Where this LCD applies
Each contract number is a jurisdiction on the remittance; the policy binds claims processed under these contracts and no others.
| Contract | Contractor | Type | States |
|---|---|---|---|
| 11004 | Palmetto GBA | A and B and HHH MAC | AL AR FL GA IL IN KY LA MS NC NM OH OK SC TN TX |
Billing and coding: diagnoses and procedure codes
Since 2019 the codes live in the companion article rather than the LCD. Billing and Coding A56641 (Billing and Coding: Home Health Skilled Nursing Care-Teaching and Training: Alzheimer's Disease and Behavioral Disturbances) carries the diagnosis and procedure lists the contractor loads as the claims edit. CPT codes are shown as bare numbers because the descriptors are licensed by the AMA; HCPCS Level II descriptors are public and shown.
A56641: Billing and Coding: Home Health Skilled Nursing Care-Teaching and Training: Alzheimer's Disease and Behavioral Disturbances (Billing and Coding, effective 2025-10-01)
- Covered ICD-10-CM codes
- 21
- 1 group
- Non-covered ICD-10-CM codes
- 0
- Procedure codes listed
- 4
- Full article
- cms.gov record
| ICD-10-CM | Description (FY2027) |
|---|---|
| F03.90 | — |
| F03.911 | — |
| F03.918 | — |
| F03.92 | — |
| F03.93 | — |
| F03.94 | — |
| G11.5 | — |
| G30.0 | — |
| G30.1 | — |
| G30.8 | — |
| G30.9 | — |
| G31.01 | — |
| G31.1 | — |
| G31.80 | — |
| G31.85 | — |
| G31.86 | — |
| G31.87 | — |
| G37.89 | — |
| R41.85 | — |
| R48.1 | — |
| R48.2 | — |
Procedure codes: G0299 (Direct Skilled Nursing Services Of A Registered Nurse (Rn) In The Home Health Or Hospice Setting, Each 15 Minutes), G0300 (Direct Skilled Nursing Services Of A Licensed Practical Nurse (Lpn) In The Home Health Or Hospice Setting, Each 15 Minutes), G0539 (Caregiver Training In Behavior Management/Modification For Caregiver(S) Of Patients With A Mental Or Physical Health Diagnosis, Administered By Physician Or Other Qualified Health Care Professional (Without The Patient Present), Face-To-Face; Initial 30 Minutes), G0540 (Caregiver Training In Behavior Management/Modification For Parent(S)/Guardian(S)/Caregiver(S) Of Patients With A Mental Or Physical Health Diagnosis, Administered By Physician Or Other Qualified Health Care Professional (Without The Patient Present), Face-To-Face; Each Additional 15 Minutes).
Coverage indications, limitations and medical necessity
This Local Coverage Determination (LCD) addresses a specific category of skilled nursing care currently available to Medicare home health (HH) beneficiaries with Alzheimer’s disease (AD) and behavioral disturbances – the category of skilled nursing care is called “teaching and training activities.” Teaching and training activities are defined in the Centers for Medicare and Medicaid Services (CMS) Internet-Only Manual (see citation under CMS National Coverage Policy section of this policy) and in the case of the beneficiary population with AD and behavioral disturbances, could be part of a unique beneficiary-centered care plan directed at teaching the family or caregiver how to manage the behavioral disturbances.
Skilled nursing services must be based on the patient's medical condition as described in the CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual Chapter 7 §40.1.1.
Behavioral disturbances often complicate the medical management of beneficiaries with AD. At baseline many individuals with AD manifest activity limitations in such domains as communication and self-care. The occurrence of behavioral disturbances, if not addressed in a comprehensive and systematic manner, may further compromise the activity limitations present at baseline resulting in sub-optimal clinical outcomes.
Each behavioral disturbance should be fully characterized and answers to the following questions should be documented in the patient’s medical records:
What is the specific behavioral disturbance being addressed?
What is the frequency of the behavior?
Are there specific situations or activities that “trigger” the behavior?
When does it occur?
Where does it occur?
Who is involved?
Are there other possible explanations for the behavior (e.g., pain, infection, change in medication, disruption in schedule, swallowing difficulties, catastrophic reaction induced by environment or personal interaction)?
What are the consequences of the behavior?
