Pediatric Coding Alert

Question: Our pediatrician saw an unvaccinated established patient at the patient’s home for measles (mainly because our doctor didn’t want the patient in the waiting room with infants). Normally, I would bill a standard E/M code for this, 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. Also, what would I use for place-of-service (POS)? Office (11) or inpatient (21) does not apply here.

Solution: You should report a home visit code from the 99341- 99350 series. These codes are only for visits to a patient’s private residence and don’t only apply to coordination of care. They are specifically for what you might refer to as “house calls.”

You should report these 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, and in this case would be measles (055.9).

Documenting the medical reason that the patient needs treatment at home can be 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.

In your case, the reason would be to avoid exposing your pediatrician’s other patients to measles.

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).