Physician house calls are experiencing a resurgence mainly due to an aging population, improved technology allowing for diagnostic tests to be done in the home. Another factor that has contributed to this development is the growing recognition of the benefits of providing care in a patient’s home setting, particularly for those with mobility issues or chronic illnesses. The reimbursement rates for home-based primary care (HBPC) has increased over the years. Home or Residence Services (CPT codes 99341–99350) may only be billed when services are provided in the beneficiary’s private residence (POS 12). Relying on professional home health medical billing services can help physicians take advantage of the growing support for HBPC by ensuring accurate billing.
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To qualify for coverage, the medical record must document the medical necessity of the home visit made in lieu of an office or outpatient visit. The Office of Inspector General (OIG) and several contractors of the Centers for Medicare & Medicaid Services (CMS) scrutinize physician home services billed to the Medicare program to ensure that house calls are medically necessary. In other words, the physician must present a medical rather than practical reason for visiting a patient outside the office.
Benefits of Adding House Calls to an Office-based Practice
According to the American Academy of Family Physicians (AAFP), the reasons to add home visits to an office-based practice include:
- Continuity of care for patients unable to visit the office, preventing them from being lost in the system.
- Enhanced care quality, more patient time, stronger doctor-patient relationships, higher patient satisfaction, more referrals, and reduced physician burnout.
- Better end-of-life care, allowing patients to pass away at home, surrounded by loved ones.
- Improved value-based care through better risk capture, fewer care gaps, higher quality, and lower costs.
- Higher reimbursement for complex patient care.
Billing Home or Residence Services – CPT Code Family 99341–99350
Beginning January 1, 2023, CPT created a new code family known as ‘Home or Residence Services.” (99341–99350) by merging two Evaluation and Management (E/M) visit families titled “Domiciliary, Rest Home (e.g., Boarding Home), or Custodial Care Services” and “Home Services.” The Place of Service (POS) code for “Home or Residence Services” is 12.
CPT codes 99341–99350 are used to report E/M services furnished to a patient residing in their home, in an assisted living facility, in a group home (that is not licensed as an intermediate care facility for individuals with intellectual disabilities), in a custodial care facility, or in a residential substance abuse treatment facility.
POS 12 medical billing requires the healthcare provider to be physically present in the patient’s residence.
CPT Codes for Home Services
Evaluation and management (E/M) services represent a medically necessary, face-to-face encounter at the patient’s residence. The description of home visits includes time for preparation, face-to-face interaction, and any necessary follow-up activities.
“New Patient” CPT Codes
The CPT codes that apply to a home visit for the evaluation and management of a new patient are:
99341 – Medically necessary face-to-face encounter conducted at the patient’s residence, 20 minutes of total time spent on the visit.
Key components required: A problem-focused history, a problem-focused examination, and straightforward medical decision-making.
Applies to patients requiring initial care in a home setting due to medical or mobility limitations.
99342 – Home visit for the evaluation and management of a new patient with a higher level of complexity than CPT 99341, at least 30 minutes of total time spent on the visit.
Components required: Expanded problem-focused history, expanded problem-focused examination, and straightforward medical decision-making.
99343 – Home visit for the evaluation and management of a new patient requiring a moderate level of care, at least 45 minutes of total time spent on the visit.
Applies to patients needing more detailed assessments and care coordination in a home setting.
Components required: Detailed history, detailed examination, and medical decision-making of low complexity.
Used for patients who need more comprehensive assessments and care management.
99344 – Home visit for the evaluation and management of a new patient requiring a moderately high level of care, at least 60 minutes of total time spent on the visit.
Components required: Comprehensive history, comprehensive examination, and medical decision-making of moderate complexity.
Used for patients with complex health issues requiring detailed assessment, care planning, and coordination
99345 – Home visit for the evaluation and management of a new patient requiring a high level of care at least 75 minutes of total time spent on the visit.
Components required: Comprehensive history, comprehensive examination, and medical decision-making of high complexity.
Applies to patients with complex medical needs requiring in-depth evaluation, care planning, and management.
“Established Patient” CPT Codes
99347: Home visit for the evaluation and management of an established patient requiring a problem-focused history, problem-focused examination, and straightforward medical decision-making, typically 15 minutes spent face-to-face with the patient.
