cpt code for home visit level 4

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Avoid denials when selecting Level 4 E/M office visit codes

CPT guidelines permit E/M code selection based on time when face-to-face counseling and/or coordination of care accounts for more than 50 percent of the encounter.

It’s a scenario probably familiar to many primary care physicians. A new patient presents with multiple chronic conditions. In most cases, the history, exam, and medical decision-making will drive the E/M level that the physician reports for billing. However, what if the physician spends 30 minutes out of the 45-minute appointment counseling the patient on diabetes management? CPT guidelines permit E/M code selection based on time when face-to-face counseling and/or coordination of care accounts for more than 50 percent of the encounter. If the physician selects CPT code 99204 (Level 4 new patient office visit) for this encounter, does that mean the claim will pass payer scrutiny even if he or she only performed an expanded problem-focused history rather than a comprehensive one? Not always, says Sonal Patel, CPMA, CPC, a healthcare coder and compliance consultant with Nexsen Pruet LLC, a business law firm in Charleston, S.C. Payers have been looking more closely at Level 4 E/M codes because of the higher payments associated with these codes, she says. If physicians choose a Level 4 E/M code based on time, their documentation must clearly describe what they did and why, she adds. In the absence of clear and detailed documentation, physicians could be subject to post-payment audits if payers suspect they’re upcoding-something that’s relatively easy to do if documentation isn’t adequate, says Patel. In that case, “Medicare will pay you for the Level 4 established patient visit again and again,” she says. “You’ll be happy for a year, but then next year, they’re going to come back, look at you under a microscope, and recoup that money.”

Document time spent The biggest mistake physicians make when selecting an E/M level based on time is not providing sufficient documentation regarding the extent of the counseling and coordination of care, says Patel. For example, a physician might document, ‘I had a lengthy discussion with the patient for more than half of the visit.’ “That tells the payer nothing,” says Patel. “You can’t make a blanket statement and think that’s going to count on the payer or auditor side.” She provides this example of proper documentation for billing CPT code 99204 based on time: “I spent 30 minutes out of the 45-minute visit with the patient talking about their surgical options [list the specific options]. The patient had many questions and concerns, and we discussed the following pros and cons of each option [insert details].” Another example of proper documentation: “This patient with cancer has undergone all preliminary studies and is deciding whether to receive chemotherapy. During the visit, I spent 30 minutes out of the 45-minute appointment discussing specific chemotherapy options [list the options] and subsequent lifestyle effects of treatment that the patient may experience, such as [insert details].”

Think ‘exception’ Most of the time, physicians won’t actually be able to select the E/M level based on time because counseling and care coordination aren’t often the focus of the visit, says Patel. Even when they are, there may be a more appropriate CPT code to report rather than a single E/M office visit code based on time, she adds. For example, a physician spends more than half the visit providing smoking cessation counseling. In this case, it may be appropriate to a report a CPT code from the 99406-99407 code range for the smoking cessation counseling in addition to an E/M code with modifier -25 based on the three key components (i.e., history, exam, and medical decision-making). However, the E/M code with modifier -25 must be separate and distinct from the smoking cessation counseling, says Patel. The same may be true for several other types of services, such as:

• Individual preventive medicine counseling and/or risk factor reduction (99401-99404)
• Alcohol and/or substance (other than tobacco) abuse counseling (99408-99409)
• Group preventive medicine counseling and/or risk factor reduction intervention (99411-99412)
• Psychotherapy (90833, 90836, or 90838) [Note: These are add-on codes, meaning physicians must also report an E/M office visit code.]

As always, it’s important for physicians to review payer policies to determine whether the E/M code with modifier -25 will be paid in full, paid at a reduced rate, or not paid at all, Patel says. Here’s another scenario: A patient presents with an acute asthma exacerbation. The patient stays in the office for 65 minutes more than what CPT deems the average time associated with that service to receive intravenous medication and monitoring until stable. In this case, it may be appropriate to report the E/M code based on the three key components (i.e., history, exam, and medical decision making) along with a separate code for prolonged ­services. “The documentation must really support the fact that you’ve gone above and beyond the E/M code,” says Patel. “I don’t think all patients in the office setting would qualify for this type of extended service, but patients with acute exacerbations or uncontrolled diabetes mellitus are good examples of where prolonged services may be warranted.”

