Local Coverage Determination (LCD): E&M Home and Domiciliary Visits (L33817)

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1 Local Coverage Determination (LCD): E&M Home and Domiciliary Visits (L33817) Contractor Information Contractor Name First Coast Service Options, Inc. LCD Information Document Information LCD ID L33817 Original ICD-9 LCD ID L29161 LCD Title E&M Home and Domiciliary Visits Original Effective Date For services performed on or after 10/01/2015 AMA CPT / ADA CDT / AHA NUBC Copyright Statement CPT only copyright American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright American Dental Association. All rights Revision Effective Date Revision Ending Date Retirement Date Notice Period Start Date Notice Period End Date

2 reserved. CDT and CDT-2010 are trademarks of the American Dental Association. UB-04 Manual. OFFICIAL UB-04 DATA SPECIFICATIONS MANUAL, 2014, is copyrighted by American Hospital Association ( AHA ), Chicago, Illinois. No portion of OFFICIAL UB-04 MANUAL may be reproduced, sorted in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior express, written consent of AHA. Health Forum reserves the right to change the copyright notice from time to time upon written notice to Company. CMS National Coverage Policy Language quoted from CMS National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals are italicized throughout the Local Coverage Determination (LCD). NCDs and coverage provisions in interpretive manuals are not subject to the LCD Review Process (42 CFR [b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See 1869(f)(1)(A)(i) of the Social Security Act. Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources: CMS Transmittal 775, Change Request 4212 Medicare Claims Processing Manual, Pub , Chapter 12, Section Medicare Program Integrity Manual, Pub , Chapter 13, Section 5.1 Coverage Guidance Coverage Indications, Limitations, and/or Medical Necessity A home or domiciliary visit includes a patient history, examination, problem solving and decision making in various levels depending upon a patient s need and diagnosis. Visits may also be performed as counseling or coordination of care if medically necessary outside the office environment and are an integral part of a continuum of care. The patients 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 can 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.

3 Home-based health care is 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 qualified non-physician practitioners (NPPs) are required to oversee or directly provide progressively more sophisticated home visits. Patients must understand the nature of a pre-arranged visit and consent to treatment in the home or domiciliary care facility. Payment for this type of service is based on face-to-face time with the patient alone or with the patient and family or caregiver and the work performed during that time is documented in the chart, such as direct patient assessment, care coordination etc. Travel time and related expenses are not separately billable services. Physician visits are payable under the physician fee schedule when provided to the patient in his/her private residence. There is no requirement that the patient must be homebound. The reason for a visit to the home rather than the office must be documented, as the visit is not payable or considered medically necessary if performed for the convenience of the physician or qualified NPP. Medical record documentation must support a medically necessary visit and made available upon request. It is important to note that visits to Residential Care Facilities/Rest Homes/Assisted Living Facilities are expected to occur in the patient s own personal living space or a room set aside for such visits. In the event of the latter occurrence, such rooms may be substituted for the patient s own living space and are not considered a doctor's office and may not be used as such. Nothing in this Home and Domiciliary E&M LCD precludes any specialty from meeting the requirements in national and/or local coverage determinations for other services performed. Any services performed in addition to the home or domiciliary visit are subject to the active national or local coverage determination (i.e., routine foot care, psychological evaluation, removal of skin lesions, Doppler study, etc.). To be reimbursable, a home or domiciliary care visit that is in lieu of an office visit, ER visit or hospital visit, must meet all of the following criteria: 1. The service/visit must be medically reasonable and necessary and not for the convenience of the physician or qualified NPP. The reason for a home visit in lieu of an office visit must be documented. 2. The service must be of equal quality to a similar service provided in an office. The 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 the frequency of visits for any given medical problem addressed in the home setting will not exceed that of an office setting,, except on rare occasion. 3. Each visit must meet the applicable medical standards of practice. 4. The service is of such nature that it could not be provided by a Visiting Nurse/Home Health Services Agency under the Home Health Benefit. There may be circumstances where home health services and the services of physician/qualified non-physician practitioners (NPPs) are performed on the same day. These services cannot be duplicative or overlapping. Specifically,

