As home-based primary care makes a comeback, be sure physicians’ payment for services isn’t obsolete.
Many of us are old enough to remember “Marcus Welby, M.D.,” and the doctors on shows like “Little House on the Prairie,” who would visit someone’s home in the event of an emergency, or if someone was homebound. House call programs — the modern, high-tech versions — are making a comeback. But for those who are tasked with capturing payment for these services, there are challenges.
Resurgence of House Calls
The case for home-based primary care (HBPC) programs is strong. Patients who need the most care often are those who can’t make it to the office, which leads to emergency services (ambulance and emergency department) and costly hospital stays. The goal of house call programs is to keep patients in their homes, functioning as well and as independently as possible for as long as possible. HBPC programs strive to lay eyes on the patient as often as medically necessary and to treat as many things in the home as possible.
HBPC Coding and Payment Realities
Despite the benefits, high on the list of challenges for HBPC programs is the lack of adequate funding. Under current fee-for-service rates, Medicare pays approximately:
- $185 for 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; and
- $152 for CPT® 99215 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity.
Although reimbursement for a home service is a bit higher, it is important to consider that a physician in an office sees anywhere from 10 to 40 patients a day whereas a house call provider only sees seven to eight patients per day.
HBPC programs allow physicians to care for the sickest of the sick — meaning that transitional care management (99495-99496) and chronic care management (99487, 99489, and 99490) services play key roles in the success of the program. Most HBPC programs are doing the necessary work for TCM and CCM but haven’t incorporated a process to capture their work and complete the billing process. This leaves money on the table!
To stay in business, HBPC programs must:
- Run efficiently (e.g., geographically correct scheduling is critical);
- Ensure proper coding for all services rendered; and
- Pay diligent attention to the revenue cycle and keep an eye out for funding from alternative sources.
Provider Education Is Key
This is a great opportunity for you to create a process that easily works for the provider and staff to meet documentation requirements for these codes. As medical coders and auditors, we must educate practitioners about these much-needed programs and the billing opportunities that are available, as well as the importance of accurate evaluation and management (E/M) documentation, which ultimately supports patient care and reimbursement.
Education for providers can be completed in many ways. For example:
- Offer coding tips at staff meetings.
- Conduct one-to-one review of progress notes. (You would be surprised at how appreciative providers are of helpful feedback — especially if the feedback makes their life easier.)
- Send email blasts to providers about new codes and changing regulations.
By being a creative leader, you are making a case for the value of having a coder/auditor in every practice.
Want More CCM and TCM Information?
For more information on chronic care management (CCM) services, visit the
AAPC Knowledge Center to read the article “Maximize Revenue for CCM Providers.”
For more information on transitional care management (TCM) services, visit the AAPC Knowledge Center to read the article “Transitional Care Management Codes Require 3 Elements.”
Shawna Ramey, CPC, CPMA, has 25-plus years of house calls practice management and coding/billing/documentation experience. Ramey consults with practices across the country to aid with operations and improve efficiencies. She serves on the AAHCM Public Policy Regulatory Work Group and is a member of the Akron, Ohio, local chapter.