health Law has been amended to require universal standards for coding of payment for home and community based long term care services claims. Specifically, it requires these codes to be based on universal billing codes approved by the Health Department and be consistent with any codes developed as part of the uniform assessment system for long term care established by the Department. Claims under contracts or agreements between long term care providers and managed long term care plans or managed care plans are required to be processed using the universal standards for coding of payments. In addition, the Public Health Law has been amended to require electronic payments of claims under contracts or agreements between long term care providers and managed long term care plans or managed care plans. These payments are required to be paid via electronic funds transfer.

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Attached is a final set of universal codes for Long Term Care Services with respective modifiers (Attachment A) and Adult Day Health Care with respective modifiers (Attachment B).

The Department is requiring the implementation of billing codes by January 1, 2018.

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If there are questions regarding the implementation deadline of these billing codes, please notify the Department immediately by email to nfrates@health.ny.gov with the subject heading: Home Care Billing Codes.

Sincerely,

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John E. Ulberg Jr.
Medicaid Chief Financial Officer
Division of Finance and Rate Setting
Office of Health Insurance Programs

Attachment A

HOME CARE BILLING CODES AND MODIFIERS

Service Type Unit of Measurement Procedure Code Procedure Code Description Modifier
Personal Care Aide Level I (Homemaker/Housekeeper)
PCS Level I – 15 MinutesPer 15 minutesS5130Homemaker service, NOS; per 15 minutesUl
PCS Level I Two ClientPer 15 minutesS5130Homemaker service, NOS; per 15 minutesU2
PCS Level I Multiple ClientPer 15 minutesS5130Homemaker service, NOS; per 15 minutesU3
PCS Level I Weekend/HolidayPer 15 minutesS5130Homemaker service, NOS; per 15 minutesTV
Personal Care Aide Level II
PCS Level II Basic – 15 MinutesPer 15 minutesT1019Personal care services, per 15 minutes, not for an inpatient or resident of a hospital, nursing facility, ICF/MR or IMD, part of the individualized plan of treatment {code may not be used to identify services provided by home health aide or certified nurse assistant)Ul
PCS Level II Basic Two ClientPer 15 minutesT1019Personal care services, per 15 minutes, not for an inpatient or resident of a hospital, nursing facility, ICF/MR or IMD, part of the individualized plan of treatment {code may not be used to identify services provided by home health aide or certified nurse assistant)U2
PCS Level II Multiple ClientPer 15 minutesT1019Personal care services, per 15 minutes, not for an inpatient or resident of a hospital, nursing facility, ICF/MR or IMD, part of the individualized plan of treatment {code may not be used to identify services provided by home health aide or certified nurse assistant)U3
PCS Level II Weekend/HolidayPer 15 minutesT1019Personal care services, per 15 minutes, not for an inpatient or resident of a hospital, nursing facility, ICF/MR or IMD, part of the individualized plan of treatment {code may not be used to identify services provided by home health aide or certified nurse assistant)TV
PCS Level II Hard to ServePer 15 minutesT1019Personal care services, per 15 minutes, not for an inpatient or resident of a hospital, nursing facility, ICF/MR or IMD, part of the individualized plan of treatment {code may not be used to identify services provided by home health aide or certified nurse assistant)U4
PCS Level IITwo Client Hard to ServePer 15 minutesT1019Personal care services, per 15 minutes, not for an inpatient or resident of a hospital, nursing facility, ICF/MR or IMD, part of the individualized plan of treatment {code may not be used to identify services provided by home health aide or certified nurse assistant)U5
PCS Level II Live inPer diem {13 hours)T1020 *Personal care services, per diem, not for an inpatient or resident of a hospital, nursing facility, JCF/MR or IMD, part of the individualized plan of treatment {code may not be used to identify services provided by home health aide or certified nurse assistant)NONE
PCS Level II Live in Two ClientPer diem {13 hours)T1020 *Personal care services, per diem, not for an inpatient or resident of a hospital, nursing facility, JCF/MR or IMD, part of the individualized plan of treatment {code may not be used to identify services provided by home health aide or certified nurse assistant\U2
PCS Level II Live in Weekend/HolidayPer diem {13 hours)T1020 *Personal care services, per diem, not for an inpatient or resident of a hospital, nursing facility, ICF/MR or IMD, part of the individualized plan of treatment {code may not be used to identify services provided by home health aide or certified nurse assistant!TV
PCS Level II Live in Two Client Hard to ServePer diem (13 hours)T1020 *Personal care services, per diem, not for an inpatient or resident of a hospital, nursing facility, ICF/MR or !MD, part of the individualized plan of treatment (code may not be used to identify services provided by home health aide or certified nurse assistant\U5
Consumer Directed Personal Assistant
CDPA Basic – 15 MinutesPer 15 minutesT1019Personal care services, per 15 minutes, not for an inpatient or resident of a hospital, nursing facility, ICF/MR or IMD, part of the individualized plan of treatment (code may not be used to identify services provided by home health aide or certified nurse assistant)U6
