Arizona Health Care Cost Containment System Arizona Long Term Care System (ALTCS) Performance Measure Initiation of Home and Community Based Services for Elderly and Physically Disabled Members Measurement Period: October 1, 2003, through September 30, 2004 Prepared by the Division of Health Care Management August 2005 Anthony D. Rodgers Director, AHCCCS Arizona Health Care Cost Containment System Arizona Long Term Care System Performance Measure: INITIATION OF HOME AND COMMUNITY BASED SERVICES FOR ELDERLY AND PHYSICALLY DISABLED MEMBERS Measurement Period: October 1, 2003, through September 30, 2004 Overview able to hire a neighbor, friend or relative to provide some care. Interviews of participants underscored the value of independence and assistance geared to their needs and preferences.4 Nearly 10 million Americans require longterm care, ranging from services to assist them in life’s daily activities to more extensive care for serious or chronic illness. Medicaid pays the largest share of long-term care expenses, accounting for 40 percent in 2003.1 The Arizona Health Care Cost Containment System (AHCCCS) has provided home and community-based services to long-term care beneficiaries through a waiver from the Centers for Medicare and Medicaid Services (CMS) since 1989. Through its Arizona Long Term Care System (ALTCS), AHCCCS provides comprehensive coverage for HCBS members residing in their own homes or approved alternative residential settings, such as assisted living facilities or group homes. Covered services include care such as home health nursing, respiratory therapy and attendant care. Members may designate a relative or friend to provide attendant care; after completion of training, these caregivers may be paid by AHCCCS. Home and community-based services (HCBS) have become a growing part of states’ Medicaid long-term care programs, providing a cost-effective alternative to institutional care for the elderly and physically disabled (E/PD). From 1992 to 2002, total Medicaid expenditures on longterm care services grew from $39 billion to $82 billion. During that time, the proportion of spending on home and community based services rose from 15 percent to 30 percent of all Medicaid longterm care expenditures.2 Fueling this growth are consumers’ desire to reside in their own homes rather than nursing homes, and changes in federal and state policy that support this option.3 Research has shown a strong connection with receiving services in the home to consumer satisfaction and health status. A recent evaluation of a demonstration project that allowed consumers with disabilities to use Medicaid funds to direct their own in-home services found that program participants had a high degree of satisfaction and overall quality of life. Through the program, consumers were By providing a variety of alternative settings with differing levels of care, ALTCS members are able to delay institutionalization or, in some cases, transfer from nursing home care into the HCBS program. Currently, about 60 percent of the more than 22,000 elderly and physically disabled Arizonans enrolled in ALTCS reside in home and communitybased settings. The proportion of HCBS members is almost equally divided between rural and urban areas of the state. 1 Contractor, who receive specific HCBS services within 30 days of enrollment. These services include adult day health care, attendant care, home-delivered meals, home health nursing and homemaker assistance (a complete list of services and service codes included in this study may be found in Appendix A, Methodology and Technical Specifications). Once eligibility for ALTCS is determined based on financial and medical criteria, E/PD members enroll with a contracted health plan (Contractor), depending on where they live. Each member is assigned a case manager, who coordinates care with the member’s primary care provider (PCP), addresses any problems with service delivery and modifies the member’s care plan based on changes in health status. Case managers visit new members and, in conjunction with those members and their authorized representatives, assess needs to determine the most appropriate placement. Services must be initiated within timelines to meet members’ medical needs, but no later than 30 calendar days from their enrollment. It should be noted that this Performance Measure does not include all covered home and community-based services. For example, emergency-alert and homemodification services are not included because they are typically provided in conjunction with nursing, personal care or supportive services. The intent of this study is to measure the health care services