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L.2.01.436
A home visit is when an appropriate skilled health professional (M.D., D.O., nurse practitioner or physician assistant) provides evaluation and management (E/M) services in a patient’s home. While physicians, nurse practitioners, and physician assistants have authorization and supervision responsibilities for a broad spectrum of skilled services that can be offered in the home, home visits have largely been supplanted by the use of Home Health Care services. Such services include home health nursing, social workers, and physical, occupational and speech therapy. Other health care support services are provided by Durable Medical Equipment companies, as well as Home Infusion and Hospice providers.
A home visit for evaluation and management must be medically necessary. Common reasons for home visits include patient assessment, illness management for homebound patients, and hospitalization follow-up. The patient seen in the home must be impaired either physically or mentally making access to a traditional office visit very difficult. There must be a clear, valid reason for the patient to be seen in the home instead of in an office. In addition, the specific home services performed must be those that cannot be provided by a Network Home Health Agency under Home Health benefits.
A home visit for evaluation and management must be medically necessary subject to the provisions in the member’s benefit plan, including not being specifically for the convenience of the provider or patient, and meet ALL of the following criteria:
The home visit must be performed by a Blue Cross & Blue Shield of Mississippi Blue Primary Care Network Provider or Network Specialist practicing within the scope of State law, AND
The Blue Cross & Blue Shield of Mississippi Blue Primary Care Network Provider or Network Specialist must be physically present in patient's personal residence, AND
The home visit must be needed to prevent, diagnose, or treat an illness, injury, condition, disease, or symptoms under an established plan of care and meets accepted standards of medicine, AND
The medical records must clearly document why the patient is not physically capable of traveling to the office due to extensive physical, medical, mental, or psychological issues or impairments, or has a medical contraindication for leaving home, AND
The key evaluation and management (E/M) components must be met and documented (see Policy Guidelines) in the medical records and must be based on face-to-face time with the patient, AND
The services must be of equal quality to a similar service provided in an office, AND
The services must be provided at a frequency that does not exceed that which is typically provided in the office and acceptable standards of medical practice, AND
The specific home services performed cannot be provided by a Network Home Health Agency under Home Health Benefits.
The following are not considered home visits, and therefore, are considered not medically necessary:
Home visit for convenience of the patient
Home visit for convenience of the patient's family
Home visit for convenience of the provider
Home visits due to financial, social, or other personal reasons
Services that are duplicative or overlapping to Home Health Care
Concierge care (also called concierge medicine, retainer-based medicine, boutique medicine, platinum practice, or direct care)
None
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
Key Home Visit Evaluation and Management (E/M) Components
Patient demographic information
Date of home visit
Individuals present during home visit
History of the present illness
Pertinent review of systems
Pertinent medical history
Active problem list
Current medications
Allergies
Social History
Primary caregivers at home
Assessment of caregiver stress
Current community resources assisting this patient (include contact numbers)
Physical Exam
Other evaluations to include as indicated:
Nutrition assessment
Fall risk assessment
Home safety assessment
PHG-9 depression screening
Mini-Mental State Exam
Activities of daily living assessment:
bathing and grooming
dressing
toileting and continence
transferring
self-feeding
Instrumental activities of daily living assessment:
cleaning and maintaining the house
managing money
preparing meals
doing laundry
shopping
taking medicines as directed
using the phone
driving or managing transportation outside the home
Assessment/Plan
New recommendations
Medication refills needed?
Durable medical equipment needed?
Health maintenance/screenings due?
Source: Home visits: A practical approach. J Fam Pract.2020 Dec; Vol. 69 (10), pp. 507-513.
Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Mental Health Disorders, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:
consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and
appropriate with regard to standards of good medical practice; and
not solely for the convenience of the Member, his or her Provider; and
the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.
For the definition of medical necessity, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.
11/18/2021: Approved by Medical Policy Advisory Committee. Effective 01/01/2022.
12/21/2022: Code Reference section updated to revise the descriptions for CPT codes 99341, 99342, 99344, 99345, 99347, 99348, 99349, and 99350. Added HCPCS code G0318, effective 01/01/2023.
12/07/2023: Policy reviewed; no changes.
03/11/2025: Policy reviewed. Policy statements unchanged. Code Reference section updated to remove deleted CPT code 99343.
The Home Visit. Am Fam Physician. 1999 Oct 1;60(5):1481-1488.
House Calls. Am Fam Physician. 2011 Apr 15;83(8):925-931.
https://www.aafp.org/afp/2011/0415/p925.html#afp20110415p925-t2
Defining “Confined to the Home”. Fam Pract Manag. 2003 Mar;10(3):20.
https://med.noridianmedicare.com/web/jeb/specialties/em/home-and-domiciliary-visits
https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00144300
Home visits: A practical approach. J Fam Pract.2020 Dec; Vol. 69 (10), pp. 507-513.
This may not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.
Medically Necessary Codes
Code Number | Description |
CPT-4 | |
99341 | Home or residence visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 15 minutes must be met or exceeded. |
99342 | Home or residence visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded. |
99344 | Home or residence visit for the evaluation and management of a new 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, 60 minutes must be met or exceeded. |
99345 | Home or residence visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 75 minutes must be met or exceeded. |
99347 | Home or residence visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded. |
99348 | Home or residence visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded. |
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. |
99350 | Home or residence visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 60 minutes must be met or exceeded. |
HCPCS | |
G0318 | Prolonged home or residence evaluation and management service(s) beyond the total time for the primary service (when the primary service has been selected using time on the date of the primary service); each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact (list separately in addition to cpt codes 99345, 99350 for home or residence evaluation and management services). (do not report g0318 on the same date of service as other prolonged services for evaluation and management 99358, 99359, 99417). (do not report g0318 for any time unit less than 15 minutes) |
ICD-10 Procedure | |
ICD-10 Diagnosis |
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