Home and Domiciliary Visits - JE Part B
Home and Domiciliary Visits
Home and domiciliary visits are when a physician or qualified non-physician practitioner (NPPs) oversee or directly provide progressively more sophisticated evaluation and management (E/M) visits in a beneficiary's home. This is to improve medical care in a home environment. A provider must be present and provide face to face services. This is not to be confused with home healthcare incident to services.
On this page, view the below information:
- Provider Eligibility
- Medical Necessity
- Documentation which Supports Home Visits
- Location of Acceptable Services
- Place of Service Codes
- Services to Homebound patients under General Supervision
- Common Denial Reasons
Home and domiciliary visits require complex or multidisciplinary care modalities involving:
- Services are covered only when the three key E/M components are met and documented in medical record and based on face-to-face time with patient
- History, exam and medical decision making
- Time spent counseling and coordinating
- Medical management
- Services must meet need of medical necessity
- These visits are an extension of normal care
- There is no requirement that patient must be homebound
- Beneficiaries seen may be disabled either physically or mentally making access to a traditional office visit very difficult, or may have limited support systems
Under provisions of the Balanced Budget Act of 1997, Physicians (MDs) and Qualified non-physicians Practitioners (NPPs) must be practicing within the scope of State law and may also bill for home and domiciliary visits.
The mere presence of inactive or chronic conditions does not constitute medical necessity for any setting (home, rest home, office etc.).
- Chief complaint or a specific, reasonable, and medical necessity is required for each visit
- A payable diagnosis alone does not support medical necessity of ANY service
- Medical necessity must exist for each individual visit
- Visit will be regarded as a social visit unless medical record clearly documents medical necessity for every visit
- Service/visit must be medically reasonable and necessary and not for physician or qualified NPP convenience
- Service must be of equal quality to a similar service provided in an office
- Frequency of visits required to address any given clinical problem should be dictated by medical necessity rather than site of service
- It is expected that frequency of visits for any given medical problem addressed in home setting will not exceed that of an office setting, except on rare occasion
- Training of domiciliary staff is not considered medically necessary
- Home visits services (CPT codes 99341-99350) may only be billed when services are provided in beneficiary's private residence (POS 12). To bill these codes, physician must be physically present in beneficiary's home.
- The service must be of such nature that it could not be provided by a Visiting Nurse/Home Health Services Agency under Home Health Benefit
- There may be circumstances where home health services and services of physician/qualified non-physician practitioners (NPPs) are performed on same day
- These services cannot be duplicative or overlapping
- Based on Consolidative Billing Regulations, no service will be covered under Medicare Part B when performed only to provide supervision for a visiting nurse/home health agency visit(s)
- If a beneficiary is receiving care under home health benefit, primary treating physician will be working in concert with home health agency
Documentation which Supports Home Visits
- A home visit must be reasonable and necessary, not a convenience.
- Physicians also cannot provide home services at their convenience (for example, visiting senior independent living facilities on a routine basis)
- As with any E/M service, documentation must include a chief complaint; history of presenting illness (HPI); review of systems; and past, family, social history elements that are the key to making any note support medical necessity
- Services provided by a physician or Mid-level practioners cannot be services that could be provided by a visiting nurse or home health agency under Medicare's home health benefits (e.g. BP check, dressing change)
Location of Acceptable Services
Home based services are provided services which are performed in:
- Private Residence - Home, apartment, townhome etc.
- Domiciliary Care Facility - A home providing mainly custodial and personal care for persons who do not require medical or nursing supervision, but may require assistance with activities of daily living because of a physical or mental disability. This may also be referred to as a sheltered living environment
- Rest Home - A place where people live and are cared for when they cannot take care of themselves
- Custodial Care Services - Custodial care is nonmedical assistance, either at home or in a nursing or assisted-living facility with the activities of daily life (such as bathing, eating, dressing, using the toilet) for someone who's unable to fully perform those activities without help
- Residential Substance Abuse Facility - A facility which provides treatment for substance (alcohol and drug) abuse to live-in residents
Place of Service (POS) Codes
- 12 - Home
- 13 - Assisted Living Facility (adult living facility)
- 14 - Group Home
- 33 - Custodial Care Facility
- 55 - Residential Substance Abuse Facility
See the Place of Service webpage for descriptions.
To view complete CPT descriptions, refer to the CPT manual.
Domiciliary, Rest Home, or Custodial Care Services Listing - CPT codes 99324 - 99337: Domiciliary, Rest Home (e.g. Boarding Home), or Custodial Care Services, are used to report E/M services to individuals residing in a facility which provides room, board, and other personal assistance services, generally on a long-term basis. Assisted living facilities may be known as adult living facilities.
|99324||Level 1 new patient domiciliary, rest home, or custodial care visit|
|99325||Level 2 new patient domiciliary, rest home, or custodial care visit|
|99326||Level 3 new patient domiciliary, rest home, or custodial care visit|
|99327||Level 4 new patient domiciliary, rest home, or custodial care visit|
|99328||Level 5 new patient domiciliary, rest home, or custodial care visit|
|99334||Level 1 established patient domiciliary, rest home, or custodial care visit|
|99335||Level 2 established patient domiciliary, rest home, or custodial care visit|
|99336||Level 3 established patient domiciliary, rest home, or custodial care visit|
|99337||Level 4 established patient domiciliary, rest home, or custodial care visit|
Home Visits Listing - CPT codes 99341 - 99350: Home Services codes, are used to report E/M services furnished to a patient residing in his or her own private residence. Private residence considered: a private home, an apartment, or town home.
|99341||Level 1 new patient home visit|
|99342||Level 2 new patient home visit|
|99343||Level 3 new patient home visit|
|99344||Level 4 new patient home visit|
|99345||Level 5 new patient home visit|
|99347||Level 1 established patient home visit|
|99348||Level 2 established patient home visit|
|99349||Level 3 established patient home visit|
|99350||Level 4 established patient home visit|
Services to Homebound Patients under General Supervision
Payment may be made in some medically underserved areas where there is a lack of medical personnel and home health services for injections, EKGs, and venipunctures that are performed for homebound patients under general physician supervision by nurses and paramedical employees of physicians or physician-directed clinics.
Common Denial Reasons
- Record does not clearly demonstrate that beneficiary, his/her delegate or another clinician involved in case sought initial service
- Service is provided at a frequency that exceeds that which is typically provided in office and acceptable standards of medical practice
- Service is solicited by physician rather than patient or caretaker or other healthcare professional providing care to patient with his/her knowledge
- Beneficiary is treated by other providers for same diagnosis
- CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual Chapter 12, Section 220.127.116.11
- CMS Medicare Learning Network (MLN) Matters (MM) 4212
Last Updated Tue, 01 Nov 2022 20:11:52 +0000