This document defines custodial care, a type of care that generally provides assistance in performing activities of daily living (ADL), (for example, 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:
Care that does not meet the criteria for skilled nursing or skilled rehabilitation services is considered custodial.
Definition of Custodial Care:
- Custodial care is that care which is primarily for the purpose of assisting the individual in the activities of daily living or in meeting personal rather than medical needs, which is not specific therapy for an illness or injury and is not skilled care.
- Custodial care serves to assist an individual in the activities of daily living, such as assistance in walking, getting in and out of bed, bathing, dressing, feeding, using the toilet, preparation of special diets, and supervision of medication that usually can be self-administered.
- Custodial care essentially is personal care that does not require the continuing attention or supervision of trained, medical or paramedical personnel.
- Custodial care is maintenance care provided by family members, health aides or other unlicensed individuals after an acute medical event when an individual has reached the maximum level of physical or mental function.
- In determining whether an individual is receiving custodial care, the factors considered are the level of care and medical supervision required and furnished. The decision is not based on diagnosis, type of condition, degree of functional limitation or rehabilitation potential.
Note: Custodial care may occur in settings other than the home.
Examples of Custodial Care, include, but are not limited to, the following:
- Assistance in dressing, eating, and toileting;
- Periodic turning and positioning in bed;
- Prophylactic and palliative skin care, including bathing and application of creams, or treatment of minor skin problems;
- Stable bolus feeding by nasogastric, gastrostomy or jejunostomy tube (Note: skilled care, supervision or observation may be required if feedings are not stable);
- Routine care of the incontinent individual, including use of diapers and protective sheets;
- Routine services to maintain satisfactory functioning of indwelling bladder catheters (this would include emptying containers and cleaning them, and clamping tubing);
- General maintenance care of colostomy and ileostomy;
- General supervision of exercises, which have been taught to the individual and do not require skilled rehabilitation personnel for their performance. This includes, but is not limited to:
- repetitive exercises to maintain function, improve gait, or maintain strength or endurance; or
- passive exercises to maintain range of motion in paralyzed extremities, or
- assisted walking.
- Changes of dressings for non-infected postoperative or chronic conditions;
- General maintenance care in connection with a plaster cast (skilled supervision or observation may be required where the individual has pre-existing skin or circulatory conditions or needs to have traction adjusted);
- Routine care in connection with braces and similar devices;
- Use of heat as a palliative and comfort measure, such as whirlpool or steam pack;
- Routine administration of medical gases after a regimen of therapy has been established (i.e., administration of medical gases after the individual has been taught how to institute therapy);
- Administration of routine oral medications, eye drops, and ointments (the fact that an individual cannot be relied upon to take such medications himself/herself or that state law requires all medications be dispensed by a nurse to those individuals in an institutions would not change this service to a skilled service);
- Chronic uncomplicated oral or tracheal suctioning (Note: skilled care, supervision or observation may be required if suctioning is complicated).
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.
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:
- An individual who has had a stroke and is ambulatory, has no bladder or bowel involvement, no serious associated or secondary illnesses, does not require medical or paramedical care, and requires only the assistance of an aide in feeding, dressing, and bathing;
- An individual with a cardiac disorder who is stable and compensated and has reasonable cardiac reserve and no associated illnesses, but who because of advanced age has difficulty in managing alone in the home, and requires assistance in meeting the activities of daily living; and
- An individual with senility who has diabetes which remains stabilized as long as someone sees to it that the individual takes his/her medication and adheres to a prescribed diet.
Government Agency, Medical Society, and Other Authoritative Publications:
- Centers for Medicare and Medicaid Services. Medicare Benefit Policy Manual. Chapter 8. Coverage of Extended Care (SNF) Services under Hospital Insurance. Rev. 204, 03-13-15. Available at: http://www.cms.hhs.gov/manuals/Downloads/bp102c08.pdf. Accessed on November 13, 2015.
- Centers for Medicare and Medicaid Services. Medicare Benefit Policy Manual. Chapter 16. General Exclusions from Coverage. Rev.198, 11-06-14. Available at: http://www.cms.hhs.gov/manuals/Downloads/bp102c16.pdf. Accessed on November 13, 2015.
- Centers for Medicare and Medicaid Services. Medicare Benefit Policy Manual. Chapter 7. Home Health Services. Rev. 208, 05-11-15. Available at: http://www.cms.hhs.gov/manuals/Downloads/bp102c07.pdf. Accessed on November 13, 2015.
|Reviewed||02/04/2016||Medical Policy & Technology Assessment Committee (MPTAC) review. Reference section updated.|
|Reviewed||02/05/2015||MPTAC review. Description and Reference sections updated.|
|Reviewed||02/13/2014||MPTAC review. Reference links updated.|
|Reviewed||02/14/2013||MPTAC review. Reference links updated.|
|Reviewed||02/16/2012||MPTAC review. Reference links updated.|
|Revised||02/17/2011||MPTAC review. Definition of custodial care and examples of custodial care updated in the Clinical Indication section. Discussion and Reference links updated.|
|Reviewed||02/25/2010||MPTAC review. Custodial care examples for stable bolus feeding and chronic uncomplicated oral or tracheal suctioning clarified. Place of Service section removed. References updated.|
| ||06/23/2009||Removed CG-MED-25 Hospice, Inpatient Setting from note referring to related documents as CG MED-25 has been archived.|
|Reviewed||02/26/2009||MPTAC review. References updated. Note under description updated with additional related document. Removed case management section.|
|Reviewed||02/21/2008||MPTAC review. Note added under description referring to other documents for additional information. References updated.|
|Reviewed||03/08/2007||MPTAC review. References updated.|
|Revised||03/23/2006||MPTAC review. Referenced Skilled Nursing and Rehabilitation clinical guideline and aligned definition of custodial care on both documents. |
|Revised||12/01/2005||MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.|
Last Review Date
|Anthem Mid West|
|MA-020||Skilled Nursing Facility Setting, Skilled and Custodial Services Defined|
|Anthem Mid West|
|MA-021||Home Health Care Setting, Skilled and Custodial Services Defined for NASCO use only|
|WellPoint Health Networks, Inc.|