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Defining home visits, and how location affects payments

From the December ACP Observer, copyright 2006 by the American College of Physicians.

By Brian Whitman

Elderly patients with multiple chronic diseases make up a significant proportion of most internists' practices, and some of these patients have trouble coming in for regular office visits. Fortunately, Medicare will pay physicians to make home visits under certain circumstances. Patients do not have to be homebound to qualify but the physician must document a medical necessity for using a home visit as opposed to an office visit in order to bill for it.

Q: What codes do I use for billing house calls?

A: Codes 99341-99345 are used to report home visits for new patients. There are five levels of codes that are reported based on level of history, exam and medical decision making. The codes do not precisely match up to the levels of initial patient office visits, generally requiring a higher level of complexity in medical decision making and a longer typical time listed in the CPT book The medical documentation for a home visit may be nearly identical to an office-based visit, but should include some mention of why the physician is seeing the patient at home.

Use codes 99347-99350 to report home visits to established patients. Notice that there are only four codes for established home visits, as opposed to the five used for reporting established patient office visits. The established visit codes for home visits match up exactly to the requirements for billing established office visits with the exception of 99211. There is no home-based equivalent for 99211 because that service does not require physician involvement.

The work that you would perform under code 99212 in the office would require you to bill under 99347 for a home-based patient. Similarly, a 99215 office visit code is equivalent to a 99350 code for a home visit. Although the documentation standards are identical, the typical times are longer for home visits. This could affect your coding level decision if you are providing counseling or coordination of care and choose to bill based on time.

Q: What is the definition of "home"?

A: Medicare considers a home to be a private dwelling of some kind, generally a house or an apartment. Group homes, boarding houses, and nursing homes are not considered homes. Services completed in such settings cannot be reported using the home visit codes.

Q: What if I see a patient in a group home setting?

A: Fortunately, there are codes that can be used for reporting evaluation and management services in a group home setting. They are listed by CPT as "Domiciliary, Rest Home, or Custodial Care Services." These services should not be mistaken for services provided in a skilled nursing facility or nursing home, which require separate CPT codes.

For new patients in domiciliary settings, services are reported using codes 99324 through 99328. For established patients, services are reported using codes 99334 through 99337. The documentation requirements for these codes are identical to those for home visits and the payment is almost exactly the same as well.

Location matters

Q: I happened to overhear a colleague mention how much he is being paid by Medicare for an office visit, and it's more than I am getting. Why?

A: Most likely your colleague works in a different geographic location. Medicare prices are set by assessing the value of the physician work, the expense to the practice, and the cost of malpractice insurance. These values are adjusted for location based on Geographic Practice Cost Indices (GPCIs). Medicare maintains 89 geographic areas and, in many cases, the entire state is considered one geographic area for GPCI purposes. These GPCIs are based on census data and other federal data on wages, rent and malpractice insurance.

Q: How much do the GPCIs affect my reimbursement?

A: The effect of the GPCI can be significant between regions, and individual payments can vary by as much as 20%.

Physicians who reside near the borders of different regions can see extraordinary differences in payment as they cross the line. One important consideration to keep in mind is that the geographic adjustors are budget neutral, meaning that if the costs of doing business in all regions go up at the same rate, there would be no increase in payment for anyone.

Brian Whitman is a Senior Analyst for Regulatory and Insurer Affairs in ACP's Washington Office.

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