Practice Management Alert

Watch out: If your physician is thinking about going to patients' homes for both sick and well visits, you need to make sure you'll be able to bill and bring in payment for those services.

If you don't know how to bill for those services, your physician's reimbursement will plummet. Here's what you need to know to be sure your doctor gets paid.

If your physician performs house calls, you will have to bill these services using the house call and domiciliary care codes in your CPT manual, says Constance Row, executive director of the American Academy of Home Care Physicians (AAHCP) in Edgewood, Md. You should use a code from the home visit series depending on whether the patient is new (99341-99345, Home visit for the evaluation and management of a new patient ...) or established (99347-99350, ... established patient ...). The higher numbers in each category reflect greater complexity. Remember to use these codes only for visits to a patient's private residence -- this includes a home, a condo, a co-op, or a rental apartment -- and enter place of service 12 for a home visit.

Error averted: Some offices try to bill visits to assisted living center residents using these codes, but you should bill home visits to those patients using the domiciliary/rest home codes (99324-99337, Domiciliary or rest home visit for the evaluation and management ...).

To be reimbursed for house call services, your physician's documentation must prove medical necessity for making house calls, "since reimbursement is higher than for an office visit reflecting both time and patient complexity," Row cautions.

Master medical necessity: Private insurers may publish individual guidelines for home visits, which you should request in writing before you set up a billing policy for these services. If you are seeing a Medicare patient at home, you should use the home visit codes only when you can document a medical reason for the visit and a medical reason that the patient cannot make the trip to the office or clinic.

Diagnosis 1: The medical reason for the visit is easy to document. It can be any type of problem that the physician would see a patient for in the office, such as influenza or a regular check for high blood pressure.

Proof 2: Documenting the medical reason that the patient needs treatment at home is more difficult. Section 30.6.14.1 of Chapter 12 of the Medicare Claims Processing Manual indicates that you can use the home services codes when a physician provides E/M services to a patient in a private residence. The patient does not have to be confined to the home (as is necessary for services provided under the home health benefit), but the "medical record must document the medical necessity of the home visit made in lieu of an office or outpatient visit," the manual says.

The key is to document a medical reason that the patient can't travel. The patient may be blind, or a paraplegic, or in severe pain and unable to travel to the office without assistance. The reason cannot be convenience -- for example, that the patient can't get transportation.

Alternative: If you provide in-home care for patients that can travel, but you are simply providing a convenient option, you can always bill the patient and not his insurance. "Some patients are willing to self-pay; however, the majority of seniors are on fixed income and cannot afford services not covered by Medicare," Row says.

In this case, you should have the patient sign an advance beneficiary notice (ABN) indicating that she has chosen the option of home care and is willing to pay for the service out of her own pocket, outside of her Medicare benefits. Because the service is not medically necessary, you should append modifier GA (Waiver of liability statement on file) to the codes you bill. Do not bill the patient without a signed ABN for each service, and do not submit a claim with a GA modifier without a signed ABN for each visit.