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:

Modalities

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

Provider Eligibility

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.

Medical Necessity

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

Requirements

  • 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.
  • Provider must be able to prove that the home visit was based on patient's inability to come to the office either this one time, or on an ongoing basis, due to physical or mental issues and not due to financial or other personal reasons. Physicians also cannot provide home services at their convenience (for example, visiting senior independent living facilities on a routine basis)
  • Documentation must indicate how visit initiated (patient request, family or other source) and should detail patient's conditions that prevented him/her from traveling to provider's place of service
    • 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
  • An example is a frail elderly person who because of snow and ice cannot safely ambulate to a vehicle and for which the care required cannot be provided by phone. This same patient may be able to travel safely when weather improves
  • Services provided by a physician or MLP 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)
  • Examples of conditions acceptable for home visits (not all inclusive)
    • 1-2 weeks after major surgery---particularly of lower extremity joints or spine. In most cases it is best for a patient to be seen in the office, so clinical documentation must detail why this was not practical
    • Requests for visits by home health nurse for something she/he needs help with
    • Very contagious diseases (e.g., varicella)
    • Severely immunocompromised patients
    • Patients with quadriplegia or debilitating neurological disorder
    • Severe diseases with patient bedbound or severely incapacitated
    • Severe inflammatory diseases with inflammation such the patient cannot ambulate without extreme effort and/or pain
    • Patients with severe dementia or other mental disorders which make it unsafe for transport to physician office except by ambulance
    • An acute onset illness in a patient for whom transportation is extremely arduous and for whom the visit may prevent deterioration or hospitalization

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.

Billing

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.

CPT Code Description
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.

CPT Code Description
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

 

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

Resources

 

Last Updated Wed, 07 Aug 2019 09:23:42 +0000