Home and Domiciliary Services (L31613)
Contractor Information
|
Contractor Name Wisconsin Physicians Service Insurance Corporation |
Contractor Number 00951, 00952, 00953, 00954, 52280, 05101, 05201, 05301, 05401, 05102, 05202, 05302, 05402 |
Contractor Type Carrier - FI - MAC |
LCD Information
Document Information
L31613 LCD Title Home and Domiciliary Services Contractor's Determination Number PHYS-081 AMA CPT/ADA CDT Copyright Statement CPT codes, descriptions and other data only are copyright 2010 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. |
Primary Geographic Jurisdiction
Oversight Region Original Determination Effective Date For services performed on or after 06/15/2011 Original Determination Ending Date Revision Effective Date Revision Ending Date |
CMS National Coverage Policy
Title XVIII of the Social Security Act section 1862 (a)(1)(A)
Title XVIII of the Social Security Act section 1862 (a)(7)
Title XVIII of the Social Security Act section 1833 (e)
CMS Transmittal 775, Change Request 4212
Medicare Claims Processing Manual, Pub 100-4, Chapter 12, Section 30.6.14 30.6.141
Medicare Program Integrity Manual, Pub 100-8, Chapter 13, Section 5.1
Medicare Benefit Policy Manual CMS Pub 100-2, 15, §50.3, §60.1, §60.2, §60.2, §60.3, and §60.4.
CMS Online Manual System, Pub.100-8, Program Integrity Manual, Chapter 13, Section 5.1
Title XVIII of the Social Security Act section 1862 (a)(7)
Title XVIII of the Social Security Act section 1833 (e)
CMS Transmittal 775, Change Request 4212
Medicare Claims Processing Manual, Pub 100-4, Chapter 12, Section 30.6.14 30.6.141
Medicare Program Integrity Manual, Pub 100-8, Chapter 13, Section 5.1
Medicare Benefit Policy Manual CMS Pub 100-2, 15, §50.3, §60.1, §60.2, §60.2, §60.3, and §60.4.
CMS Online Manual System, Pub.100-8, Program Integrity Manual, Chapter 13, Section 5.1
Indications and Limitations of Coverage and/or Medical Necessity
A
home or domiciliary visit includes a beneficiary history, examination,
problem solving and decision making in various levels depending upon a
beneficiary's need and diagnosis.
The beneficiaries seen may have chronic conditions, may be disabled either physically or mentally making access to a traditional office visit very difficult, or may have limited support systems. The home or domiciliary visit in turn should lead to improved medical care by identification of unmet needs, coordination of treatment with appropriate referrals and potential reduction of acute exacerbations of medical conditions, resulting in less frequent trips to the hospital or emergency rooms.
Home-based health care and domiciliary health care services are rapidly expanding. Growth in hospital-based house call programs, early hospital discharge programs, and an increased effort to expand the role of house calls in medical education has contributed to this expansion. Physicians and non-physician providers (NPP) are required to oversee or directly provide progressively more sophisticated home visits. Beneficiaries must understand the nature of a pre-arranged visit and consent to treatment in the home or domiciliary care facility. Coverage for this type of service is based on face-to-face time only with the beneficiary alone or with the beneficiary and family or caregiver and the work performed during that time is documented in the chart, such as direct beneficiary assessment, care coordination etc. Travel time and related expenses are not separately billable services and as such should not be included when determining the CPT code that best defines the service rendered.
It is important to note that services performed to a beneficiary in a Residential Care Facilities/Rest Homes/Assisted Living Facilities is expected to occur in the beneficiary's own personal living space or a room set aside for such visits. In the event of the latter occurrence, such rooms are not considered a doctors office, and shall not be used for the routine performance of rounds on beneficiaries.
Medically necessary provider visits are payable under the physician fee schedule in Medicare Part B when provided to the beneficiary in his/her private residence. There is no requirement that the beneficiary must be homebound. To be reimbursable by Medicare, a home or domiciliary care visit must meet all of the following criteria:
1. The medical record must document the medical necessity of the home visit made in lieu of an office or outpatient visit. MCM Pub 100-4, Chapter 12, Section 30.6.14 30.6.141
2. The service must be of equal quality, as if it were performed in the office, including frequency of visits, which should be consistent with the frequency at any other site of service for that particular code and beneficiary condition. It is expected that the frequency of the visits for any given medical problem addressed in the home setting will not exceed that of an office setting.