Focus on diagnosis codes Diagnosis codes can help justify the rationale for selecting an E/M level based on time, says Patel. However, they can also call attention to potential upcoding. For example, payers will question why a physician spent more than half of a visit counseling a patient with an ear infection. What to do when a payer down-codes your services Payers frequently down-code Level 4 E/M office visits during a pre- or post-payment audit when physicians don’t document all of the work they perform, says Leslie C. Murphy, JD, CHC, partner at King & Spalding, a healthcare law firm in Sacramento, Calif. Unless it’s documented, physicians have no way of proving they did the work, and payers certainly won’t give them the benefit of the doubt, she adds. Do physicians have any recourse if a payer downcodes a Level 4 E/M office visit code? Possibly, says Murphy. First, they must review the explanation of benefits. How did the payer process the claim? Did the payer designate a certain amount as the patient’s responsibility? If so, the physician can almost always bill the patient directly for this amount. On the other hand, physicians cannot usually bill the patient for the difference between the billed charge (e.g., 99214) and the allowable (e.g., 99212). Physicians should review their contracts with each payer to determine whether and how much they’re allowed to bill the patient directly, she adds. If a payer denies the entire claim-and assigns no patient responsibility-the physician’s only recourse is to contact the payer to understand the reason for the denial and then correct and resubmit the claim or appeal it, says Murphy.

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Billing and Coding for Physician Home Visits

by Rajeev Rajagopal | Published on May 23, 2018 | Medical Coding

Physician home visits have begun making a comeback, according to a recent report from the Association of American Medical Colleges (AAMC). With 80% of U.S. adults age 65+ having one or more chronic diseases, this is a welcome development. Point of care testing along with advancements in home health technology and support have improved the physician’s ability to cater to the needs of older weak patients with multiple comorbidities outside the office setting. Outsourcing medical coding can ensure accurate claim submission for optimal reimbursement for services provided. However, to qualify for coverage, the medical record must document the medical necessity of the home visit made in lieu of an office or outpatient visit. The Office of Inspector General (OIG) and several contractors of the Centers for Medicare & Medicaid Services (CMS) scrutinize physician home services billed to the Medicare program to ensure that house calls are medically necessary and not for the convenience of the patient, the patient’s family, or the physician (or provider).

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Physician Home Visits must be “Medically Necessary”

Medicare.gov defines “medically necessary” as “health-care services or supplies needed to prevent, diagnose, or treat an illness, injury, condition, disease, or it’s symptoms and that meet accepted standards of medicine”.

CPT codes 99341 through 99350, Home Services codes, are used to report E/M services provided to a patient residing in his or her own private residence and not any type of facility. According to a 2017 AAPC report:

• For home visits to qualify as medically necessary, providers need to document if the home visit is based upon a one-time need, or if the visit is provided to meet an ongoing or permanent need because of the patient’s physical, medical, mental, or psychological issues.
• The physician should provide proof that the patient is not physically capable of traveling to the office either this one time, or on an ongoing basis, due to physical or mental issues and not due to financial or other personal reasons.
• Home services cannot be provided at the physician’s convenience (for e.g., visiting senior independent living facilities on a routine basis, without requests for or by patients).
• Under Medicare’s home health benefit, the beneficiary must be confined to the home for services to be covered.
• For home services provided by a physician billed under CPT codes 99341 through 99350, the beneficiary does not need to be confined to the home.

CGS Adminstrators, LCC points out that if the physician visits the patient in his/her home on a regular basis, each note should show how the patient’s condition has changed. Providers should take care to avoid cloned or copied documentation that does not explain how the patient’s condition has improved or deteriorated.

Home Services CPT Code Range 99341- 99350

Codes 99341-99350 report evaluation and management (E/M) services provided in a private residence (place of service 12) and cannot be used if the patient resides in a shared living facility or group home. The description of home visits includes the average time to be used when counseling/coordination of care dominate the visit (for e.g., comprises over 50 percent of total face-to-face time between the provider and patient).