Applies to patients with minor health concerns needing follow-up care at home.
99348: Home visit for the evaluation and management of an established patient requiring an expanded problem-focused history, expanded problem-focused examination, and low-complexity medical decision-making, typically 25 minutes spent face-to-face with the patient.
Applies to patients with moderate health concerns requiring more detailed follow-up care.
99349: Home visit for the evaluation and management of an established patient requiring a detailed history, detailed examination, and moderate-complexity medical decision-making, typically 40 minutes spent face-to-face with the patient.
For patients with more complex conditions needing ongoing management at home.
99350: Home visit for the evaluation and management of an established patient requiring a comprehensive history, comprehensive examination, and high-complexity medical decision-making, typically 60 minutes or more spent face-to-face with the patient.
For patients with severe, complicated conditions requiring intensive management and care at home.
For patients to receive care under Medicare’s home health benefit, they must be “home-bound based on the Centers for Medicare & Medicaid (CMS) criteria,” meaning they are typically unable to leave their home without assistance due to illness or injury.
For billing CPT Codes 99341 through 99350, patients do not need to be home-bound. Home visits can be billed as long as the patient is at home, regardless of whether they meet the “home-bound” criteria required for Medicare’s home health benefit.
Common Denial Reasons
Claim denials for POS 12 services result in delayed or missed reimbursements, affecting the provider’s financial stability and limiting patients’ access to essential care. Here are common reasons for denials:
- The service was provided more frequently than typical office standards or accepted medical practices.
- Services were duplicative or overlapped with other billed services.
- The patient received treatment from other providers for the same diagnosis.
- The service was not personally performed or ordered by the billing provider.
- The service was deemed not medically necessary.
- Documentation submitted does not support homebound status.
- The service was solely provided by an NPP but only the physician, not the treating NPP, is credentialed with Medicare.
Billing Home Services: Tips for Success
- Ensure proper documentation: Documentation of E/M services in the home setting must include key components to support medical necessity, which are: a chief complaint; history of presenting illness (HPI), review of systems, past, family, and social history. Track the total time spent on the visit, including preparation and follow-up tasks, to ensure it matches the time required for the service code you’re billing. Make sure the clinical notes and care plan justify the home-based care as appropriate for the patient’s condition. Document if the home visit is based upon a one-time, ongoing, or permanent need.
- Perform patient eligibility verification: Before scheduling a home visit, verify the patient’s eligibility for home-based services with their insurance provider. As home health care services typically require insurance prior authorization, it’s essential to obtain explicit permission from the insurance company to provide the services to the patient. This proactive approach helps avoid unnecessary work and potential claim denials.
- Understand Place of Service (POS) Codes: For correct billing of home services, use POS 12 to indicate the patient’s residence. This code informs the payer that the service was rendered at home, rather than in an office or hospital setting.
- Utilize modifiers correctly: For home visits, make sure you’re using the appropriate modifiers based on payer requirements. Use relevant modifiers like “QW” for home visits to correctly indicate the service location and facilitate accurate claim processing.
- Stay updated on payer guidelines: Keep up with payer-specific rules and regulations for billing home services. Since these guidelines change frequently, staying informed is essential to maintain compliance and avoid billing errors.
- Keep an eye on patient-provider relationship: Home visits may be subject to scrutiny if they are not personally performed by the attending physician or their authorized person. Ensure that the service is performed or directly supervised by the billing provider. Make sure to comply with the billing rules regarding provider involvement in the service to avoid claims being rejected for lack of proper oversight.
- Follow-up on claims: Implement a robust follow-up process to identify and resolve any potential denials or issues early, and ensure that payments are received in a timely manner.
Outsource Medical Billing, Optimize Reimbursement
The growth in physician house calls can be attributed to increased payment rates, advancements in technology, and the aging population. Studies have demonstrated that house calls not only improve patient outcomes but also reduce healthcare costs by $2,000 per patient annually (AAFP). Partnering with an experienced medical billing company can help physicians optimize reimbursement as they focus on delivering comprehensive, team-based care to elderly, chronically ill, frail, or functionally limited patients in their residence.
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