3. The minimum level of documentation of a home visit should be that which is rendered in the office with the expectation that the level of documentation, given the fact that home visits historically have had a higher level of reimbursement, would be more complex.
4. The physician/qualified non-physician practitioner must be the provider of record and be responsible for managing the entire disease process addressed in the visit. All medical services provided to the beneficiary must be either ordered or personally performed by the provider.
5. Services provided to a beneficiary for the first time must be either requested by the beneficiary, his/her delegate, or another Medicare provider managing the beneficiary's care. The Medicare Part B provider cannot solicit the visit. Examples of visit solicitation include a provider arriving without an appointment to see a beneficiary or seeing a beneficiary for a scheduled, requested visit and then providing additional visits in a Residential Care Facility to other individuals in the facility without appropriate advance requests.
6. The Medicare Part B provider or that provider's medical group practice has an ongoing beneficiary-physician relationship with the beneficiary must provide follow-up visits. Exceptions include beneficiaries who are traveling through an area and are not residents in the location where they are being seen and beneficiaries who are being seen in their homes or domiciles for urgent or episodic illness.
7. Services provided to a beneficiary by a Medicare Part B provider on the same day as an employee of a home health agency cannot be duplicative or overlapping. Medicare Part B does not cover supervision for a visiting nurse/home health agency visit(s).
8. Beneficiaries receiving care under the home health benefit have a primary treating Medicare Part B provider working in concert with the home health agency and that service is billed using the care plan oversight service CPT codes. It is highly unlikely that additional Medicare Part B providers would be seeing/performing services for the beneficiary.
9. There is no "incident to" a physician's service in place of service home or domiciliary setting; therefore all drugs or services must be personally administered by the Medicare Part B provider. Medical necessity of the home or domiciliary care visit is not supported when the administration of the drug or biological is the sole reason for the visit.
10. Active wound care is not covered for beneficiaries who are also seen by home health agencies (HHA) because this service is included in the payment to the HHA. Medicare Part B providers who see beneficiaries for the evaluation of a wound must bill the appropriate evaluation and management (E&M) service.
11. Debridement of wounds must be billed with the appropriate CPT code and follow the guideline of LCD GSURG-051 Wound Care and/or any other appropriate national or local coverage determination.
12 Services performed to beneficiaries who are also seeing other Medicare Part B providers for the same diagnosis will be assumed not medically necessary.
13. Visits to multiple beneficiaries by the same Medicare Part B provider or the same group may occur on the same date of service, but each service must meet the medical needs of the individual beneficiary. Each visit must stand on its own and the medical necessity of the visit must be supported in documentation. Each visit, which is part of an episode of care, must not exceed the frequency of service that would be expected by the acceptable standards of medical practice for any other site of service.
This policy is subordinate to all National Coverage Determinations (NCDs), Medicare rules and regulations, and Local Coverage Determinations (LCDs) of this contractor for the specific test/procedure/service performed.
A. Requirement for Physician Presence
Home services codes 99341 99350 are paid when they are billed to report evaluation and management services provided to a beneficiary in their private residence. A home visit cannot be billed by a Medicare Part B provider unless the provider is actually present in the beneficiary's home and he/she personally performs the service.
B. Homebound Status
Under the home health benefit (Medicare Part A) the beneficiary must be confined to the home for services to be covered. For home services provided by a Medicare Part B provider using these codes, the beneficiary does not need to be confined to the home. The medical record must document the medical necessity of the home visit made in lieu of an office or outpatient visit.
C. Diagnostic Tests
Code of Federal Regulations (CFR), Title 42, part 410.32, specifies that all diagnostic tests must be ordered by the provider who is the treating provider for the beneficiary and who will use the test results in the beneficiary's care. Tests not ordered by the physician who is treating the beneficiary and tests, which are not used in the management of the beneficiary's condition, are not reasonable and necessary. As with any service reimbursed by Medicare, to support medical necessity, there must be documentation in the medical record as to why a certain modality was chosen/performed.
