When a Home is Not a Home

There are some key 2023 CPT® Evaluation and Management (E&M) Code changes for Home and Residence Services.

EDITOR’S NOTE: The American Medical Association (AMA) announced major revisions to Evaluation and Management (E&M) Services, to take effect Jan. 1, 2023. The E&M categories that will undergo revision in 2023 include inpatient and observation care services, emergency department services, consultations, nursing facility services, home and residence services, and prolonged services.

For 2023, revisions to the E&M Home or Residence Services category include two deleted categories, deleted codes, revised codes, and guidelines revisions. 

To start, the E&M category Domiciliary, Rest Home (alternatively, Boarding Home), or Custodial Care Services and the E&M category Domiciliary, Rest Home (alternatively, Assisted Living Facility), or Home Care Plan Oversight Services are deleted for 2023. The parenthetical notes direct the provider or coder to report these services elsewhere:

• For the E&M category Domiciliary, Rest Home (Boarding Home), or Custodial Care Services, in 2023, these services should be reported using the home or resident services E&M codes for New or Established Patients.
  
• For the E&M category Domiciliary, Rest Home (Assisted Living Facility), or Home Care Plan Oversight Services, in 2023, these services should be reported using the care management services codes or principal care management codes.

The Home or Residence subsection parenthetical notes or guidelines indicate that these codes are used to report services provided in a home or residence. “Home” may be defined as a private residence, temporary lodging, or short-term accommodation (hotel, campground, hostel, or cruise ship). These codes are also used to report services when the residence is in an assisted living facility, a group home that is not licensed as an intermediate care facility for individuals with intellectual disabilities, a custodial care facility, or a residential substance abuse treatment facility.

For services provided in an intermediate care facility for individuals with intellectual disabilities and services provided in a psychiatric residential treatment center, the parenthetical notes direct the provider or coder to the Nursing Facility Services E&M category. The Medicare Claims Processing Manual states that “a home visit cannot be billed by a provider unless the provider is present in the beneficiary’s home.”

The parenthetical notes also state that travel time should not be counted towards total time when time is used for selecting the level of service.  

Home Services are divided into two subcategories – New Patient and Established Patient – with the subcategories currently divided into four or five levels of service. For 2023, the category title is revised to Home or Residence Services and the New Patient subcategory levels of service will have four levels of services, with E&M code 99344 deleted (for 2023, both categories will have four levels of service).

As with the above-mentioned E&M categories, the Home and Resident Services category aligns the 2023 E&M codes with the 2021 revisions made to the office and other outpatient services codes. The three key components, history, exam, and medical decision-making (MDM) are no longer required for reporting these services.

A medically appropriate history or physical, as determined by the physician or APP, should be documented; the level of service is determined solely by the level of MDM or time. The AMA has redefined what “time” includes for the selection of the level of service. Time is now considered the total time on the date of the encounter, and includes both face-to-face time and non-face-to-face time.  

Coding professionals should be aware of these revisions, as home calls or home visits are increasing for patients who can’t leave their house and those who prefer home visits. Some steps to take to be prepared include reviewing current documentation practices and revising documentation templates not needed for patient care. Also, consider how your providers can track the total time to correctly report and bill for these services.   

Programming note: Listen to Colleen Deighan Ejak today on Talk Ten Tuesdays, when she will report on the revisions to Prolonged Services from both the AMA’s E&M revisions and the 2023 Medicare Physician Fee Schedule Proposed Rule. 

Two Services, One Encounter: Reporting Procedure Plus E&M

Understanding what constitutes “significant and separately identifiable evaluation and management” is crucial for reporting both E&M and a procedure in a single patient encounter.

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