What interventions have been successful in addressing this behavior in the past?
What other techniques or interventions can be used to address the behavior?
Teaching and training interventions should be based on the answers to the above questions, the specific impairment(s) and activity limitation(s) identified for each beneficiary, as well as the ability of the family or caregiver to learn and implement the proposed interventions. Environmental factors impacting the identified behavior(s) and the resultant care plan must also be considered.
The CMS Internet-Only Manual, Pub. 100-02, Chapter 7 §40.1.2.3 provides guidance in determining the reasonableness and necessity of the number of training visits and the appropriateness of re-teaching and re-training.
In the HH setting, skilled education services are no longer needed if it becomes apparent, after a reasonable period of time, that the patient, family, or caregiver could not or would not be trained. Further teaching and training would cease to be reasonable and necessary in this case and would cease to be considered a skilled service. Notwithstanding that the teaching or training was unsuccessful, the services for teaching and training would be considered to be reasonable and necessary prior to the point that it became apparent that the teaching or training was unsuccessful, as long as such services were appropriate to the patient's illness, functional loss, or injury.
Summary of evidence (opening)
N/A
the full summary and analysis of evidence are in the CMS record.
Dates, lineage and related policies
- Original determination effective
- 2015-10-01
- Current revision effective
- 2025-08-07
- Last reviewed by the contractor
- 2025-06-26
- MCD version
- 45
- Derived from
- L31532
Using this policy on a claim
Match the documented indication to the covered indications above before the service is scheduled, carry a diagnosis from the article's covered list on the claim line, and keep the elements the documentation section asks for in the record, because the contractor can request it later through medical review. A denial under this policy arrives as CARC 50 with remark N115; the LCD lookup guide walks through the appeal path and the Advance Beneficiary Notice rules, and the Palmetto GBA hub lists every other active policy from the same contractor.
Frequently asked questions
What does LCD L34562 cover?
This Local Coverage Determination (LCD) addresses a specific category of skilled nursing care currently available to Medicare home health (HH) beneficiaries with Alzheimer’s disease (AD) and behavioral disturbances – the category of skilled nursing care is called “teaching and training activities.” Teaching and training activities are defined in the Centers for Medicare and Medicaid Services (CMS) Internet-Only… The full indications and limitations are reproduced on this page from the CMS Medicare Coverage Database export of September 24, 2026.
Which states does LCD L34562 apply to?
Palmetto GBA applies it to Medicare claims in AL, AR, FL, GA, IL, IN, KY, LA, MS, NC, NM, OH, OK, SC, TN, TX. A Local Coverage Determination binds only the contractor that wrote it; the same service in another jurisdiction is judged under that contractor's own policy or, where none exists, claim by claim.
Which diagnosis codes support medical necessity under LCD L34562?
The companion billing and coding article A56641 lists 21 ICD-10-CM codes in 1 group that support medical necessity; the first 21 appear on this page and the complete list is in the article on cms.gov.
How do I appeal a denial under LCD L34562?
The remittance carries claim adjustment reason code 50 with remark code N115, naming the LCD. Compare the documented indication with the policy's covered indications and the article's diagnosis list, then file a redetermination within 120 days with the record attached; if the service genuinely falls outside the policy, the patient can be billed only when a valid Advance Beneficiary Notice was obtained before the service.
Sources
Every figure on this page is taken from the CMS publications below, as released by the Centers for Medicare & Medicaid Services. Projection built 2026-10-02. Verify against the primary file before billing or contracting decisions.
- Medicare Coverage Database, current LCD exportVersion MCD release 2026-09-24 · effective 2026-09-20 · file lcd.csvSHA-256 2fcc4251b6ddd1eb…
- Medicare Coverage Database, current Billing and Coding Articles exportVersion MCD release 2026-09-24 · effective 2026-09-20 · file article.csvSHA-256 f31932f1df3b4035…
- ICD-10-CM FY2027 code descriptionsVersion FY2027 · effective 2026-10-01 · file icd10cm_codes_2027.txtSHA-256 3c0583a38ee0e848…
Disclaimer
The policy text and code lists are reproduced from the CMS Medicare Coverage Database export as an operational reference. Verify against the current LCD and article on cms.gov before billing; coverage depends on the full record and the contractor. Not legal, clinical or billing advice.