4 the certification/ development/ changing/supervision of a Home Health Plan of Care, including contacts with the HHA and its personnel, has been covered under G0180/G0179. The service provided by the physician/npp, when occurring on the same date of service as a HHA visit, must be separate from those services described by G0180/G0179. The E/M service will not be considered medically necessary when it is performed only to provide supervision for a visiting nurse/home health agency visit(s). 5. A qualified physician or qualified non-physician practitioner must perform the service. 6. If the service is provided to a patient for the first time, the patient, his/her delegate, or another medical provider managing the patient s care, must request the service. The visiting provider may not directly solicit referrals. An example of inappropriate solicitation is knocking on residents doors or placing calls to residents on the telephone to offer medical care services when there has been no referral from another professional that is already involved in the case. 7. If laboratory and diagnostic tests are performed during the course of home or domiciliary care visits, they must meet reasonable and necessary criteria. Medical reasons for repeat testing must be clearly documented. Performance of multiple or common tests without clear evidence of medical need of the patient or changes in the treatment regimen based on the lab tests would not be considered reasonable and necessary as mandated by 42CFR Any drugs and biologicals administered in the course of home or domiciliary care visits must meet reasonable and necessary criteria. To be reimbursed as incident to a physician s services in the home or domiciliary setting, the drug or biological must be personally administered by the provider or under his/her personal or direct supervision. Coverage for the Home/Domiciliary services are covered only when the three key components are met and documented in the medical record. Medical necessity of the Home or Domiciliary E/M service is not supported when the administration of the drug or biological is the sole reason for the visit. The medical necessity criteria as outlined elsewhere in this policy must apply. Any specialized or invasive services, such as surgical procedures, physiologic monitoring, or advanced imaging preformed during the course of home or domiciliary care visits must meet reasonable and necessary criteria and must be in compliance with all applicable safety rules and quality standards. 9. Training of domiciliary staff is not considered medically necessary. Visits to multiple patients by the same physician or physicians/npps of the same group may occur on the same date of service, but each service must meet the medical needs of the individual patient. Each visit must stand on its own and the medical necessity of the visit must be supported in documentation. Services provided in the home or domiciliary setting must not unnecessarily duplicate services provided to the patient by other practitioners, regardless of whether those practitioners provide the service in the office, facility or home/domiciliary setting. Home/domiciliary services provided for the same diagnosis, same condition or same episode of care as services provided by other practitioners, regardless of the site of service, may constitute concurrent or duplicative care. When such visits are provided, the record must clearly document the medical necessity of such services. When documentation is lacking, the services may be considered not medically necessary.

5 If the total number of Home and Domiciliary E/M services exceeds what could reasonably be provided, based upon the applicable standard of care and the component requirements for those E/M codes, those E/M codes may be subject to medical review. For follow-up visits, the physician or qualified NPP or that provider s medical group practice must have an ongoing patient-physician relationship with the beneficiary. Exceptions include patients who are traveling through an area and are not residents in the location where they are being seen and patients who are being seen in their homes or domiciles for urgent or episodic illness. However, the medical necessity of a home visit must be clearly documented in the medical record and the home/domiciliary care provider cannot solicit the visit. Examples of visit solicitation include a provider arriving without an appointment to see a patient or seeing a patient 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. 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. If the home/domiciliary care is being provided by other than the provider of record for a limited condition that would not typically prevent return to an office environment after recovery, the service will be presumed to be not medically necessary, unless the provider of record requests a consultation and the care is medically necessary and clearly documented in the medical record. The provision of services provided under the Hospice Benefit are not in the scope of this LCD. Background and Provisions of Coverage: CMS Online Manual System, Pub.100-8, Program Integrity Manual, Chapter 13, Section 5.1 ( outlines that reasonable and necessary services are ordered and/or furnished by qualified personnel. Services will be considered medically reasonable and necessary only if performed by appropriately trained providers. This training and expertise must have been acquired within the framework of an accredited residency and/or fellowship program in the applicable specialty/subspecialty or must reflect extensive continued medical education activities. If these skills have been acquired by way of continued medical education, the courses must be comprehensive, offered or sponsored or endorsed by an academic institution in the United States and/or by the applicable specialty/subspecialty society in the United States, and designated by the American Medical Association (AMA) or the American Osteopathic Association (AOA) as category I credit. Code of Federal Regulations (CFR), Title 42, part , specifies that all diagnostic tests must be ordered by a provider who is the treating provider for the patient and who will use the test results in the patient s care. Tests not ordered by the physician who is treating the beneficiary and tests, which are not used in the management of the patient s condition, are not reasonable and necessary. Like with any reimbursable service, to support medical necessity there must be documentation in the medical record as to why a certain modality was chosen/performed. It is recognized that the miniaturization of electronic diagnostic testing devices is an on-going trend that may be associated with either improved or diminished test performance. Hand-carried