Codes for New Patients

99341 Home visit; low severity problem, 20 min. 99342 moderate severity problem, 30 min. 99343 moderate to high severity problem, 45 min. 99344 high severity problem, 60 min. 99345 patient unstable or significant new problem requiring immediate attention 75 min.

Codes for Established Patients

93347 Self-limited or minor problem, 15 min. 99348 Low to moderate problem, 25 min. 99349 Moderate to high problem, 40 min. 99350 Patient unstable or significant new problem requiring immediate physician attention, 60 min.

If other services such as advanced care planning, diagnostic services, and some minor procedures are performed, they can be documented and billed in addition to the visit code in this setting.

Demographics, Insurance, and Billing Information

As the home visit with a new patient has the same business requirements as a visit to the office, AAPC says that maintaining a complete and accurate medical record for each patient is critical. Physicians should gather the necessary demographic and insurance information and provide patients with the appropriate forms such as Notice of Privacy Practices, general consent for treatment, new patient intake form, history form, and financial policies.

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Billing for Physician Home Visits – Risk Factors

DC based Law Firm Liles Parker lists the risk factors that can lead Medicare reviewers to deny claim payment:

• If it appears that one or more of the home services were was conducted for the convenience of the patient, the patient’s family, or the physician
• The documentation does not prove that the patient was not able come to the physician’s office or an outpatient clinic for care.
• The medical record does not clearly show that the patient, his/her family or another clinician involved in the case sought the initial service
• The home services are provided at a frequency that exceeds that which is typically provided in the office and acceptable standards of medical practice
• The physician does not personally provide the home services. The service is performed by a non-physician practitioner (NPP) but the claim is being billed at the physician’s rate.
• The home services are solely provided by an NPP but only the physician, not the treating NPP, is credentialed with Medicare.
• The specific home services performed could be provided by a visiting nurse or home health agency.

With OIG and many CMS contractors auditing home services (CPT codes 99341 through 99350) billed to Medicare, participating physicians should understand the coverage and billing requirements. The documentation should provide clear proof of medical necessity. Other services such as minor procedures or advanced care planning services can also be rendered in a variety of living situations and providers should be familiar with the specifics to each code location. It is important that physicians review all the relevant CPT codes with their medical billing company . Partnering with an experienced medical billing and coding service provider can help home-based primary care practices achieve savings while delivering holistic, team-based care to old, sick, frail, or functionally limited people.

Rajeev Rajagopal, the President of OSI, has a wealth of experience as a healthcare business consultant in the United States. He has a keen understanding of current medical billing and coding standards.

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September 11, 2024

Codes for Visits in Assisted Living

In 2023, how will we code for visits in assisted living?

January 1 st 2023, the codes for boarding home, rest home and domiciliary care are gone from the CPT® book. What are the codes for visits in assisted living in 2023 and beyond?

Home and residence services (99341—99345 for new patients) and (99347—99350 for established patients) are used for both settings. The definition of home includes a private residence, temporary lodging or short term accommodation, including hotel, campground, hostel or cruise ship. The codes are also used for people in “ assisted living facility, group home (that is not licensed as an intermediate care facility for individuals with intellectual disabilities), custodial care facility, or residential substance abuse treatment facility.”

A patient in assisted living is reported with these codes.

What about patients in continuing care facilities? These are facilities that include both private apartments, condos and homes and assisted living units with support. CPT® doesn’t talk about continuing care facilities, but these often include both completely independent living (home) and supportive care in assisted living. Since the same set of codes are used, does it matter?

Yes, because you still need to select the correct place of service.  The place of service code for a home visit is 12. The place of service for assisted living is 13.  Both are considered non-facility settings and Medicare pays claims in both settings at the non-facility rate.

Place of service codes

12        Home 13        Assisted living facility 14        Group home 16        Temporary lodging 33        Custodial care facility 55        Residential substance abuse treatment facility

Additional Resources

• Webinar – March 2024 – Home and Nursing Facility Category of Code Rules

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Last revised July 16, 2024 - Betsy Nicoletti Tags: office and other E/M

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At [Your Company Name], we believe in providing healthcare professionals with the knowledge and resources they need to excel in their field. Today, we will be exploring the essentials of the 99204 CPT code, a vital component of medical billing for level 4 new patient office visits. It is crucial for healthcare providers to have a comprehensive understanding of this code to ensure accurate reimbursement for their services.