Depending on a beneficiary's condition and in situations when life threatening and other severe adverse reactions could be expected as a result of the administration of certain drugs or the performance of other services, the administration/performance of these services must take place in a facility equipped and staffed for cardiopulmonary resuscitation and where the beneficiary can be closely monitored by qualified personnel for an appropriate period of time based on his or her health status. Such services performed in the home or domiciliary environment without appropriate oversight, qualified staff and equipment for reasonably foreseeable complications will not be considered medically necessary.
The primary treating physician must either personally perform the diagnostic test(s) or order the tests performed by mobile diagnostic testing facilities following LCD PHYS-078 Independent Diagnostic Testing Facilities (IDTFs).
Any specialized or invasive services, such as surgical procedures, physiologic monitoring, or advanced imaging performed during the course of home or domiciliary care visits must meet Medicare's reasonable and necessary criteria and must comply with all applicable safety rules and quality standards. If the results of the testing will not change the medical management or result in surgery, there is no medical necessity for the procedures. In these cases, the testing/service will not be medically necessary.
Laboratory and diagnostic tests performed during the course of home or domiciliary care visits must meet Medicare's reasonable and necessary criteria and be ordered by the primary care. A valid referring NPI number from a Medicare Part B provider who has previously seen the beneficiary must be on the claim. Medical reasons for repeat testing must be clearly documented. Performance of multiple or common tests without clear evidence of medical need of the beneficiary or changes in the treatment regimen based on the lab tests would not be considered reasonable and necessary as mandated by 42CFR410.32.
The beneficiaries seen may have chronic conditions, may be disabled either physically or mentally making access to a traditional office visit very difficult, or may have limited support systems. The home or domiciliary visit in turn should lead to improved medical care by identification of unmet needs, coordination of treatment with appropriate referrals and potential reduction of acute exacerbations of medical conditions, resulting in less frequent trips to the hospital or emergency rooms.
Home-based health care and domiciliary health care services are rapidly expanding. Growth in hospital-based house call programs, early hospital discharge programs, and an increased effort to expand the role of house calls in medical education has contributed to this expansion. Physicians and non-physician providers (NPP) are required to oversee or directly provide progressively more sophisticated home visits. Beneficiaries must understand the nature of a pre-arranged visit and consent to treatment in the home or domiciliary care facility. Coverage for this type of service is based on face-to-face time only with the beneficiary alone or with the beneficiary and family or caregiver and the work performed during that time is documented in the chart, such as direct beneficiary assessment, care coordination etc. Travel time and related expenses are not separately billable services and as such should not be included when determining the CPT code that best defines the service rendered.
It is important to note that services performed to a beneficiary in a Residential Care Facilities/Rest Homes/Assisted Living Facilities is expected to occur in the beneficiary's own personal living space or a room set aside for such visits. In the event of the latter occurrence, such rooms are not considered a doctors office, and shall not be used for the routine performance of rounds on beneficiaries.
Medically necessary provider visits are payable under the physician fee schedule in Medicare Part B when provided to the beneficiary in his/her private residence. There is no requirement that the beneficiary must be homebound. To be reimbursable by Medicare, a home or domiciliary care visit must meet all of the following criteria:
1. The medical record must document the medical necessity of the home visit made in lieu of an office or outpatient visit. MCM Pub 100-4, Chapter 12, Section 30.6.14 30.6.141
2. The service must be of equal quality, as if it were performed in the office, including frequency of visits, which should be consistent with the frequency at any other site of service for that particular code and beneficiary condition. It is expected that the frequency of the visits for any given medical problem addressed in the home setting will not exceed that of an office setting.
3. The minimum level of documentation of a home visit should be that which is rendered in the office with the expectation that the level of documentation, given the fact that home visits historically have had a higher level of reimbursement, would be more complex.
4. The physician/qualified non-physician practitioner must be the provider of record and be responsible for managing the entire disease process addressed in the visit. All medical services provided to the beneficiary must be either ordered or personally performed by the provider.
