Internal Medicine Coding Alert

Published on Wed Mar 01, 2000 PDF

Question: Do Medicare patients have to meet Medicares homebound standard for home visits by the physician, physician assistant or clinical nurse practitioner to be reimbursed?

Anonymous Florida Subscriber

Answer: Not if the visit is a standard physician service, advises Ron Nelson, PA-C, president of Health Services Associates in Freemont, Mich., and an advisor to the American Medical Associations CPT healthcare professionals advisory committee.

It is important to understand the difference between a physicians home visit and a home-health service, says Nelson.

To report the home visit codes (99341-99345, new patient; 99347-99350, established patient), the patient visit simply 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.

Designated home-health services are generally nursing support types of services usually billed by a home-health agency. These are services that, if performed in a physicians office, are billed as incident to the physician service. Those services require the patient to meet homebound status.

If the patient has a medically necessary problem and they want the physician (or physician assistant or nurse practitioner) to come to their 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 upon the level of service. Homebound status as defined by Medicare for the home-health services is not required.

Medicares homebound criteria are a separate set of requirements under their home-health agency billing mechanism that stipulates that the patient must have certain limitations to keep him or her from traveling to receive the services that they need (i.e., nurse educator visits, skilled nursing, physical therapy, social work, etc.).

The only time a physician can provide those services is when there is no authorized home-health agency available and an employee of the physicians office can provide the services. In that situation, for regular home-health services, the patient must meet the homebound status, and the service must be incident to the physicians initial visit and diagnosis.