Medicare Compliance & Reimbursement

Troubleshoot denials with our handy checklist

Watch out: When your doctor makes house calls, you'd better make sure the checks come to your office afterward.

Some practices have reported receiving Medicare denials for home visit codes 99341-99345 and 99347-99350 for "medical necessity." The main snag: proving the patient couldn't have gone to the doctor's office instead.

Myth: Patients must be homebound to receive a home visit from a doctor.

Reality: Medicare only requires patients to be "homebound" for home health agency (HHA) services, says Stephanie Fiedler, senior health care consultant with Loeb & Troper Health Care Consulting in New York.

Medicare's Internet Only Manual (IOM) states that the patient must be confined to the home "under the home health benefit." But it adds that for a physician providing home services, "the beneficiary does not need to be confined to the home." However, the medical record must document the medical necessity for a home visit instead of an office visit.

In other words: "It must be extremely difficult for the patient to leave the home because of health-related issues," says Fiedler. For example, an amputee who lives in a fourth-floor walk-up apartment could have a hard time leaving home, so it makes sense for the doctor to visit.

Documentation: Make sure every visit note contains the reason the patient couldn't see the doctor in the office, Fiedler advises. For example: Document "office visit requires excessive effort/pain," or "office visit requires ambulance transport," or "patient homebound."

Other examples of patients who might have a hard time leaving home include a patient who's had a stroke and can't ambulate without help; a blind or senile patient who can't leave home without another person's help; a patient who's lost the use of upper extremities and can't open doors or use handrails; someone suffering from post-surgical weakness and pain; and someone whose heart disease is so bad that he must avoid all stress and physical activity, says Alameda, CA podiatrist Anthony Poggio.

Be realistic, Fiedler adds. You can't send the doctor to the patient's home every month to check on all the patient's ongoing conditions and expect to bill a high level of service every time.

When the doctor goes to the effort of visiting a patient at home, checking every one of the patient's problems makes sense.

But if one of the patient's problems is hypertension that's been stable for over a year, the doctor can't expect Medicare to pay for reviewing the hypertension every month, Fiedler insists.

Some doctors feel they should visit these chronically ill patients on a monthly schedule, instead of a schedule that depends on the individual patient's problems, Fiedler notes. Such a regular schedule creates a "billing pattern" that the carriers are bound [...]