5. Services provided to a beneficiary for the first time must be either requested by the beneficiary, his/her delegate, or another Medicare provider managing the beneficiary's care. The Medicare Part B provider cannot solicit the visit. Examples of visit solicitation include a provider arriving without an appointment to see a beneficiary or seeing a beneficiary for a scheduled, requested visit and then providing additional visits in a Residential Care Facility to other individuals in the facility without appropriate advance requests.
6. The Medicare Part B provider or that provider's medical group practice has an ongoing beneficiary-physician relationship with the beneficiary must provide follow-up visits. Exceptions include beneficiaries who are traveling through an area and are not residents in the location where they are being seen and beneficiaries who are being seen in their homes or domiciles for urgent or episodic illness.
7. Services provided to a beneficiary by a Medicare Part B provider on the same day as an employee of a home health agency cannot be duplicative or overlapping. Medicare Part B does not cover supervision for a visiting nurse/home health agency visit(s).
8. Beneficiaries receiving care under the home health benefit have a primary treating Medicare Part B provider working in concert with the home health agency and that service is billed using the care plan oversight service CPT codes. It is highly unlikely that additional Medicare Part B providers would be seeing/performing services for the beneficiary.
9. There is no "incident to" a physician's service in place of service home or domiciliary setting; therefore all drugs or services must be personally administered by the Medicare Part B provider. Medical necessity of the home or domiciliary care visit is not supported when the administration of the drug or biological is the sole reason for the visit.
10. Active wound care is not covered for beneficiaries who are also seen by home health agencies (HHA) because this service is included in the payment to the HHA. Medicare Part B providers who see beneficiaries for the evaluation of a wound must bill the appropriate evaluation and management (E&M) service.
11. Debridement of wounds must be billed with the appropriate CPT code and follow the guideline of LCD GSURG-051 Wound Care and/or any other appropriate national or local coverage determination.
12 Services performed to beneficiaries who are also seeing other Medicare Part B providers for the same diagnosis will be assumed not medically necessary.
13. Visits to multiple beneficiaries by the same Medicare Part B provider or the same group may occur on the same date of service, but each service must meet the medical needs of the individual beneficiary. Each visit must stand on its own and the medical necessity of the visit must be supported in documentation. Each visit, which is part of an episode of care, must not exceed the frequency of service that would be expected by the acceptable standards of medical practice for any other site of service.
This policy is subordinate to all National Coverage Determinations (NCDs), Medicare rules and regulations, and Local Coverage Determinations (LCDs) of this contractor for the specific test/procedure/service performed.
A. Requirement for Physician Presence
Home services codes 99341 99350 are paid when they are billed to report evaluation and management services provided to a beneficiary in their private residence. A home visit cannot be billed by a Medicare Part B provider unless the provider is actually present in the beneficiary's home and he/she personally performs the service.
B. Homebound Status
Under the home health benefit (Medicare Part A) the beneficiary must be confined to the home for services to be covered. For home services provided by a Medicare Part B provider using these codes, the beneficiary does not need to be confined to the home. The medical record must document the medical necessity of the home visit made in lieu of an office or outpatient visit.
C. Diagnostic Tests
Code of Federal Regulations (CFR), Title 42, part 410.32, specifies that all diagnostic tests must be ordered by the provider who is the treating provider for the beneficiary and who will use the test results in the beneficiary's care. Tests not ordered by the physician who is treating the beneficiary and tests, which are not used in the management of the beneficiary's condition, are not reasonable and necessary. As with any service reimbursed by Medicare, to support medical necessity, there must be documentation in the medical record as to why a certain modality was chosen/performed.
Depending on a beneficiary's condition and in situations when life threatening and other severe adverse reactions could be expected as a result of the administration of certain drugs or the performance of other services, the administration/performance of these services must take place in a facility equipped and staffed for cardiopulmonary resuscitation and where the beneficiary can be closely monitored by qualified personnel for an appropriate period of time based on his or her health status. Such services performed in the home or domiciliary environment without appropriate oversight, qualified staff and equipment for reasonably foreseeable complications will not be considered medically necessary.
The primary treating physician must either personally perform the diagnostic test(s) or order the tests performed by mobile diagnostic testing facilities following LCD PHYS-078 Independent Diagnostic Testing Facilities (IDTFs).
