Pulmonology Coding Alert

Question: We are in a rural area and sometimes make house calls. Do Medicare patients have to meet Medicares homebound standard for home visits by the physician, physician assistant or clinical nurse practitioner to be reimbursed?

Florida Subscriber

Answer: Medicares homebound criteria are specific requirements under its home-health agency billing mechanism that stipulate that the patient must have certain limitations to keep him or her from traveling to receive the services that he or she needs (i.e., nurse educator visits, skilled nursing, physical therapy, social work, etc.). When deciding whether these criteria apply to your services, you need to understand the difference between a physicians home visit and a home-health service.

For a physicians home visit, you would report the home visit codes (99341-99345, new patient; 99347-99350, established patient). The patient visit must be medically necessary (i.e., there must be a chief complaint, and the service must involve a level of history, exam and medical decision-making) and take place in a private residence.

If the patient has a medically necessary problem and wants the physician (or physician assistant or nurse practitioner) to come to his or her home, the clinician can go to the home and provide the service as long as medical necessity exists. The visit is then reported with the appropriate home visit CPT code based on the level of service. There are no homebound requirements for reporting the home visit codes if the service is performed and reported by a physician or a non-physician provider practicing independently (using his or her own identification number).

Answers to Reader Questions provided by Cynthia Thompson, CPC, senior consultant at Gates, Moore & Co., a physician-practice management consulting firm in Atlanta; Carol Pohlig, CPC, RN, a reimbursement analyst for the Office of Clinical Documentation, Department of Medicine at the University of Pennsylvania, Department of Medicine in Philadelphia; Ron Nelson, PA-C, member of the practice expense advisory committee AMA/HCFA, past president, American Academy of Physician Assistants, president, Health Services Associates in Freemont, Mich.; and Susan Callaway-Stradley, CPC, CSS-P, an independent coding consultant and educator in North Augusta, S.C.