Re: Home Visit Reimbursement Denials

[Guest guest]

Hey all -

Another thought on the payment issue here...

If we consider Medicare, if I am recalling correctly, the fee we are

paid is a combination of various factors including overhead

('facility component'). Arguably, the overhead is different in the

office and in the home, so the formulas would not work out. Hence

coding craziness. Private insurance tends to follow medicare - even

if they don't to the RVU formulas directly.

Not disagreeing with anything anyone said (and certainly not

defending the status quo!) -just hopefully adding some clarity as to

where this craziness come from.

Steve Hersch

Ashland, OR

 

Medicare does pay for home visits.  They also pay for

visits in assisted living facilities under a different

code.  They do not require the patient to be homebound

under the same definition as for home health

certification.  The language in their manuals re: what

they do require is a bit vague.

 

Do you guys know how to access the physician fee

schedule for medicare?  Here is a link:  http://www1.cms.gov/apps/physician-fee-schedule/overview.aspx 

you can look up what medicare will pay you for certain

codes.

 

Here is a medicare publication from 2006 that

addresses which codes to use for these visits:  https://www.noridianmedicare.com/provider/updates/docs/mm4212_homecare_docillarycare.pdf%3f 

info in this is also in the link below.

 

ANd this is the link to the medicare claims manual

with the "rules":  http://www1.cms.gov/manuals/downloads/clm104c12.pdf 

search for 'home care"  or look for section 30.6.14 and

read from there.

 

Here is an example of the definition re: need for

home visit: 

B. Homebound Status

Under the home health benefit 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.

 

Carla

From:

To:

Sent:

Mon, September 27, 2010 1:58:56 PM

Subject:

Home Visit Reimbursement

Denials

 

Marc and others,

If you do not see adults this does not apply to

you. When I worked for another physician I did

nursing home visits as well as home visits and the

patients were medicare. I understood that we were

paid because the patients could not come in and

they were called "homebound." They either could

not walk, could not get into a car, or be carried

into a car by whomever cared for them.

There was a question about my seeing a patient in

"Assisted Living" which is care not covered by

medicare but the patient wanted me to see her at

her facility because I went to the nursing home

there anyway and assisted living was in the same

building. We checked with the billing company but

found it would not be covered, so she had to be

brought to the office via the facility's van and a

nurse's aide had to accompany her. Medicare

covered the office visit but I do not believe they

covered the van or aide.

In this case, the lady had paid the facility for

an apartment by giving them a certain amount of

her estate (maybe all) which paid the bills; and

she was told she would be cared for by them for

life. When she could no longer remain in her

apartment, she was placed in assisted living.

Medicare did not have to cover her assisted living

bills, the facility did, even if they had run out

of her money. Since it was not cheaper for

medicare to have me see her there, they did not

pay.

I also once saw a patient that was on medicaid in

a van in the parking lot because my employer had

no way to get her into the building (she could not

sit up in a w/c and we had no stretcher). It was

unusual. I believe it was billed as an office

visit.