Services are initiated that primarily allow promptly when the members at risk of individual is determined institutionalization to remain in their homes eligible and selects HCBS or the community. Focus Area 1.B.4, Prompt Initiation, According to a 2003 report from the U.S. General Accounting Office, states may lack adequate quality assurance mechanisms for their Framework for Quality in HCBS, HCBS programs.5 Methodology from the Centers for Medicare and However, Arizona Medicaid Services The methodology for has established a this measurement is number of based on two study mechanisms to ensure questions: that people are placed in programs that • What is the number and percentage provide the proper level of care and that (overall, by urban and rural counties, services are monitored. These include and by individual Contractor) of reassessment of member needs at regular sample members to whom a home and intervals by case managers with the community-based service was provided member’s health plan, review of case within 30 days of enrollment? management services by AHCCCS and • For those members who did not receive monitoring by both Contractors and services within 30 days of enrollment, AHCCCS of the timeliness of initiation of what were the reasons? services after enrollment. As part of its quality assessment and performance improvement program, AHCCCS measures the percentage of newly placed ALTCS members, by The measurement period for the study was October 1, 2003, through September 30, 2004. The sample frame consisted of E/PD members who: 2 • providers, or verification of claims paid by Contractors for qualifying services. were enrolled for 30 days or more with an ALTCS Contractor during the measurement period, and • were newly placed in the HCBS program. This study did not include ventilatordependent members, as Contractors are required to initiate services for those members within 14 days of enrollment. Performance Standards AHCCCS has established a Minimum Performance Standard that Contractors achieve a rate of at least 74 percent for this measure. If Contractors are already achieving the minimum standard, they should strive for a rate of at least 76 percent. The AHCCCS long-range goal is that all Contractors achieve a rate of at least 87 percent for this measure. A representative random sample was selected for each Contractor. Data were first collected from AHCCCS encounter data (records of claims paid by Contractors). If services within 30 days of enrollment were not found in AHCCCS encounter data, Contractors were asked to provide service delivery information from medical or case management records or their claims data. Results and Analysis The study sample included 824 HCBS members. Of those, 239 people were residing in an assisted living facility, were admitted to a hospital or nursing facility, were receiving hospice services, or refused services within 30 days of enrollment (Table 1). Seventy-eight members refused services and more than half of those (51.3 percent) had family or friends who were in the process of being trained as attendant caregivers. In analyzing initiation of services, AHCCCS did not include members who: • were residing in and receiving services from an assisted living facility, • were admitted to a hospital or nursing home, • were receiving hospice services, or • refused services when these situations were documented as occurring within 30 days of enrollment. Among the remaining 585 people, 522 or 89.2 percent received services within 30 days of enrollment (Table 2). The overall rate of initiation of services increased from the previous rate of 83.7 percent (p= .008). There was no difference in the rate of initiation of services between rural and urban counties. To validate additional information collected by Contractors, AHCCCS required documentation of services provided or reasons why a member did not receive services (for example, the member refused services while waiting for a family member to become trained to provide attendant care or was hospitalized during all or part of the first 30 days of enrollment). Documentation provided by Contractors included copies of the pertinent sections of case management records, medical/service records from Initiation of Services Within 30 Days 10/03-9/04 Received Services 3 Did Not Receive Services n based services that fit with their individual choices. Clearly, some AHCCCS Contractors are effectively meeting this challenge, with rates of initiation within 30 days of 90 percent or better. Rates by Contractor ranged from 82.4 percent to 98.2 percent. All seven Contractors exceeded the AHCCCS Goal for the current measurement period, and