Orthopedic Coding Alert

Question: Our orthopedist often visits homebound elderly patients who live in a retirement village where they receive assisted-living services. The patients either own their apartments or lease them from the facility. Do 99321-99333 or 99341-99350 better describe the physician's services for these patients?

Massachusetts Subscriber

Answer: Because CPT's definition of domiciliary, rest home (e.g., boarding home) or custodial care services best describes the situation in which the patients reside, you should use the domiciliary or rest home visit codes (99321-99333, Domiciliary or rest home visit for the evaluation and management of a new or an established patient ), rather than the home services codes (99341-99350, Home visit for the evaluation and management of a new or an established patient). The introduction to 99321-99333 states that you should report these E/M services "in a facility which provides room, board and other personal assistance services, generally on a long-term basis." This code series, therefore, reflects the facility that you describe.

If you consider the home services codes, as some coders do, you should note that CPT reserves these codes for "evaluation and management services provided in a private residence." In your case, you may argue that because the patients own or lease their apartments, the unit qualifies as a private residence. Medicare transmittal 1709, however, eliminates this gray area by adding that you should not report 99341-99350 when a physician provides E/M services to a patient in "any type of facility." Because you describe the retirement village as a facility that provides meals, personal-assistance services, etc., to the patient, the unit does not qualify as a private residence.

You Be the Coder and Reader Questions were reviewed by Heidi Stout, CPC, CCS-P, coding and reimbursement manager at University Orthopaedic Associates in New Brunswick, N.J.