CPT® 99349; Home or residence visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded

In order to fulfill its contractual obligation with CMS, Noridian Healthcare Solutions (Noridian), your Medicare Contractor, performs pre-payment reviews in accordance with CMS direction. CMS is required by the Social Security Act to ensure that payment is made only for those medical services that are reasonable and necessary. Medical review assesses submitted documentation to validate provider compliance with Medicare payment rules and regulations, including coverage, coding and billing guidelines.

This is to update providers of the claim review findings for CPT® 99349; Home or residence visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded. The results of this focused review are not a reflection on providers' competence as a health care professional or the quality of care provided to patients. Specifically, the results are based on the documentation requested by Medicare and/or your facility's compliance with the required documentation.

The Jurisdiction F, Part B Medical Review Department is conducting a Targeted Probe and Educate (TPE) review of CPT® 99349; Home or residence visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded. The quarterly edit effectiveness results from October 1, 2025, through December 31, 2025, are as follows:

Top Denial Reasons

  • Denial Reason 1- Failure to return records
  • Denial Reason 2 - The documentation submitted supports the performing and billing providers are different
  • Denial Reason 3 - The documentation submitted did not support incident-to criteria were met

Educational Resources

Education

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 the home environment. A provider must be present and provide face-to-face services and is not to be confused with home healthcare, prolonged or incident to services.

Requirements:

  • Must be medically necessary
  • Must meet key elements of an E/M
  • Home visits must be provided in a beneficiary’s private residence
  • Service must be of the nature it could not be provided by a visiting nurse/Home Health Services Agency under Home Health Benefit
  • Service cannot be duplicative or overlapping
  • If a beneficiary is receiving care under home health benefit, primary treating physician would be working in concert with home health agency

Medical Necessity:

  • The presence of inactive or chronic conditions does not constitute medical necessity for any setting.
  • There must be a chief complaint or specific reasonable and medically necessary need for each visit and how the visit will change/changed the care of the beneficiary
  • The service must be of equal quality to a similar service provided in an office

Frequency should not exceed that of an office setting, except on rare occasions.

Last Updated Feb 19 , 2026