four Contractors exceeded the long-range goal of 87 percent. Case management notes indicate that some sample members did not receive services within 30 days despite repeated attempts by Contractors to conduct assessments and initiate care. Some members were not available or out of the area for several days or even weeks, some members missed visit appointments, and one member refused two scheduled home health nursing visits, according to documentation submitted by Contractors. Conclusions and Recommendations A large majority of new ALTCS members who are placed in a home or community based setting receive services within 30 days of enrollment. These services are designed to help long-term care recipients maintain or improve their health and functional status, and enjoy a greater degree of independence. In addition, all ALTCS E/PD Contractors are meeting the AHCCCS Goal for this Performance Measure, and several have achieved the long-range goal established by AHCCCS. Since much of the data for this indicator is collected from case management records when claims or encounters for services are not available, Contractors must ensure that case managers thoroughly and consistently document when home and communitybased services are initiated for new members or when members or authorized representatives refuse services. Over the past year, AHCCCS has worked with Contractors to improve documentation. The option of having a relative, friend or neighbor provide care appears to be a popular choice among elderly and disabled individuals. A recent study shows that more than 60 percent of care for such people nationally is provided by unpaid “informal caregivers”: spouses, other relatives and friends.6 Given the high proportion of unpaid family and friends who already provide care and support, it is logical that these people would continue to provide care under a paid arrangement. In this study, AHCCCS did not include in the analysis of rates those members whom case managers documented were waiting for a relative or friend to be trained as an attendant caregiver, as these members already were being cared for. Promising practices related to timely provision of home and community-based services have been identified through other programs, including disease management programs.7-11 Some of the following strategies also are utilized by ALTCS Contractors. • Building ongoing relationships with PCPs and other providers. This enables case management staff to better coordinate care and facilitate communication and authorizations. • Building ongoing relationships with the client and family members. The foundation for this relationship often is laid during the initial assessment. Given the variety and complexity of members’ needs and personal situations when they enroll in the ALTCS program, Contractors’ case managers face distinct challenges in ensuring that enrollees have prompt access to home and community 4 • • Communicating with providers through secure electronic means. An HCBS program in Ohio has implemented a process that allows providers to respond to a Request for Services and advise case managers within 24 hours if they are able to provide specific services to a particular person. The process safeguards the recipients’ privacy and reduces the amount of time case managers spend on the phone or faxing information to find a provider. Utilizing automated case management systems. These systems can be used to track timeliness of service initiation and generate reports to evaluate overall quality and outcomes. Reminders for case managers may be built into the systems. References 1 Kaiser Commission on Medicaid and the Uninsured. Medicaid and long-term care. Kaiser Family Foundation. Washington, DC. March 2005. Available at: http://www.kff.org/medicaid/loader.cfm?url=/com monspot/security/getfile.cfm&PageID=36296. Accessed June 21, 2005 2 Reester H, Missmar R, Tumlinson A. Recent growth in medicaid home and community- based service waivers. The Kaiser Commission on Medicaid and the Uninsured. Kaiser Family Foundation. Washington, DC. April 2004. Available at: http://www.kff.org/medicaid/loader.cfm?url=/com monspot/security/getfile.cfm&PageID=36119. Accessed June 21, 2005 3 Cubanski J, Kline J. In pursuit of long-term care: Ensuring access, coverage, quality. The Commonwealth Fund. New York,NY. April 2002. Available at: http://www.cmwf.org/programs/elders/cubanski_pu rsuit_ib_536.pdf. Accessed June 15, 2004 In October 2004, AHCCCS implemented a new policy that each ALTCS Contractor should develop a standardized system for verifying the delivery of services with the member or representative after authorization, in order to better ensure that the services that have been ordered are put in place in a timely manner. Implementation of this policy may help to further improve AHCCCS rates for initiation of home and community-based services when they are measured in the future. 