Medicare Compliance & Reimbursement

Medical necessity is key to reimbursement.

If your physician makes a house call, you don’t have to write that off.  Ensure that medical necessity, not convenience, dictated the visit before you code for it.

Background: CPT^® introduced home visit codes 99341-99345 (for new patients) and 99347-99350 (for established patients) several years ago. Many physicians, however, are reluctant to use the codes in fear of knowing what the requirements are.

Consider This Example

A subscriber recently posed this question to Codify: “The physician saw a patient at his home to treat an elbow dislocation. Normally, I would bill 24600 for the procedure and 832.00 for the diagnosis, but with the place of service not being in our office, I’m not sure. I checked CPT^® and found some home services codes, but if I understand the definitions correctly, they are for counseling and/or coordination of care with other physicians. And wouldn’t 24600 still be the most appropriate code? Also, what would I use for place-of-service (POS)? Office (11) or inpatient (21) does not apply here.”

Solution: This practice should bill a home visit code from the 99341- 99350 series, says Donelle Holle, RN, a coding consultant in Indiana. “These codes are only for visits to a patient’s private residence,” Holle says. “These codes are not just for coordination of care, but for that specific home visit.”

However, Holle adds, medical necessity is key to reimbursement. “Use the home visit codes only when you can document a medical reason for the visit and a medical reason that the patient cannot make the trip to the office or clinic.”

The medical reason for the visit is easy to document, Holle says. “It can be any type of problem that the physician would see a patient for in the office, such as influenza or a regular check for high blood pressure.”

Documenting the medical reason that the patient needs treatment at home is more difficult. Section 15515 of the Medicare Carriers Manual says that the patient does not have to be confined to the home (as is necessary for services provided under the home health benefit) but the “medical record must document the medical necessity of the home visit made in lieu of an office or outpatient visit.”

So how can you show that it was medically necessary for the physician to see the patient at home? The key is to document a medical reason that the patient can’t travel. For instance, the patient may be blind (369.00), a paraplegic (344.1) or in severe pain (780.96) and unable to travel to the office without assistance.

Warning: The reason for the home visit cannot be convenience — for example, that the patient can’t get transportation. Although Medicare doesn’t require that a patient to be homebound before a physician can report home services (99341-99350), many patients requesting home services probably meet the definition of homebound.

Modifier reminder: Because the physician also provided a procedure, you’ll want to report 24600 (Treatment of closed elbow dislocation; without anesthesia). This means you’ll append modifier 25 (Significant, separately identifiable evaluation and management [E/M] service by the same physician or other qualified healthcare professional on the same day of a procedure or other service) to the E/M code.

You should use place of service code 12 (Location, other than a hospital or other facility, where the patient receives care in a private residence).

In summary: For an established patient on whom you perform a problem-focused history and exam, your billing will be 99347-25 and 24600 with diagnosis code 832.00 and POS 12.