Created by the American Medical Association (AMA), CPT codes are standardized codes used to streamline medical billing procedures. The 99204 CPT code specifically represents an office or other outpatient visit for the evaluation and management of a new patient. It requires a medically appropriate history and/or examination and a moderate level of medical decision-making. Understanding the documentation requirements and billing guidelines associated with this code is essential for proper reimbursement.

Key Takeaways:

The 99204 CPT code is used for level 4 new patient office visits.

• CPT codes are standardized coding systems developed by the American Medical Association (AMA).
• The 99204 code requires a comprehensive history, examination, and a moderate level of medical decision-making.
• Proper documentation is crucial to ensure accurate billing for CPT code 99204.
• Using CPT code 99204 can lead to higher reimbursement for healthcare providers.

The Importance of CPT Codes

CPT codes, including the 99204 code, are a standardized coding system developed by the American Medical Association (AMA) to streamline and organize medical billing procedures. CPT codes provide a way for healthcare professionals to bill for the medical services and procedures they provide. The use of CPT codes ensures clear communication between healthcare providers and insurance companies, facilitating accurate reimbursement for services rendered. The CPT code set is regularly updated to reflect advances in medical knowledge and technology.

Having a standardized coding system like CPT codes is crucial in the healthcare industry. It allows for consistency and efficiency in medical billing procedures, ensuring that healthcare providers are properly compensated for the services they deliver. Without CPT codes, the billing process would be more complex and prone to errors, leading to delays in reimbursement and potential financial challenges for healthcare providers.

By using CPT codes, healthcare professionals can accurately translate the services they provide into a language that insurance companies understand. This clear communication minimizes confusion and reduces the chances of billing inaccuracies or claim denials. It ultimately helps healthcare providers receive the appropriate reimbursement for their services, which is essential for maintaining the financial viability of their practices.

The regular updates to the CPT code set reflect the dynamic nature of the healthcare industry. As medical knowledge and technology advance, new procedures and services are introduced, and existing ones may undergo revisions. The updates ensure that the codes accurately reflect the current clinical practices, allowing healthcare providers to bill for the latest procedures and services. Staying up-to-date with the most recent CPT code set is crucial for accurate billing and proper reimbursement.

Understanding CPT Code 99204

CPT code 99204 represents an office or other outpatient visit for the evaluation and management of a new patient. This level 4 code requires a medically appropriate history and/or examination and a moderate level of medical decision-making. It is important to note that CPT code 99204 is only applicable to new patients who have not received medical services from the physician or the physician’s group within the past three years.

Key Components of CPT Code 99204:

• Medically appropriate history and/or examination
• Moderate level of medical decision-making

When selecting CPT code 99204 based on time, the total time spent on the date of the encounter should be between 45-59 minutes. This includes the time spent by the physician face-to-face with the patient and any additional necessary documentation or coordination of care.

By accurately understanding and utilizing CPT code 99204, healthcare providers can ensure appropriate reimbursement for level 4 new patient visits, while adhering to the documentation guidelines and requirements.

Documentation Requirements for CPT Code 99204

Accurate documentation is essential when billing for CPT code 99204. To ensure proper reimbursement and compliance with coding guidelines, healthcare providers must meet the documentation requirements outlined for this level 4 new patient office visit.

When documenting a visit with CPT code 99204, healthcare providers should include:

• A comprehensive history: This should include a review of systems, documenting the patient’s present illness, past medical history, family history, and social history.
• A detailed physical examination: Healthcare providers should perform a thorough examination, paying attention to multiple organ systems or a single complex system, and document their findings.
• Medical decision-making: The documentation must demonstrate the thought process behind the medical decision-making, including the data reviewed, risk assessment, and management options considered.

By meeting these documentation requirements, healthcare providers can support the level 4 visit associated with CPT code 99204 and ensure accurate billing for their services.