4 Appelbaum R, Schneider B, Kunkel S, Davis S. A guide to quality in consumer directed services. Scripps Gerentology Center. Miami University. May 2004. Available at: http://www.hcbs.org/files/42/2099/Guidefront.pdf. Accessed June 21, 2005 5 General Accounting Office. Long-term care: Federal oversight of growing medicaid home and community-based waivers should be strengthened. U.S. General Accounting Office, Report to Congressional Requesters. GAO-03-576, June 2003. Available at: http://www.gao.gov/docdblite/summary.php?recfla g=&accno=A07309&rptno=GAO-03-576. Accessed June 15, 2004 Another key component of improving the timeliness of health care service delivery is the availability of performance information. By publishing this and other performance data, AHCCCS expects the timeliness of services to members to continue improving. 6 Center on an Aging Society. A decade of informal caregiving. Georgetown Univeristy. Washington DC. February 2005. Available at: http://www.hcbs.org/files/65/3249/caregivers.pdf. Accessed June 22, 2005 7 Brown R, Chen A. Disease management options: Issues for state medicaid programs to consider. Mathematica Policy Research Inc. Princeton, NJ. April 2004. Available at: http://www.mathematicampr.com/publications/pdfs/diseaseman.pdf. Accessed June 8, 2004 5 8 . MEDSTAT Group. Promising practices in home and community-based services, Ohio – Increasing timely access to services. Centers for Medicare and Medicaid Services. Baltimore Md. Available at: http://www.hcbs.org/promisingpractices/Ohio_increasingtimelyaccess.pdf. Accessed February 10, 2004 9 MEDSTAT Group. Promising practices in home and community-based services, South Carolina’s case management system. Centers for Medicare and Medicaid Services. Baltimore Md. Available at: http://www.cms.hhs.gov/promisingpractices/datarea dinessIN.pdf. Accessed June 21, 2005 10 MEDSTAT Group. Promising practices in home and community-based services, Indiana’s quality improvement process. Centers for Medicare and Medicaid Services. Baltimore Md. Available at: http://www.cms.hhs.gov/promisingpractices/datarea dinessSC.pdf. Accessed June 21, 20 6 Table 1 AHCCCS ALTCS Performance Measure INITIATION OF HOME AND COMMUNITY-BASED SERVICES Exclusions from Analysis of Initiation of Services, All Contractors Measurement Period: October 1, 2003, through September 30, 2004 n Percent Relative Percent Change 128 52.70% -5.7% 127 55.90% 20 8.20% 15 6.60% 9 3.70% 5 2.20% 78 32.10% 80 35.20% 4 3.30% 0 0.00% TOTAL 239 100.00% TOTAL 227 100.00% Reason Member in Assisted Living Facility Member Recieving Hospice Services Member Admitted to Hospital or Nursing Facility Member Refused Services/Awaiting Designated Caregiver to be Trained Other Shaded rows show results of the previous measurement period (Oct. 1, 2002, through Sept. 30, 2003). 7 24.2% 68.2% -8.8% N/A Table 2 AHCCCS ALTCS Performance Measure INITIATION OF HOME AND COMMUNITY-BASED SERVICES WITHIN 30 DAYS OF ENROLLMENT, BY ALTCS CONTRACTOR Measurement Period: October 1, 2003, through September 30, 2004 Number of Members Included Number who Received Service Within 30 Days Relative Percent Change Statistical Significance Cochise Health Systems * 56 98.2% 0.5% p=1.000 Cochise Health Systems 43 97.7% Evercare Select * 82 85.4% 24.3% p=.015 Evercare Select 67 68.7% Maricopa LTC * 68 82.4% 20.5% p=.069 Maricopa LTC 57 68.4% Mercy Care LTC * 165 85.5% 5.4% p=.330 Mercy Care LTC 122 81.1% Pima Health System LTC * 120 96.7% -1.1% p=.701 Pima Health System LTC 91 97.8% Pinal/Gila County LTC * 64 89.1% 3.6% p = .621 Pinal/Gila County LTC 50 86.0% Yavapai County LTC * 30 90.0% 0.3% p = 1.000 Yavapai County LTC 29 89.7% TOTAL 585 89.2% 6.6% p = .008 TOTAL 459 83.7% Contractor * Denotes that the Contractor met or exceeded the AHCCCS Minimum Performance Standard. Shaded rows show results of the previous measurement period (Oct. 1, 2002, through Sept. 30, 2003). Cells highlighted in blue indicate statistically signficiant changes from the previous measurement period. 