Any specialized or invasive services, such as surgical procedures, physiologic monitoring, or advanced imaging performed during the course of home or domiciliary care visits must meet Medicare's reasonable and necessary criteria and must comply with all applicable safety rules and quality standards. If the results of the testing will not change the medical management or result in surgery, there is no medical necessity for the procedures. In these cases, the testing/service will not be medically necessary.
Laboratory and diagnostic tests performed during the course of home or domiciliary care visits must meet Medicare's reasonable and necessary criteria and be ordered by the primary care. A valid referring NPI number from a Medicare Part B provider who has previously seen the beneficiary must be on the claim. Medical reasons for repeat testing must be clearly documented. Performance of multiple or common tests without clear evidence of medical need of the beneficiary or changes in the treatment regimen based on the lab tests would not be considered reasonable and necessary as mandated by 42CFR410.32.
Coding Information
Bill Type Codes:
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
Revenue Codes:
CPT/HCPCS Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.
| 99324 | DOMICILIARY OR REST HOME VISIT FOR THE EVALUATION AND MANAGEMENT OF A NEW PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A PROBLEM FOCUSED HISTORY; A PROBLEM FOCUSED EXAMINATION; AND STRAIGHTFORWARD MEDICAL DECISION MAKING. |
| 99325 | DOMICILIARY OR REST HOME VISIT FOR THE EVALUATION AND MANAGEMENT OF A NEW PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; AND MEDICAL DECISION MAKING OF LOW COMPLEXITY. |
| 99326 | DOMICILIARY OR REST HOME VISIT FOR THE EVALUATION AND MANAGEMENT OF A NEW PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. |
| 99327 | DOMICILIARY OR REST HOME VISIT FOR THE EVALUATION AND MANAGEMENT OF A NEW PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. |
| 99328 | DOMICILIARY OR REST HOME VISIT FOR THE EVALUATION AND MANAGEMENT OF A NEW PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. |
| 99334 | DOMICILIARY OR REST HOME VISIT FOR THE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A PROBLEM FOCUSED INTERVAL HISTORY; A PROBLEM FOCUSED EXAMINATION; STRAIGHTFORWARD MEDICAL DECISION MAKING. |
| 99335 | DOMICILIARY OR REST HOME VISIT FOR THE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. |
| 99336 | DOMICILIARY OR REST HOME VISIT FOR THE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. |
| 99337 | DOMICILIARY OR REST HOME VISIT FOR THE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A COMPREHENSIVE INTERVAL HISTORY; A COMPREHENSIVE EXAMINATION; MEDICAL DECISION MAKING OF MODERATE TO HIGH COMPLEXITY. |
| 99341 | HOME VISIT FOR THE EVALUATION AND MANAGEMENT OF A NEW PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A PROBLEM FOCUSED HISTORY; A PROBLEM FOCUSED EXAMINATION; AND STRAIGHTFORWARD MEDICAL DECISION MAKING. |
| 99342 | HOME VISIT FOR THE EVALUATION AND MANAGEMENT OF A NEW PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; AND MEDICAL DECISION MAKING OF LOW COMPLEXITY. |
| 99343 | HOME VISIT FOR THE EVALUATION AND MANAGEMENT OF A NEW PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. |
| 99344 | HOME VISIT FOR THE EVALUATION AND MANAGEMENT OF A NEW PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. |
| 99345 | HOME VISIT FOR THE EVALUATION AND MANAGEMENT OF A NEW PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. |
| 99347 | HOME VISIT FOR THE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A PROBLEM FOCUSED INTERVAL HISTORY; A PROBLEM FOCUSED EXAMINATION; STRAIGHTFORWARD MEDICAL DECISION MAKING. |
| 99348 | HOME VISIT FOR THE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. |
| 99349 | HOME VISIT FOR THE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. |
| 99350 | HOME VISIT FOR THE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A COMPREHENSIVE INTERVAL HISTORY; A COMPREHENSIVE EXAMINATION; MEDICAL DECISION MAKING OF MODERATE TO HIGH COMPLEXITY. |
ICD-9 Codes that Support Medical Necessity
| XX000 | Not Applicable |
Diagnoses that Support Medical Necessity
Not Applicable
ICD-9 Codes that DO NOT Support Medical Necessity
Not Applicable
| XX000 | Not Applicable |
ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation
Diagnoses that DO NOT Support Medical Necessity
Not Applicable
General Information
The medical record
must document the medical necessity of all services performed during a
home or domiciliary visit.
