Billing OV E/M codes for Home visits

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Hello,
I have a potentially new account with the company I work for, and this provider does Pediatric house calls only. He does not ever see patients in his office. He tells me that his current biller bills his home visits with E/M codes 99212 through 99215, as well as Preventative codes 99381-99384, and 99391-99394. I am concerned that this is fraudulent billing and I will not be able to bill for him this way. Thoughts/feedback?
Thank you,
Polly
 

mitchellde

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As far as I know the office visit levels will be rejected with the POS of 12. Also the 99201-99215 codes specifically state they are to be used in the office setting or other outpatient facially setting. Since there are codes specifically set up for home visits and the POS of 12 to indicate home then this is what will be required to be billed. The preventive levels do not specifically state office or outpatient facility for the usage but you would still need to use the POS of 12. The question is did the previous biller use the 12 as the POS or did they bill will the 11.
 

thomas7331

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Home visit E&M should be billed with 99341-99345 for new patients and 99347-99350 for established, with place of service 12. It would be incorrect coding to use 99201-99215. I'd agree with the above post that the preventive care visits are not specific to home or office but still need to have the correct place of service on the claims.

Whether or not it's fraud is really a different question entirely - I wouldn't use that term without know all of the facts and it may have been an honest error that they will want to correct. Depending on the fee schedules and member benefits, the provider may even have been losing revenue in some cases by using the wrong codes.
 

mitchellde

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I think it is a question as to why was it billed that way? To say they did not know better is not a good excuse in this day of electronic media, in an instant you can look up everything you want to know. This is a simple thing and so easy to find the answer to. Was it done this way by provider instruction? And again the question is why? If the answer to all of these is the magic "we did it to get paid" then there may be serious issues. At any rate you know this is incorrect and you know the right way to bill. If the claims do not pay because there is no medical necessity for the patient to be seen in the home, then it will be patient responsibility. You may need to make your supervisor aware of this.
 
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Ok so I have a little more clarity on this. ALL claims were billed with POS 12 for home is what the provider tells me. I know that E/M codes 99212-99215 and 99202-99205 cannot be billed with POS 12, as I imagine if the claim made it past scrubbing and the clearinghouse by a miracle, then the insurance carrier would definitely denied it as incorrect POS. If he bills home visits for sick children with 99341-99350 for new or Est then the carrier usually requires an auth/pre-cert which is hard to obtain quickly so he does not bill those codes at all. He does do Preventative services for children where he can bill 99381-99385 or 99391-99394 at home, but these codes can only be billed in the absence of illness per the coding rules in the CPT book, so he cannot bill these for a sick child with the sick diagnosis. So I am in a quandary for what code he can bill for a home visit with POS 12 for a sick child. That is without needing an auth beforehand for Home visit codes.
 
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mitchellde

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Home visit codes are the 99341-99345 for new patient and 99347-99350 for established. I am pretty sure will need some variety of medical necessity for the reason for home vs office visit, but it would be best to check with the carrier. I am curious as to how he has been reimbursed in the past if these were not the codes used. The only way he could have been paid is if the POS had been changed to 11 prior to submission. It is possible this was done without the providers knowledge. If th payer requires an authorization for home visits then that will need to be done otherwise these will go to patient responsibility. Does the provider not have an office?
 
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