8 Figure 1 AHCCCS ALTCS PERFORMANCE MEASURE INITIATION OF HOME AND COMMUNITY-BASED SERVICES WITHIN 30 DAYS OF ENROLLMENT, ALL CONTRACTORS Current Measurement Period Compared with the Previous Measurement Period Percent of Members Receiving Services Within 30 Days 100% 90% 80% 70% 60% CYE 2003 50% CYE 2004 40% 30% 20% 10% 0% Cochise Health Systems Evercare Select Maricopa LTC Mercy Care LTC Pima Health System LTC Pinal/Gila County LTC AHCCCS Minimum Performance Standard AHCCCS Long-range Goal 9 Yavapai County LTC Arizona Health Care Cost Containment System (AHCCCS) Arizona Long Term Care System (ALTCS) Performance Measure Methodology Performance Measure: Initiation of Home and Community-Based Services (HCBS) Background: Health care services and supports should be provided to members in the Arizona Long Term Care System (ALTCS) who are residing in home and community-based settings as quickly as possible after enrollment. These services and supports include, but are not limited to: adult day health care, attendant care, behavioral health services, habilitation services, homedelivered meals, home health aide services, home health nursing, homemaker assistance, home infusion therapy and respiratory therapy. Arizona Health Care Cost Containment System (AHCCCS) medical policy requires that service be provided within the first 30 days after enrollment to new ALTCS members who are placed in the Home and CommunityBased Services (HCBS) program. Purpose: The purpose of this study is to evaluate ALTCS Contractor compliance with AHCCCS medical policy in initiating services to newly enrolled elderly and physically disabled (E/PD) members in the HCBS program. Measurement Period: October 1, 2003, through September 30, 2004 Study Questions: 1. What is the number and percentage (overall, by urban and rural counties, and by individual Contractor) of sample members to whom a service was provided within 30 days of enrollment? 2. For those members who did not receive services within 30 days of enrollment, what were the reasons? Population: All newly enrolled E/PD members placed in the HCBS program Sample Frame: The sample frame consists of E/PD members who met the following criteria: • Newly enrolled with an ALTCS Contractor during the measurement period, • Enrolled in ALTCS for 30 or more days during the measurement period, and • Placed in an ALTCS-authorized HCBS setting Sample Frame Exclusions: • • This measure did not include members who were enrolled in the Ventilator Dependent program. AHCCCS requires services for these members to be implemented within 14 days of enrollment. Members with Prior Period Coverage (PPC) were excluded from the sample frame. PPC is a retroactive coverage period for which Contractors are financially responsible for paying for covered services. i Sample Selection: A statistical software package was used to select a random representative sample by Contractor from the sample frame. The sample size was determined using a confidence level of 95 percent and a 5-percent confidence interval, plus 10 percent oversampling. Sample Strata: The random sample was further stratified by urban and rural counties. Data Sources: AHCCCS recipient enrollment data were used to identify members who met the sample frame criteria. AHCCCS encounter data, and member medical records and/or case management files, and Contractor claims data were used to identify services received by members in the sample frame. Data Collection: Data were first collected from AHCCCS administrative (encounter) data. If acceptable services were not identified as being provided within 30 days of enrollment, AHCCCS requested that Contractors use medical records, case management files or their own claims data to verify whether any of the services measured in this study were provided to those members within the first 30 days of enrollment. If services were not provided within 30 days, Contractors were to provide the reason and supporting documentation for each case. Contractors were required to collect data using the AHCCCS standardized methodology in an electronic format provided by AHCCCS. Each Contractor was provided an electronic file of its sample members for whom encounters for services within 30 days of enrollment were not found in the AHCCCS encounter system. After collection of data, Contractors were required to return the data to AHCCCS in the predetermined electronic format. Confidentiality Plan: AHCCCS continues to work in collaboration with Contractors to develop, implement and maintain compliance with Health Insurance Portability and Accountability Act (HIPAA) requirements. The Data Analysis & Research (DAR) Unit maintains the following security and confidentiality protocols: • To prevent unauthorized access, the sample member file is maintained on a secure, password-protected computer, by the DAR project lead, • Only select Division of Health Care Management (DHCM) employees, who enter or analyze data, have access to study data. • Sample files given to Contractors are tracked to ensure that all records are returned. • All employees and