Home Visit Documentation
Medicare reviews of home visit documentation have identified situations in which documentation does not support either the level of service billed or the medical necessity for a home service in lieu of an office visit. We are asking providers to review the following information and conduct an internal audit to determine whether they are billing home services appropriately.
It is imperative that providers understand the documentation requirements for home visit services in order to be reimbursed appropriately for the services provided. This will ensure Medicare pays providers appropriately for the services provided. According to Chapter 6 of the Medicare Resident and New Physician Guide, a CMS (Centers for Medicare and Medicaid Services) publication on Evaluation and Management services, there are seven components used to define Evaluation and Managements services. Those components are:
- history,
- examination,
- medical decision making,
- counseling,
- coordination of care,
- nature of the presenting problem,
- time.
The three key components in selecting the level of E/M services, are the history, examination, and medical decision making.
The exception to this is when the visit consists predominantly of counseling or coordination of care. In this case, total time of the visit is the deciding factor in determining the level of E/M service. The documentation guidelines state, "If the physician elects to report the level of service based on counseling and/or coordination of care, then the total length of face-to-face time of the encounter should be documented and the record should describe the counseling and/or activities performed to coordinate the care." The amount of time spent in counseling must be more than 50% of the total encounter.
The Medicare Resident and New Physician Guide includes both the 1995 and 1997 Documentation Guidelines for E/M services. Providers can choose either the 1995 or 1997 guidelines when billing their services to Medicare Part B. Carriers have been instructed by CMS to review and adjudicate claims using both sets of guidelines and to ultimately use the guideline that is the most advantageous to the provider.
The chief complaint is the reason for the encounter (visit). The medical record should clearly reflect the chief complaint, as well as make obvious the medical reason for the visit.
The history of the present illness can only be performed and documented by the billing provider. This is a description of the development of the present illness and is distinguished by the amount of detail documented, such as the location of pain, severity, and duration. (Medicare Resident and New Physician Guide-pg.64-'95 Guidelines; pg 76-'97 Guidelines)
The review of systems is an inventory of the body systems that is obtained through a series of questions. These questions attempt to identify symptoms the patient may be experiencing or has experienced. The questions are subjective, rather than objective, and may be addressed by ancillary staff. Positive responses and pertinent negatives must be elaborated on and documented in the review of systems.
When documenting the patient's past, family, and/or social history, simply using the notation "Non-Contributory" or "negative" is not considered adequate documentation. Documentation must include social and/or family history information (such as alcohol consumption, smoking history, occupation, or familial hereditary conditions).
The use of exam templates or checklists is acceptable, but they must clearly demonstrate the level of the examination performed. Providers should document specific abnormal and relevant findings of the exam concerning the affected/symptomatic body areas/organ systems with a brief statement or notation such as "negative" or "normal."
The medical decision making component of the visit refers to the complexity of establishing a diagnosis and/or selecting a management option. Medical decision making must always be a part of each encounter, and the documentation should reflect the assessment, clinical impression or diagnosis, and individualized patient plan of care.
Medical records must support the medical necessity for the level of service billed. The documentation should always substantiate the appropriateness of each E/M service or procedure billed. It is not appropriate to bill a high level of E/M service when a lower level of service is supported by the medical necessity of the issues addressed. For example, billing a level 99350 for an uncomplicated acute sore throat, without documentation of either symptoms or circumstances that describe a problem of moderate to high severity, does not meet the medical necessity for this level of E/M service. Even if enough other body systems were addressed in the visit, if the findings for those body systems do not relate to the reasons for this visit or the problem(s) addressed, then these systems would not count toward the level of the E/M service. The volume of documentation is not the primary influence on the specific level of service billed.
Medicare does not require the patient to be homebound in order to allow a home visit. However, the medical records must support the medical necessity for a home visit in lieu of an office visit. Because chronic conditions are not static and symptoms and/or circumstances can vary greatly, it is very important that the reasons why the patient was seen in the home instead of the office clearly are documented.