Benefits of Using CPT Code 99204

Using CPT code 99204 offers several benefits for healthcare providers. It provides greater flexibility for the time spent with patients, allowing for more comprehensive care. Additionally, billing for CPT code 99204 may result in higher reimbursement due to the higher level of service provided. By accurately documenting and billing for CPT code 99204, healthcare providers can ensure appropriate reimbursement for their services.

When healthcare providers utilize CPT code 99204, they are able to allocate adequate time to thoroughly assess and address their patients’ medical concerns. This extended time allows for a comprehensive evaluation and management, ensuring that all aspects of the patient’s health are properly analyzed and addressed.

Accurate reimbursement is another key advantage of using CPT code 99204. Due to the coding’s alignment with a higher level of service, healthcare providers are more likely to receive appropriate reimbursement for the care they provide. This reimbursement reflects the comprehensive nature of the assessment and the level of expertise required for the evaluation and management of new patients.

Benefits of Using CPT Code 99204:

• Greater flexibility in patient care
• Opportunity for a more comprehensive evaluation
• Potential for higher reimbursement

Incorporating CPT code 99204 into medical billing practices enables healthcare providers to prioritize quality patient care while ensuring fair compensation for their services.

Common Mistakes to Avoid with CPT Code 99204

When billing for the 99204 cpt code, healthcare providers need to ensure they avoid common mistakes that can lead to billing inaccuracies. By understanding and adhering to the 99204 billing guidelines, providers can ensure accurate reimbursement for their services. Here are some common mistakes to avoid:

• Failing to document all three critical components: For a level 4 visit, proper documentation of the patient’s history, physical examination, and medical decision-making is essential. Failing to document any of these components may result in downcoding or inaccurate billing.
• Downcoding when documentation does not support it: Downcoding is the process of assigning a lower level of care than actually provided. It is crucial to code accurately based on the documentation and not downcode to a lower level of care if the documentation does not support it.
• Billing for an established patient visit instead of a new patient visit: The 99204 cpt code specifically applies to new patient office visits. It is important not to mistakenly bill for an established patient visit when the patient is new to the physician or the physician’s group within the past three years.

To ensure accurate billing for the 99204 cpt code, healthcare providers should stay up-to-date with coding guidelines and avoid these common mistakes. By maintaining proper documentation and adhering to the billing guidelines, providers can minimize errors and ensure accurate reimbursement for their services.

Tips for Proper Coding with CPT Code 99204

Proper coding with the 99204 CPT code is essential for accurate medical billing and reimbursement. To ensure coding accuracy, healthcare providers should follow these tips:

• Familiarize yourself with the coding system and guidelines: Thoroughly review the documentation requirements and guidelines for CPT code 99204. Understand the specific elements that must be documented to support billing for a level 4 new patient office visit.
• Invest in a coding manual or software: Utilizing a reliable coding manual or software can help streamline the coding process and ensure adherence to coding guidelines. These resources provide valuable references for accurate code selection and documentation requirements.
• Review documentation thoroughly: Carefully review the patient’s medical record and documentation to ensure all necessary elements are documented. This includes a comprehensive history, detailed physical examination, and proper medical decision-making. A thorough review helps ensure accurate code selection.
• Double-check your work: After coding, take the time to double-check your work for any potential errors or discrepancies. Review the documentation against the selected code and ensure consistency and accuracy throughout.
• Cross-check coding with other resources: Cross-checking the selected code with other reliable coding resources can further validate the accuracy of your coding. This step helps catch any potential errors or inconsistencies and ensures proper coding compliance.

By following these coding tips, healthcare providers can improve coding accuracy and ensure appropriate reimbursement for their services.

The Role of CPT Codes in Medical Billing

CPT codes play a crucial role in medical billing by providing a standardized way to record and bill for medical services. These codes serve as a common language between healthcare providers and insurance companies, ensuring clarity and accuracy in the billing process. When it comes to the 99204 CPT code, accurate coding is essential for healthcare providers to receive appropriate reimbursement from insurance companies and other third-party payers.

Medical billing services, such as those provided by Medical Bill Gurus, can be a valuable resource for healthcare providers navigating the complexities of medical billing. These services have in-depth knowledge of the coding guidelines and requirements, and can help ensure proper coding and reimbursement for services rendered. By partnering with a reliable medical billing service, healthcare providers can focus on delivering quality care to their patients while leaving the intricate details of billing to the experts.