CDPA EnhancedPer 15 minutesT1019Personal care services, per 15 minutes, not for an inpatient or resident of a hospital, nursing facility, ICF/MR or IMD, part of the individualized plan of treatment (code may not be used to identify services provided by home health aide or certified nurse assistant)U8
CDPA Two ConsumerPer 15 minutesT1019Personal care services, per 15 minutes, not for an inpatient or resident of a hospital, nursing facility, ICF/MR or IMD, part of the individualized plan of treatment (code may not be used to identify services provided by home health aide or certified nurse assistant)U7
CDPA Two Consumer EnhancedPer 15 minutesT1019Personal care services, per 15 minutes, not for an inpatient or resident of a hospital, nursing facility, ICF/MR or IMD, part of the individualized plan of treatment (code may not be used to identify services provided by home health aide or certified nurse assistant)U9
CDPA Live inPer diem (13 hours)T1020 *Personal care services, per diem, not for an inpatient or resident of a hospital, nursing facility, ICF/MR or IMD, part of the individualized plan of treatment (code may not be used to identify services provided by home health aide or certified nurse assistant\U6
CDPA Live in EnhancedPer diem (13 hours)T1020 *Personal care services, per diem, not for an inpatient or resident of a hospital, nursing facility, ICF/MR or IMD, part of the individualized plan of treatment (code may not be used to identify services provided by home health aide or certified nurse assistant\U8
CDPA Live in Two ConsumerPer diem (13 hours)T1020 *Personal care services, per diem, not for an inpatient or resident of a hospital, nursing facility, ICF/MR or IMD, part of the individualized plan of treatment (code may not be used to identify services provided by home health aide or certified nurse assistant)U7
CDPA Live in Two Consumer EnhancedPer diem (13 hours)T1020 *Personal care services, per diem, not for an inpatient or resident of a hospital, nursing facility, ICF/MR or IMD, part of the individualized plan of treatment (code may not be used to identify services provided by home health aide or certified nurse assistant)U9
*T1020 Per diem rate code may not be used if a personal care aide or personal assistant is not able to meet the sleep requirements required in Fair Labor Standards Act (FLSA).
Home Health Aide
HHA – 15 minutesPer 15 minutesS5125Attendant care services; per 15 minutesNONE
HHAPer hourS9122Home health aide or certified nurse assistant, providing care in the home; per hourNONE
HHA Two ClientPer 15 minutesS5125Attendant care services; per 15 minutesU2
HHA – Live inPer diem {13 hours)S5126Attendant care services; per diemNONE
HHA Live in Two ClientPer diem (13 hours)S5126Attendant care services; per diemU2
Advanced Home Health AidePer hourS9122Home health aide or certified nurse assistant, providing care in the home; per hourUl
Nursing Services
Nursing Assessment/EvaluationPer visitT1001Nursing Assessment/evaluationNONE
UAS AssessmentPer visitT2024T1001–Nursing Assessment/evaluation. T2024–Service Assessment/plan of care development.NONE
UAS ReassessmentPer visitT2024T1001–Nursing Assessment/evaluation. T2024–Service Assessment/plan of care development.NONE
Nursing Care in Home (RN)Per diem (13 hours)T1030Nursing care, in the home, by registered nurse, per diemNONE
RNPer hourS9123Nursing care, in the home; by registered nurse, per hour (use for general nursing care only, not to be used when CPT codes 99500–99602 can be used)NONE
RN – 15 minutesPer 15 minutesT1002RN services, up to 15 minutesNONE
Nursing Care in Home (LPN)Per diem (13 hours)T1031Nursing care, in the home, by licensed practical nurse, per diemNONE
LPNPer hourS9124Nursing Care, in the home; by licensed practical nurse, per hourNONE
LPN – 15 minutesPer 15 minutesT1003LPN/LVN services, up to 15 minutesNONE
Home Health Care Services
Occupational TherapyPer visitS9129Occupational therapy, in the home, per diemNONE
Physical TherapyPer visitS9131Physical therapy, in the home, per diemNONE
Speech TherapyPer visitS9128Speech therapy, in the home, per diemNONE
Respiratory TherapyPer 15 minutesG0237Therapeutic procedures to increase strength or endurance of respiratory muscles, one–on–one, face–to–face, per 15 minutes (includes monitoring)NONE
Respiratory TherapyPer 15 minutesG0238Therapeutic procedures to improve respiratory function, other than described by G0237, one–on–one, face–to–face, per 15 minutes (includes monitoring)NONE
Nutritional CounselingPer visitS9470Nutritional counseling, dietician visitNONE
Medical Social ServicesPer visitS9127Social work visit, in the home, per diemNONE
Sign Language/Oral interpreterPer 15 minutesT1013Sign language or oral interpretive services, per 15 minutesNONE
Social and Environmental Supports –Home ModificationPer serviceS5165Home modifications; per serviceNONE
Social and Environmental Supports –AssessmentPer serviceT1028Assessment of home, physical and family environment, to determine suitability to meet patients medical needsNONE
Telehealth
InstallationPer service59110Telemonitoring of patient in their home, including all necessary equipment; computer system, connections, and software; maintenance; patient education and support; per monthNONE
MonitoringMonthly59110Telemonitoring of patient in their home, including all necessary equipment; computer system, connections, and software; maintenance; patient education and support; per monthU1
Medication Dispensers
InstallationOne TimeTl505Electronic medication compliance management device, includes all components and accessories, not otherwise classifiedNONE
MonitoringMonthly55185Medication reminder service, nonface–to–face; per monthNONE