6 diagnostic equipment ranges in complexity and capability from lightweight pocket-sized units completely contained within the examiner's hand, to complex equipment systems where only a part, such as an ultrasonic probe itself, is hand-held. The appropriate assignment of a specific CPT code to a diagnostic test/equipment is not solely determined by the weight, size, or portability of the equipment, but rather by the extent, quality, and documentation of the procedure. To be reimbursable, a diagnostic test/equipment must meet at least these minimum criteria (this is not an all inclusive list): It must be medically reasonable and necessary for the diagnosis or treatment of illness or injury. It should be done for the same purpose that a reasonable physician would order the standard diagnostic examination. It must be billed using the CPT code that accurately describes the service performed. The technical quality of the exam must be in keeping with accepted national standards and not require a follow-up diagnostic examination to confirm the results. The study must be performed and interpreted by qualified individuals. The medical necessity, images, findings, interpretation and report must be documented in the medical record. In order to be covered, use of a drug or biological must be safe and effective and otherwise reasonable and medically necessary. The medical reasonableness and necessity of drugs and biologicals are extensively discussed in the Medicare manuals. This contractor has published numerous local coverage determinations (LCDs) and educational articles about drugs and biologicals, specifically anti-cancer agents. Please refer to these publications for more detailed information. Dosage and Frequency: Drugs or biologicals approved for marketing by the FDA are considered safe and effective when used for indications specified on the labeling. The labeling lists the safe and effective, i.e. medically reasonable and necessary dosage and frequency. Therefore, doses and frequencies that exceed the accepted standard of recommended dosage and/or frequency, as described in the package insert, are considered not medically reasonable and necessary and, therefore, not reimbursable. Route of Administration: CMS Online Manual System, Pub , Medicare Benefit Policy Manual, Chapter 15, Section addresses medical reasonableness and necessity based on the FDA approval and labeling: Drugs or biologicals approved for marketing by the FDA are considered safe and effective for purposes of this requirement when used for indications specified on the labeling. This statement extends to the mode of administration that is considered safe and effective, i.e., medically reasonable and necessary by Medicare s criteria. Furthermore, the CMS Online Manual System, Pub.100-2, Medicare Benefit Policy Manual, Chapter 15, Section 50.2 K Reasonable and Necessary, stipulates that, carriers and fiscal

7 intermediaries will make the determination of reasonable and necessary with respect to the medical appropriateness of a drug to treat the patient s condition. Contractors will continue to make the determination of whether the intravenous or injection form of a drug is appropriate as opposed to the oral form. Based on the above, for agents administered parenterally, the mode of administration (IV, IM, SQ) must be in keeping with the instructions in the package insert, as approved by the FDA. If a drug is available in both oral and injectable forms and both forms are equally effective, the oral preparation shall be used, unless there is a medical reason not to do so. Depending on a patient 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 patient 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. This policy is subordinate to all National Coverage Determinations (NCDs), Medicare rules and regulations, and Local Coverage Determinations (LCDs) of this contractor. In the event that this policy conflicts with other Medicare Coverage Determinations, National/Local Determinations will override any similar information in this policy. The American Medical Associations Current Procedural Terminology (CPT) 2006 new patient codes and established patient codes (new codes beginning January 2006), for Domiciliary, Rest Home (e.g., Boarding Home), or Custodial Care Services, are used to report evaluation and management (E/M) services to residents residing in a facility which provides room, board, and other personal assistance services, generally on a long term basis. These CPT codes are used to report E/M services in facilities assigned places of service (POS) codes 13 (Assisted Living Facility), 14, (Group Home), 33 (Custodial Care Facility) and 55 (Residential Substance Abuse Facility). Assisted living facilities may also be known as adult living facilities. Physicians and qualified non-physician practitioners (NPPs) furnishing E/M services to residents in a living arrangement described by one of the POS listed above must use the level of service code in the CPT code range to report the service they provide. The CPT codes for Domiciliary, Rest Home (e.g. Boarding Home), or Custodial Care Services are deleted beginning January The CPT codes through 99350, Home Services codes, are used to report E/M services furnished to a patient residing in his or her own private residence (e.g., private home, apartment, town home) and not residing in any type of congregate/shared facility living arrangement including assisted living facilities and group homes. The Home Services codes apply only to the specific 2-digit POS 12 (Home). Home Services codes may not be used for billing E/M services provided in settings other than in the private residence of an individual as described above. A. Requirement for Physician Presence

