Primary Care Coding Alert

Question: One of my family medicine physicians wants to make house calls for a select few patients. How should we bill these house calls?

West Virginia Subscriber

Answer: You should use a code from the 99341-99345 series for home services provided to a new patient and a code from the 99347-99350 series for a home visit to an established patient. The higher numbers in each category reflect greater complexity. Remember to use these codes only for visits to a patient's private residence, and enter place of service 12 for a home visit
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Some offices try to bill visits to assisted living center residents using these codes, but you should bill visits to those patients using the domiciliary/rest home codes (99324-99337).

Master medical necessity: Private insurers may publish individual guidelines for home visits, which you should request in writing before you set up a billing policy for these services. If you are seeing a Medicare patient at home, you should only use the home visit codes 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. 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 30.6.14.1 of Chapter 12 of the Medicare Claims Processing Manual says that you can use the home services codes when a physician provides E/M services to a patient in a private residence. 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,- the manual says.

The key is to document a medical reason that the patient can't travel. The patient may be blind, or a paraplegic or in severe pain and unable to travel to the office without assistance. The reason cannot be convenience -- for example, that the patient can't get transportation.