Attachment A

Note: For modifiers that state "as defined by each state", please refer to the column labeled NYS Definition. Each program utilizes modifiers for their specific program. Modifiers may be utilized more than once and are unique based on individual program

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Modifier Descriptions

ModifierModifier DescriptionNYS DefinitionNotes
Personal Care Aide Level I (Homemaker/Housekeeper)
U1Medicaid level of care 1, as defined by each stateThis rate code modifier will be used for the provision of personal care Level I for basic services.
U2Medicaid level of care 2, as defined by each stateThis rate code modifier will be used for the provision of personal ca re Level I services to one of two clients in the same household where both clients are receiving personal care services from the sa me aide.
U3Medicaid level of care 3, as defined by each stateThis rate code modifier will be used for the provision of personal ca re Level I services for each personal care recipient who resides with other personal care recipients in a designated geographic area, such as in the same apartment building.
TVSpecial payment rate, holidays/weekends This rate code modifier will be used for the provision of personal care Level I services on weekends (defined as between Saturday 8 a.m. to Monday 8 a.m.) and designated holidays.
Personal Care Aide Level II
U1Medicaid level of care 1, as defined by each stateThis rate code modifier will be used for the provision of personal care Level II for basic services.
U2Medicaid level of care 2, as defined by each stateThis rate code modifier will be used for the provision of personal care Level II services to one of two clients in the same household where both clients are receiving personal care services from the same aide.
U3Medicaid level of care 3, as defined by each stateThis rate code modifier will be used for the provision of personal care Level II services for each personal care recipient who resides with other personal care recipients in a designated geographic area, such as in the same apartment building.
U4Medicaid level of care 4, as defined by each stateThis rate code modifier will be used for the provision of personal care Level II services for clients who have exceptional needs and/or are in exceptional circumstances, such as the following situations: (1) a client is left alone in the community in a life-threatening situation, and services must be provided within four hours; (2) a client has severe mental or physical diagnosis or has several documented social and/or behavioral problems which make him or her extremely difficult to serve; or (3) a client resides in a problematic environment which may include housing or geography or be influenced by the behavior or problems of family members residing with the client.
U5Medicaid level of care 5, as defined by each stateThis rate code modifier will be used for the provision of personal care Level II care services to one of two clients in the same household where both clients are receiving personal care services from the same aide and where at least one of the clients has exceptional needs and/or is in exceptional circumstances, such as the following situations: (1) a client is left alone in the community in a life–threatening situation, and services must be provided within four hours; (2) a client has severe mental or physical diagnosis or has several documented social and/or behavioral problems which make him or her extremely difficult to serve; or (3) a client resides in a problematic environment which may include housing or geography or be influenced by the behavior or problems of family members residing with the client.
TVSpecial payment rate, holidays/weekends This rate code modifier will be used for the provision of personal care Level I or Level II (defined as between Saturday 8 a.m. to Monday 8 a.m.) and designated holidays.
Consumer Directed Personal Assistant
U6Medicaid level of care 6, as defined by each stateThis rate code modifier will be used for the provision of consumer directed personal assistance services for basic services.