8 Home services codes are paid when they are billed to report evaluation and management services provided in a private residence. A home visit cannot be billed by a physician unless the physician was actually present in the beneficiary s home. 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 physician 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. 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. 999x Not Applicable Revenue 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 Not Applicable CPT/HCPCS Codes Group 1 Paragraph: I. Domiciliary, Rest Home, Assisted Living and/or Nursing Facility Codes

9 Group 1 Codes: MANAGEMENT OF A NEW PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A PROBLEM FOCUSED HISTORY; A PROBLEM FOCUSED EXAMINATION; AND STRAIGHTFORWARD MEDICAL DECISION MAKING. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PRESENTING PROBLEM(S) ARE OF LOW SEVERITY. TYPICALLY, 20 MINUTES ARE SPENT WITH THE PATIENT AND/OR FAMILY OR CAREGIVER. 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. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PRESENTING PROBLEM(S) ARE OF MODERATE SEVERITY. TYPICALLY, 30 MINUTES ARE SPENT WITH THE PATIENT AND/OR FAMILY OR CAREGIVER. MANAGEMENT OF A NEW PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PRESENTING PROBLEM(S) ARE OF MODERATE TO HIGH SEVERITY. TYPICALLY, 45 MINUTES ARE SPENT WITH THE PATIENT AND/OR FAMILY OR CAREGIVER. MANAGEMENT OF A NEW PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PRESENTING PROBLEM(S) ARE OF HIGH SEVERITY. TYPICALLY, 60 MINUTES ARE SPENT WITH THE PATIENT AND/OR FAMILY OR CAREGIVER MANAGEMENT OF A NEW PATIENT, WHICH REQUIRES THESE 3 KEY

10 COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PATIENT IS UNSTABLE OR HAS DEVELOPED A SIGNIFICANT NEW PROBLEM REQUIRING IMMEDIATE PHYSICIAN ATTENTION. TYPICALLY, 75 MINUTES ARE SPENT WITH THE PATIENT AND/OR FAMILY OR CAREGIVER. 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. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PRESENTING PROBLEM(S) ARE SELF-LIMITED OR MINOR. TYPICALLY, 15 MINUTES ARE SPENT WITH THE PATIENT AND/OR FAMILY OR CAREGIVER. 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. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PRESENTING PROBLEM(S) ARE OF LOW TO MODERATE SEVERITY. TYPICALLY, 25 MINUTES ARE SPENT WITH THE PATIENT AND/OR FAMILY OR CAREGIVER. 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. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PRESENTING PROBLEM(S) ARE OF MODERATE TO HIGH SEVERITY. TYPICALLY, 40 MINUTES ARE SPENT WITH THE PATIENT AND/OR FAMILY OR CAREGIVER. MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST OF THESE 3 KEY COMPONENTS: A COMPREHENSIVE INTERVAL HISTORY; A COMPREHENSIVE EXAMINATION; MEDICAL DECISION MAKING OF

11 MODERATE TO HIGH COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PRESENTING PROBLEM(S) ARE OF MODERATE TO HIGH SEVERITY. THE PATIENT MAY BE UNSTABLE OR MAY HAVE DEVELOPED A SIGNIFICANT NEW PROBLEM REQUIRING IMMEDIATE PHYSICIAN ATTENTION. TYPICALLY, 60 MINUTES ARE SPENT WITH THE PATIENT AND/OR FAMILY OR CAREGIVER. Group 2 Paragraph: II. Home Visit Codes Group 2 Codes: 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. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PRESENTING PROBLEM(S) ARE OF LOW SEVERITY. TYPICALLY, 20 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY. 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. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PRESENTING PROBLEM(S) ARE OF MODERATE SEVERITY. TYPICALLY, 30 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY. 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. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PRESENTING PROBLEM(S) ARE OF MODERATE TO HIGH SEVERITY. TYPICALLY, 45 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY. HOME VISIT FOR THE EVALUATION AND MANAGEMENT OF A NEW PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A

