Corporate

This article is no longer valid as of 01 January 2019.

August 22, 2017

Home Services (CPT codes 99341 – 99350)

During the  J15 Part B Medical Review department review of  Home Visit codes (CPT codes  99341-99350), several findings continue to persist (January 12, 2016 article).  These  findings include: failure to support the medical need for a home visit in lieu of an office visit, failure to meet the key component levels required for the code billed, and medical necessity  not supported. Due to continued  prepay probe review findings,  CGS would like to provide guidance  on documentation requirements  for  Home Services (CPT codes 99341 – 99350) specifically how it relates to “in lieu of” and “medical necessity”.

A. Requirement for Physician Presence

  • Home services CPT codes 99341-99350 are paid when they are billed to report evaluation and management services provided in a private residence.  A home visit cannot be billed by a physician unless the physician was actually present in the beneficiary’s home.
  • Make sure your documentation is clear as to why the home visit is necessary and the acuity of the patient’s condition.  Include the reason the patient cannot be seen in the office.
    • For example, while a patient with severe osteoarthritis can safely travel to the office in the summer; winter months may be a different story.  Make sure your note clearly states the contraindications of the patient traveling in the winter.
  • The  patient’s fall risk assessment and quantification of how many times in the recent past the patient has fallen is another example of a reason the patient cannot be seen in the office.  Also if obesity is a reason  then a weight needs to be included in the documentation.
  • All clinical and non-clinical factors should be included in addition to your rationale for establishing medical necessity.

 If you visit the patient in his/her home on a regular basis, be sure that each note shows how the patient’s condition has changed. Avoid cloned or copied documentation that does not explain how the patient’s condition has improved or deteriorated.

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