U7Medicaid level of care 7, as defined by each stateThis rate code modifier will be used for the provision of consumer directed personal assistance services to one of two consumers in the same household where both consumers are receiving personal assistance services from the same personal assistant.
U8Medicaid level of care 8, as defined by each stateThis rate code modifier will be used for the provision of consumer directed personal care services for consumers who have exceptional needs and/or are in exceptional circumstances, such as the following situations: (1) a consumer has a documented inability to hire or retain sufficient staff, where the consumer can document that attempts have been made and that the wage rate is directly responsible for the inability to hire or retain staff and provided further that the consumer is at a nursing home level of care and therefore the lack of sufficient staff will result in institutionalization; (2) a consumer has severe mental and/or physical diagnosis or has several documented social and/or behavioral problems which make him or her extremely difficult to serve; or (3) a consumer resides in a problematic environment which may include housing or geography, or be influenced by the behavior or problems of family members residing with the consumer.
U9Medicaid level of care 1, as defined by each stateThis rate code modifier will be used for the provision of consumer directed personal assistance services to one of two consumers in the same household where both consumers are receiving personal assistance services from the same personal assistant and where at least one of the consumers has exceptional needs and/or is in exceptional circumstances, such as the following situations: (1) a consumer has a documented inability to hire or retain sufficient staff, where the consumer can document that attempts have been made and that the wage rate is directly responsible for the inability to hire or retain staff and provided further that the consumer is at a nursing home level of care and therefore the lack of sufficient staff will result in institutionalization; (2) a consumer has severe mental and/or physical diagnosis or has several documented social and/or behavioral problems which make him or her extremely difficult to serve; or (3) a consumer resides in a problematic environment which may include housing or geography, or be influenced by the behavior or problems of family members residing with the consumer.
Telehealth
U1Medicaid level of care 1, as defined by each stateThis rate code modifier would be used for the monthly fee of telemonitoring of patient.
Home Health Aide
U1Medicaid level of care 1, as defined by each stateThis rate code modifier would be used for the provision of Advanced Home Health Aide services on an hourly basis.
U2Medicaid level of care 2, as defined by each stateThis rate code modifier will be used for the provision of personal care Level I or Level II services to one of two clients in the same household where both clients are receiving personal care services from the same aide.

Attachment B

ADULT DAY HEALTH CARE BILLING CODES AND MODIFIERS

Service TypeUnit of MeasurementProcedure CodeProcedure Code DescriptionModifier
Adult Day Health Care – Basic LevelPer Diem55102Day care services, adult; per diemU1
Adult Day Health Care – Standard LevelPer Diem55102Day care services, adult; per diemU2
Adult Day Health Care – Intensive LevelPer Diem55102Day care services, adult; per diemU3

Attachment B

Modifier Descriptions

ADULT DAV HEALTH CARE PROGRAM
ModifierModifier DescriptionNYS Definition
U1Medicaid level of care 1, as defined by each stateServices will include, personal care, supervision and monitoring, socialization, meals, therapeutic recreation activities.
U2Medicaid level of care 2, as defined by each stateAll services in basic level and all ADHC core services listed under 425.5.
U3Medicaid level of care 3, as defined by each stateAll in basic and standard levels. Intensive skilled nursing, including, but not limited to: tube feeds, wound care, hoyer, marisa or sara lifts, TB screening and on going follow up, palliative care.

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