Internal Medicine Coding Alert

In Documentation and Correct Coding are Key to Reimbursement for Home Visits by the Internist, on page 81 of the November Internal Medicine Coding Alert, we covered coding and billing for home visits by the internist. In that article, we stated that a nurse cannot provide home services to patients incident to the physician service without the physicians actual presence.

In fact, in areas that Medicare defines as medically underserved, nurses and other paramedical personnel may be able to provide these services under the general supervision of the physician. General supervision, according to the Medicare Carriers Manual (MCM), means the physician need not be physically present at the patients place of residence when the service is performed; however, the service must be performed under his/her overall supervision.

According to the Medicare Carriers Manual Services section 2051 Incident to a Physicians Service to Homebound Patients Under General Physician Supervision: In some medically underserved areas, there are only a few physicians available to provide services over broad geographic areas or to a large patient population. The lack of medical personnel (and, in many instances a home health agency [HHA] servicing that area) significantly reduces the availability of certain medical services to homebound patients. Some physicians and physician-directed clinics, therefore, call upon nurses and other paramedical personnel to provide these services under general rather than direct supervision. In some areas, such practice has tended to become the accepted method of delivery of these services.

The following criteria must be met in order for these incident to services to be paid for by the Medicare carrier:

1. The patient is homebound (i.e., confined to his or her home). Section 2051.1 of the MCM defines what the carrier will consider homebound. Generally speaking, a beneficiary will be considered to be homebound if he has a condition due to an illness or injury which restricts his ability to leave his place of residence except with the aid of supportive devices such as crutches, canes, wheelchairs, and walkers, the use of special transportation, or the assistance of another person. Or, the patient has a condition which is such that leaving his home is medically contraindicated. Section 2051.1 also lists examples of homebound patients.

2. The service provided is an integral part of the physicians service to the patient and is performed under general physician supervision by employees of the physician or clinic. The physician must order the service(s) to be performed, and contact must be maintained between the nurse or other employee and the physician, and the physician must retain professional responsibility for the service. All other incident to requirements must be met. These are listed in Sections 2050 and 2050.5 of the MCM.

3. The services are included in the physician/clinic bill and he or she has incurred an expense for them.

4. The services of the paramedical personnel are required for the patients care; that is, they are reasonable and necessary.

5. When the service can be furnished by an HHA in the local area, it cannot be covered when furnished by a physician/clinic to a homebound patient under this provision, except as described in Section 2051C.

Also, in the same article, a quote from Emily Hill, PA-C, president of Hill and Associates in Southport, N.C., was reported out of context and mistakenly implied that Medicare only covers home visits by physicians when the severity of the patients condition warrants the visit. Actually, physicians may make home visits to patients if they choose, and report the home services codes (99341-99350). It is when the services are provided by a non-physician provider in an underserved area that the patient must meet the Medicare definition of homebound for the services to be paid.