Contractors are required to sign a confidentiality agreement. • Member names are never identified or used in reporting. • Upon completion, all study information is removed from the computer and placed on a compact disk, and stored in a secure location. Data Validation: The sample frame was validated to ensure that members met criteria for inclusion in the study. ii Data files received back from Contractors were reviewed to ensure that: • all members included in the sample were listed in the returned data file, • services met numerator criteria for this performance measure, • all requested information was provided. Service data provided by Contractors must have been accompanied with documentation of the source data (i.e., copy of the pertinent section of the medical record or case management file and/or a copy of a paid claim), including the date(s) of service. Contractor-supplied data were validated by clinical staff of the AHCCCS ALTCS unit. Indicators: 1. The number and percentage (overall, by urban and rural counties, and by individual Contractor) of sample members who received at least one acceptable home and community-based service within 30 days of enrollment during the measurement periods. 2. The number and percentage of members who did not receive an acceptable home and community-based service within 30 days of enrollment, by reason category. Denominators: 1. The number of members who met the sample frame criteria 2. The number of members who met the sample frame criteria and did not receive a service within 30 days of enrollment Numerators: 1. The number of sample members who received an acceptable service within 30 days of enrollment in ALTCS 2. The number of sample members who did not receive an acceptable service within 30 days of enrollment for one of the following reasons: • The number of members in denominator #2 who refused all services (including those who refused other services while waiting for a specific person to be trained as an attendant caregiver) • The number of members in denominator #2 who died within 30 days of enrollment • The number of members in denominator #2 who were admitted to a hospital or nursing facility within 30 days of enrollment • The number of members in denominator #2 who were receiving hospice services within 30 days of enrollment • The number of members in denominator #2 who were in an assisted living facility within 30 days of enrollment • The number of members in denominator #2 for whom no reason was given Analysis Plan: • • • The numerator was divided by the corresponding denominator for each indicator (i.e., study question) to determine the indicator rate. Data for services received within 30 days were analyzed as a statewide aggregate, and by urban and rural counties, to determine overall and urban- and rural- county rates. When calculating rates for initiation of services within 30 days of enrollment (study question #1), members were excluded from the denominator for the following reasons: o refused all applicable services iii died within 30 days of enrollment admitted to a hospital or nursing facility within 30 days of enrollment o received hospice services within 30 days of enrollment o resided in an assisted living facility within 30 days of enrollment No outliers were identified using standard deviations and patterns of abnormal distribution of data. Differences between prior study results were analyzed for statistical significance and relative change. The following assumptions were used to determine whether the indicator criteria was met: o Members included in the sample sent to Contractors for which were not received back from the Contractor were counted as having no service within 30 days; o Any service documented by the Contractor that did not include the date it was first delivered was counted as being provided outside the 30-day requirement. o o • • • Comparative Analysis: • • Deviations from HEDIS: This Performance Measure is based on an AHCCCS contractual requirement and is not based on any nationally recognized methodology, such as the Health Plan Employer Data and Information Set (HEDIS). Deviations from Previous AHCCCS Methodology: There are no substantive deviations from the methodology used for the previous measurement. However, the list of acceptable service codes was updated to allow AHCCCS to extract more complete information from administrative data and to reflect code revisions under the Health Insurance Portability and Accountability Act (HIPAA). The following services were included in the numerator when identified though medical records or case management reviews in previous studies, but were not included in the codes used to