12 COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PRESENTING PROBLEM(S) ARE OF HIGH SEVERITY. TYPICALLY, 60 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY. 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. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PATIENT IS UNSTABLE OR HAS DEVELOPED A SIGNIFICANT NEW PROBLEM REQUIRING IMMEDIATE PHYSICIAN ATTENTION. TYPICALLY, 75 MINUTES ARE SPENT FACE-TO- FACE WITH THE PATIENT AND/OR FAMILY. 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. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PRESENTING PROBLEM(S) ARE SELF LIMITED OR MINOR. TYPICALLY, 15 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY. 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. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PRESENTING PROBLEM(S) ARE OF LOW TO MODERATE SEVERITY. TYPICALLY, 25 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY. 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. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE

13 PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PRESENTING PROBLEM(S) ARE MODERATE TO HIGH SEVERITY. TYPICALLY, 40 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY. 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. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PRESENTING PROBLEM(S) ARE OF MODERATE TO HIGH SEVERITY. THE PATIENT MAY BE UNSTABLE OR MAY HAVE DEVELOPED A SIGNIFICANT NEW PROBLEM REQUIRING IMMEDIATE PHYSICIAN ATTENTION. TYPICALLY, 60 MINUTES ARE SPENT FACE-TO- FACE WITH THE PATIENT AND/OR FAMILY. ICD-10 Codes that Support Medical Necessity Group 1 Paragraph: Group 1Codes ICD-10 Code Description XX000 Not Applicable Showing 1 to 1 of 1 entries in Group 1 ICD-10 Codes that DO NOT Support Medical Necessity Additional ICD-10 Information

14 General Information Associated Information Documentation Requirements The medical record must document the medical necessity of the home visit whether made in lieu of an office or outpatient visit or in addition to such visits. In the latter scenario, documentation must clearly reflect the need for such concurrent care to avoid being considered duplicative and therefore, not medically reasonable and necessary. When services are provided in ANY setting, medically reasonable and necessary criteria must be met. Standing visits (i.e. standing order q 3 months ) are not considered medically necessary unless the patient s medical condition is clearly documented and they are only considered to be medically necessary when they relate to acceptable standards of medical practice or published medical guidelines for a specific diagnosis. This must be validated each time by a statement documented in the clinical record of the patient s status. Each visit must stand-alone and be supported in the documentation. Many elderly patients have chronic conditions, such as hypertension, diabetes, orthopedic conditions, and abnormalities of the toenails. The mere presence of inactive or chronic conditions does not constitute medical necessity for any setting (home, rest home, office etc). There must be a chief complaint or a specific reasonable and medically necessary need for each visit. In support of this, the documentation of each patient encounter must include: 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. Medical necessity must exist for each individual visit. The visit will be regarded as a visit of convenience in the following instances (unless the medical record clearly documents the necessity for the visit): The initial visit and the reason for subsequent visits must not be driven by group visits to one domiciliary facility without other factors as mentioned above (e.g. the clear support of medical necessity for each individual visit). The record does not clearly demonstrate that the patient, his/her delegate or another clinician involved in the case sought the initial service. The service is being provided at a frequency that exceeds that which is typically provided in the office and acceptable standards of medical practice. The service was solicited.

15 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 patient s record. All documentation must be available upon request. Utilization Guidelines 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 generally consistent with that at any other site of service for any medical problem. When services are preformed in excess of established parameters, they may be subject to review for medical necessity. Sources of Information and Basis for Decision FCSO reference LCD number L29421 American Academy of Home Care Physicians [online] at Landers, S.H. et al, Trends in House Calls to Medicare Beneficiaries. JAMA, 2005; 294: Levine, S.A., Boal, J, Boling, P.A., Home Care. JAMA. 2003; 290: Oldenquist, GW, Scott, L, Finucane, TE, Home care: What a physician needs to know. Cleveland Clinic Journal of Medicine (5): Stuck, AE et al., Home Visits to Prevent Nursing Home Admission and Functional Decline in Elderly People. JAMA. 2002; 287: Revision History Information Associated Documents Attachments Related Local Coverage Documents

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