Clinical UM Guideline


Subject:Custodial Care
Guideline #:  CG-MED-19Current Effective Date:  04/15/2014
Status:ReviewedLast Review Date:  02/13/2014

Description

Custodial care generally provides assistance in performing activities of daily living (ADL), (e.g., assistance walking, transferring in and out of bed, bathing, dressing, using the toilet, and preparation of food, feeding and supervision of medication that usually can be self-administered). Custodial care essentially is personal care that does not require the continuing attention of trained medical or paramedical personnel.

Note: Please see the following related documents for additional information:

Clinical Indications

Care that does not meet the criteria for skilled nursing or skilled rehabilitation services is considered custodial.

Definition of Custodial Care:

Note: Custodial care may occur in settings other than the home.  

Examples of Custodial Care, include, but are not limited to, the following:

Coding

Coding edits for medical necessity review are not implemented for this guideline.  Where a more specific policy or guideline exists, that document will take precedence and may include specific coding edits and/or instructions.  Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy.  Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

Discussion/General Information

In determining whether care is custodial, consideration should be given to the complexity of care and medical supervision required and furnished. Determinations are not based on the diagnosis, type of condition, degree of functional limitation, or rehabilitation potential.

Institutional care that is below the level of care covered in a Skilled Nursing Facility (SNF) is custodial care. Some examples of custodial care in hospitals and SNFs include, but are not limited to:

References

Government Agency, Medical Society, and Other Authoritative Publications:

  1. Centers for Medicare and Medicaid Services. Medicare Benefit Policy Manual. Chapter 8. Coverage of Extended Care (SNF) Services under Hospital Insurance. Rev. 161, 10-26-12. Available at: http://www.cms.hhs.gov/manuals/Downloads/bp102c08.pdf. Accessed on December 26, 2013.
  2. Centers for Medicare and Medicaid Services. Medicare Benefit Policy Manual. Chapter 16. General Exclusions from Coverage. Rev.270, 05-10-13. Available at: http://www.cms.hhs.gov/manuals/Downloads/bp102c16.pdf. Accessed on December 26, 2013.
  3. Centers for Medicare and Medicaid Services. Medicare Benefit Policy Manual. Chapter 7. Home Health Services. Rev. 172, 10-18-13. Available at: http://www.cms.hhs.gov/manuals/Downloads/bp102c07.pdf. Accessed on December 26, 2013.
  4. National Institute for Health and Clinical Excellence (NICE). Nutrition Support for Adults: Oral Nutrition Support, Enteral Tube Feeding and Parenteral Nutrition. Clinical Guideline 32. London, UK. NICE; February 2006. Available at: http://www.nice.org.uk/nicemedia/live/10978/29979/29979.pdf. Accessed on December 26, 2013.
History
StatusDateAction
Reviewed02/13/2014Medical Policy & Technology Assessment Committee (MPTAC) review. Reference links updated.
Reviewed02/14/2013MPTAC review. Reference links updated.
Reviewed02/16/2012MPTAC review. Reference links updated.
Revised02/17/2011MPTAC review. Definition of custodial care and examples of custodial care updated in the Clinical Indication section. Discussion and Reference links updated.
Reviewed02/25/2010MPTAC review. Custodial care examples for stable bolus feeding and chronic uncomplicated oral or tracheal suctioning clarified. Place of Service section removed. References updated.
 06/23/2009Removed CG-MED-25 Hospice, Inpatient Setting from note referring to related documents as CG MED-25 has been archived.
Reviewed02/26/2009MPTAC review. References updated. Note under description updated with additional related document. Removed case management section.
Reviewed02/21/2008MPTAC review. Note added under description referring to other documents for additional information. References updated.
Reviewed03/08/2007MPTAC review. References updated.
Revised03/23/2006MPTAC review. Referenced Skilled Nursing and Rehabilitation clinical guideline and aligned definition of custodial care on both documents. 
Revised12/01/2005MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.
Pre-Merger Organizations

Last Review Date

Document Number

Title

Anthem, Inc.

 

None 
Anthem Mid West

02/11/2005

MA-020Skilled Nursing Facility Setting, Skilled and Custodial Services Defined
Anthem Mid West

02/11/2005

MA-021Home Health Care Setting, Skilled and Custodial Services Defined for NASCO use only
WellPoint Health Networks, Inc.

06/24/2004

DefinitionsCustodial Care