select services from AHCCCS encounter data until the current measurement period: • Home Infusion therapy • Companion care • Skills training and development • Supported Employment • Behavioral Health Day Programs Quality Control: To ensure consistency and reliability in data abstraction, AHCCCS: • provided each Contractor with the methodology for this measure • provided each Contractor with a data specification sheet, file layout, and data dictionary for this measure • provided Contractors with detailed written instructions for data collection • provided updates and ongoing technical assistance to Contractors regarding data collection for this measure Overall rates for urban and rural counties were compared. Individual Contractor rates were compared to each other and to the AHCCCS Minimum Performance Standard and Goal. iv Acceptable HCBS Service Codes The following services met the indicator criteria for the AHCCCS HCBS Performance Measure for the measurement period of October 1, 2003, through September 30, 2004: Adult Day Health Personal Care Z3000/S5100 Day care service; per 15 min. Z3000/S5101 Day care service; per ½ day. Z3000/S5102 Day care service; per diem. Z3050/T1019 Personal care services; per 15 min. Not for IP Attendant Care Respite Z3725/S5125 Attendant care service; per 15 min. Z3060/S5150 Unskilled, not hospice; per 15 min in home respite care. Z3080/S5125 Attendant care services; per diem. Z3070/S5151 Unskilled, not hospice; per diem in home respite care. Z3061/S5150 Unskilled, not hospice; per 15 min respite care. Home-Delivered Meals Z3010/S5170 Home-delivered meals; per meal including preparation. Homemaker Z3040/S5130 Homemaker services, NOS; per 15 min. Home Health Aide Z3020/T1021 Home health aide or CNA; per visit. Other S5180 and S5181– applies to following: Home Health Nursing – S9123 =RN, S9124= LPN Z3039/ S9123 Nursing Care in home by RN; per hour. (Modifier TG) W2404/S5180 Home health respiratory therapy, initial evaluation. Z3030/ S9123 or S9124 Nursing Care in home by RN and LPN; per hour. W2405/S5180 Home health respiratory therapy, initial evaluation. Z3038/ S9124 - Nursing Care in home by LPN; per hour. (Modifier TG) W2406/S5181 Home health respiratory therapy, NOS; per diem. Z3037/ S9124 Nursing Care in home by LPN per hour. Habilitation Services Z3032/ S9123 Nursing Care in home by RN; per hour (Modifier TG) Z3132 /T2021 Day habilitation waiver; per 15 min. Z3031/ S9123 and S9124 Nursing Care in home by RN; per hour. Z3133/T2016 Habilitation residential, waiver; per diem. Z3036/ S9123 Nursing Care in home by LPN; per hour. (Modifier TG) Z3134/T2017 Habilitation residential, waiver; per 15 minutes. Z3035/ S9124 Nursing Care in home by LPN; per hour. (Modifier TG) T2020 Day Habilitation, waiver; per diem. v Home Health Nursing (Con’t) Behavioral Health Z3034/ S9124 Nursing Care in home by RN; per hour. (Modifier TG) Z3050, /T1019 Personal care services; per hour. W4044/T1019 Personal care services; per 15 minutes, up to 11 ¾ hours. W4045/T1020 Personal care services; per diem. W4006 /H2014 Skills training and development; per 15 minutes. W4015/H2014 Group skills training and development; per 15 minutes. (*Modifier HQ) W4031/H2025 Ongoing support to maintain employment; per 15 minutes Home Infusion Z3470/S9379 Home Infusion Therapy; per diem. Not otherwise classified. T2018 Habilitation, supported employment, waiver; per diem. Z3084/T2019 Habilitation, supported employment, waiver; per 15 minutes. W4071/H2012 Behavioral health day treatment (supervised day program); per hour Companion care W4072/H2015 Comprehensive community support services (supervised day program); per 15 minutes S5135 Companion care adult; 15 minutes. W4073 /H2019 Therapeutic behavioral services (therapeutic day program); per 15 minutes. W4074, W4077/H2019 Therapeutic behavioral services (therapeutic day program); per diem. (*Modifier TF) W4075, W4078/H2020 Therapeutic behavioral services (therapeutic day program); per diem. W4079, W4082 /H0036 Community psychiatric supportive treatment, Face to Face (medical day program); per 15 minutes. W4080, W4083/H0036 Community psychiatric supportive treatment, Face to Face (medical day program); per 15 minutes. (*Modifier TF) W4081, W4084/H0037 Community psychiatric supportive treatment program (medical day program); per diem. HIPAA Crosswalk for Codes: Use of the new codes was optional for dates of service on and after October 1, 2003. use of the new codes was required for dates of service after January 1,2004. *Modifier HG – Modifier for group setting *Modifier TF - Modifier for intermediate level of care *Modifier TG - Modifier for complex/high level of care vi