Documentation for billed visits must meet the required components of the E&M CPT code. The medical record must clearly support all the criteria and provisions contained in the "Indications and Limitations of Coverage and/or Medical Necessity" section of this policy. Providers may also show need to assess a home situation, including involvement of caregivers. Clear documentation supporting the medical necessity of the home visit or domiciliary visit must be maintained in the beneficiary's record.
In support of this, the documentation of each beneficiary encounter must include at a minimum:
Thus, a payable diagnosis alone does not support medical necessity of ANY service. All documentation must be available to Medicare upon request.
Appendices
Documentation for billed visits must meet the required components of the E&M CPT code. The medical record must clearly support all the criteria and provisions contained in the "Indications and Limitations of Coverage and/or Medical Necessity" section of this policy. Providers may also show need to assess a home situation, including involvement of caregivers. Clear documentation supporting the medical necessity of the home visit or domiciliary visit must be maintained in the beneficiary's record.
In support of this, the documentation of each beneficiary encounter must include at a minimum:
- Reason for the encounter and relevant history
- Physical examination findings, and prior diagnostic test results, if applicable
- Assessment, clinical impression, or diagnosis
- Medical plan of care
Thus, a payable diagnosis alone does not support medical necessity of ANY service. All documentation must be available to Medicare upon request.
It is expected that
these services would be performed as indicated by current medical
literature and/or standards of practice. Frequency of visits should be
consistent with the frequency at any other site of service for that
code.
Sources of Information and Basis for Decision
American Academy of
Home Care Physicians [online] at http://www.aahcp.org/index.shtml.
Landers, S.H. et al, Trends in House Calls to Medicare Beneficiaries. JAMA, 2005; 294: 2435-2436.
Levine, S.A., Boal, J, Boling, P.A., Home Care. JAMA. 2003; 290:1203-1206.
Oldenquist, GW, Scott, L, Finucane, TE, Home care: What a physician needs to know. Cleveland Clinic Journal of Medicine. 2001.68(5):433-440.
Stuck, AE et al., Home Visits to Prevent Nursing Home Admission and Functional Decline in Elderly People. JAMA. 2002; 287: 1022-1028.
Advisory Committee Meeting Notes
Landers, S.H. et al, Trends in House Calls to Medicare Beneficiaries. JAMA, 2005; 294: 2435-2436.
Levine, S.A., Boal, J, Boling, P.A., Home Care. JAMA. 2003; 290:1203-1206.
Oldenquist, GW, Scott, L, Finucane, TE, Home care: What a physician needs to know. Cleveland Clinic Journal of Medicine. 2001.68(5):433-440.
Stuck, AE et al., Home Visits to Prevent Nursing Home Admission and Functional Decline in Elderly People. JAMA. 2002; 287: 1022-1028.
Meeting Date:
Wisconsin 01/28/2011
Illinois 01/26/2011
Michigan 02/02/2011
Minnesota 01/20/2011
J-5 MAC Iowa, Kansas
Missouri, Nebraska 02/10/2011
Open Meeting 01/06/2011
This policy does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the MAC contractor this policy was developed in cooperation with advisory groups which include representatives from various specialties, and adapted for the purpose of converting to MAC jurisdiction.
Start Date of Comment Period
Wisconsin 01/28/2011
Illinois 01/26/2011
Michigan 02/02/2011
Minnesota 01/20/2011
J-5 MAC Iowa, Kansas
Missouri, Nebraska 02/10/2011
Open Meeting 01/06/2011
This policy does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the MAC contractor this policy was developed in cooperation with advisory groups which include representatives from various specialties, and adapted for the purpose of converting to MAC jurisdiction.
02/10/2011
End Date of Comment Period
03/27/2011
Start Date of Notice Period
05/01/2011
Revision History Number
05/01/2011
Related Documents
This LCD has no Related Documents.
LCD Attachments
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Page Last Updated: Wednesday, 22-Jun-2011 10:51:20 CDT
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