Billing and Coding for Physician Home Visits

by | Published on May 23, 2018 | Medical Coding

Billing and Coding for Physician Home Visits
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Physician home visits have begun making a comeback, according to a recent report from the Association of American Medical Colleges (AAMC). With 80% of U.S. adults age 65+ having one or more chronic diseases, this is a welcome development. Point of care testing along with advancements in home health technology and support have improved the physician’s ability to cater to the needs of older weak patients with multiple comorbidities outside the office setting. Outsourcing medical coding can ensure accurate claim submission for optimal reimbursement for services provided. However, to qualify for coverage, the medical record must document the medical necessity of the home visit made in lieu of an office or outpatient visit. The Office of Inspector General (OIG) and several contractors of the Centers for Medicare & Medicaid Services (CMS) scrutinize physician home services billed to the Medicare program to ensure that house calls are medically necessary and not for the convenience of the patient, the patient’s family, or the physician (or provider).

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Physician Home Visits must be “Medically Necessary” defines “medically necessary” as “health-care services or supplies needed to prevent, diagnose, or treat an illness, injury, condition, disease, or it’s symptoms and that meet accepted standards of medicine”.

CPT codes 99341 through 99350, Home Services codes, are used to report E/M services provided to a patient residing in his or her own private residence and not any type of facility. According to a 2017 AAPC report:

  • For home visits to qualify as medically necessary, providers need to document if the home visit is based upon a one-time need, or if the visit is provided to meet an ongoing or permanent need because of the patient’s physical, medical, mental, or psychological issues.
  • The physician should provide proof that the patient is not physically capable of traveling to the office either this one time, or on an ongoing basis, due to physical or mental issues and not due to financial or other personal reasons.
  • Home services cannot be provided at the physician’s convenience (for e.g., visiting senior independent living facilities on a routine basis, without requests for or by patients).
  • Under Medicare’s home health benefit, the beneficiary must be confined to the home for services to be covered.
  • For home services provided by a physician billed under CPT codes 99341 through 99350, the beneficiary does not need to be confined to the home.

CGS Adminstrators, LCC points out that if the physician visits the patient in his/her home on a regular basis, each note should show how the patient’s condition has changed. Providers should take care to avoid cloned or copied documentation that does not explain how the patient’s condition has improved or deteriorated.

Home Services CPT Code Range 99341- 99350

Codes 99341-99350 report evaluation and management (E/M) services provided in a private residence (place of service 12) and cannot be used if the patient resides in a shared living facility or group home. The description of home visits includes the average time to be used when counseling/coordination of care dominate the visit (for e.g., comprises over 50 percent of total face-to-face time between the provider and patient).

Codes for New Patients

99341 Home visit; low severity problem, 20 min.
99342 moderate severity problem, 30 min.
99343 moderate to high severity problem, 45 min.
99344 high severity problem, 60 min.
99345 patient unstable or significant new problem requiring immediate attention 75 min.

Codes for Established Patients

93347 Self-limited or minor problem, 15 min.
99348 Low to moderate problem, 25 min.
99349 Moderate to high problem, 40 min.
99350 Patient unstable or significant new problem requiring immediate physician attention, 60 min.

If other services such as advanced care planning, diagnostic services, and some minor procedures are performed, they can be documented and billed in addition to the visit code in this setting.

Demographics, Insurance, and Billing Information

As the home visit with a new patient has the same business requirements as a visit to the office, AAPC says that maintaining a complete and accurate medical record for each patient is critical. Physicians should gather the necessary demographic and insurance information and provide patients with the appropriate forms such as Notice of Privacy Practices, general consent for treatment, new patient intake form, history form, and financial policies.

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Billing for Physician Home Visits – Risk Factors

DC based Law Firm Liles Parker lists the risk factors that can lead Medicare reviewers to deny claim payment:

  • If it appears that one or more of the home services were was conducted for the convenience of the patient, the patient’s family, or the physician
  • The documentation does not prove that the patient was not able come to the physician’s office or an outpatient clinic for care.
  • The medical record does not clearly show that the patient, his/her family or another clinician involved in the case sought the initial service
  • The home services are provided at a frequency that exceeds that which is typically provided in the office and acceptable standards of medical practice
  • The physician does not personally provide the home services. The service is performed by a non-physician practitioner (NPP) but the claim is being billed at the physician’s rate.
  • The home services are solely provided by an NPP but only the physician, not the treating NPP, is credentialed with Medicare.
  • The specific home services performed could be provided by a visiting nurse or home health agency.

With OIG and many CMS contractors auditing home services (CPT codes 99341 through 99350) billed to Medicare, participating physicians should understand the coverage and billing requirements. The documentation should provide clear proof of medical necessity. Other services such as minor procedures or advanced care planning services can also be rendered in a variety of living situations and providers should be familiar with the specifics to each code location. It is important that physicians review all the relevant CPT codes with their medical billing company. Partnering with an experienced medical billing and coding service provider can help home-based primary care practices achieve savings while delivering holistic, team-based care to old, sick, frail, or functionally limited people.

Rajeev Rajagopal

Rajeev Rajagopal, the President of OSI, has a wealth of experience as a healthcare business consultant in the United States. He has a keen understanding of current medical billing and coding standards.

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