Pediatric Coding Alert

99341-99350 can be your friend if you make house calls.

The image of a physician carrying a black bag through the streets of a small town visiting sick patients at home may seem like it’s out of an episode of a 1950s television program, but even in today’s busy world, there’s still a place for home visits—and you can collect for them, if you know how.

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

Consider This Example

A subscriber wrote to Pediatric Coding Alert with the following question: “Our doctor saw a patient at his home for nursemaid's elbow.  Normally, I would bill 24640 for the procedure and 832.2 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 24640 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 consultant at Pedscoding.com. “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.” Not all payers follow Medicare guidelines, so you should check with your insurer to find out its home visit regulations.

Modifier reminder: Because the physician also provided a procedure, you’ll want to report 24640 (Closed treatment of radial head subluxation in child, nursemaid elbow, with manipulation). 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 day of a procedure) 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 24640 with diagnosis code 832.2 and POS 12.