What’s Next for Home Health Programs and Select Condition Scenarios

home health programs

My previous post outlined the 5 challenges impacting care plans that are managed. In the final post of this series, I highlight a few specific scenarios and outline next steps for home health programs (HHP).


If hypertension is a targeted chronic condition, that state (e.g., California, New York, etc.) will want reports on participants’ improved blood pressure as evidence of successful interventions. Payers will either “require” that providers send blood pressure readings or include appropriate coding in the claim. This can be done by using CPT codes. CPT Category II codes in the claim 3074F, 3075F and 3077F identify systolic ranges, and 3078F, 3079F and 3080F represent diastolic ranges, which will reveal if a hypertensive patient has their blood pressure under control or could benefit from an HHP case manager’s intervention.


For obesity, BMI will likely be the measure of success. It is unlikely that an inbound data file is coming from providers to payers that contains height, weight, and a BMI. In this case, payers either need to set up inbound data files to capture that data or “require” providers to use the ICD-10 coding that relays results (i.e., Z68 series).

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Diabetes patient improvement is measured by a number of indicators. One is Hba1c results. Payers get the claim for the lab, but rarely get the results unless providers send claims containing CPT Category II codes 3044F (below 7), 3045F (8-9) or 3046F (above 9) for Hba1c results. To collect this information, payers have to create new channels of data exchange with lab vendors or providers to get lab results.

Mental Health

Integration of care around mental health and substance use disorder diagnoses are major focal points for many state’s Health Home Program. Many providers will do a basic depression screening, like a Patient Health Questionnaire (PHQ-9) or Pediatric Symptom Checklist (PSC-17), and will set up a follow-up plan based on the results. Both of these activities can be sent via data files or as a claim with the appropriate HCPCS code (i.e., activities complete: G8431 or G8510; activities not complete: G8432 or G8511).

What’s Next for HHP?

As CMS continues to require participation in programs to provide improved healthcare benefits to Medicaid members, the industry will see significant impacts on providers and payers, as well as members.

The Health Home Program’s focus on coordinating care for Medicaid patients with the highest need has introduced some new challenges for payers. The need for well-planned, effective improvements in health information technology, as well as communication between providers and payers for HHP, will be far reaching. It will enable payers and providers to collaborate on other initiatives and will be well worth the investment of time and resources.

This guide provides an overview of the Health Home Programs and presents five common challenges payers will face when creating a successful program. To learn more, you can click here or submit the form below.

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