Benefits of Using Medical Billing Services

• Expertise in medical coding and billing
• Access to up-to-date knowledge of coding guidelines and requirements
• Streamlined billing processes for increased efficiency
• Reduced billing errors and denials
• Maximized reimbursement through accurate coding and documentation
• Time and cost savings for healthcare providers

By leveraging the expertise of medical billing services, healthcare providers can ensure compliance with coding regulations, minimize billing errors, and optimize reimbursement for their services. With the ever-changing landscape of medical billing, it is crucial for healthcare providers to stay updated on the latest coding guidelines and requirements. Medical billing services can provide the necessary support and guidance to navigate these complexities, ultimately allowing healthcare providers to focus on what they do best – delivering excellent patient care.

Using CPT Code 99204 for Healthcare Reimbursement

Accurate usage of CPT code 99204 is essential for healthcare reimbursement. By meeting the documentation requirements and accurately coding for level 4 new patient office visits, healthcare providers can ensure appropriate reimbursement for their services. It is important to follow billing guidelines and ensure all necessary documentation is completed to support the use of CPT code 99204 for reimbursement purposes.

When billing for level 4 new patient office visits with CPT code 99204, healthcare providers must adhere to specific billing guidelines to ensure accurate reimbursement. These guidelines involve proper documentation and coding to reflect the level of service provided. Let’s take a closer look at the billing guidelines for CPT code 99204:

• Document a comprehensive patient history: It is important to record a detailed history of the patient’s medical condition, including past diagnoses, treatments, and any relevant family or social history.
• Perform a thorough physical examination: Conduct a comprehensive physical examination and document findings accurately. This examination should cover multiple organ systems or a single complex system.
• Evaluate the medical decision-making process: Document the thought process involved in diagnosing and treating the patient. This includes reviewing data, assessing risks, and considering management options.

By carefully following these billing guidelines and ensuring proper documentation, healthcare providers can support the use of CPT code 99204 for reimbursement purposes. This code allows for accurate representation of the level of service provided during a level 4 new patient office visit.

Here is a table summarizing the reimbursement rates for CPT code 99204 in different regions:

As seen in the table above, the reimbursement rates for CPT code 99204 can vary depending on the region. It is essential for healthcare providers to be aware of the reimbursement rates in their specific area to ensure accurate financial compensation for their services.

By carefully adhering to the billing guidelines and accurately coding for level 4 new patient office visits with CPT code 99204, healthcare providers can confidently submit reimbursement claims and ensure fair compensation for the services they provide.

The Role of CPT Code 99204 in Patient Care

CPT code 99204 plays a significant role in patient care by providing a level 4 new patient office visit. This ensures that patients receive a comprehensive evaluation and management of their healthcare needs. With the use of CPT code 99204, healthcare providers can:

• Provide appropriate care
• Order necessary diagnostic tests
• Make referrals to other specialists as needed

The thoroughness of a level 4 visit allows for proper assessment and treatment planning, leading to better patient outcomes.

Relevance of CPT Codes in Healthcare Billing

CPT codes, including CPT code 99204, play a crucial role in healthcare billing. These codes provide a common language between healthcare providers and payers, ensuring clear communication of the services rendered. Accurate coding with CPT codes is essential for proper reimbursement, allowing healthcare providers to receive fair compensation for their services. The CPT code set is regularly updated to keep pace with contemporary medical science and technology, ensuring its relevance in the ever-evolving healthcare landscape.

Benefits of using CPT codes in healthcare billing

Using CPT codes offers several benefits for healthcare billing:

• Standardization: CPT codes provide a standardized way to categorize and report medical services, streamlining the billing process.
• Clear communication: By using CPT codes, healthcare providers can effectively communicate the services rendered to insurance companies and other payers, reducing the chances of misinterpretation.
• Accurate reimbursement: Accurate coding with CPT codes ensures that healthcare providers receive proper reimbursement for the services they provide, avoiding underpayment or claim denials.
• Documentation support: CPT codes help healthcare providers document and track the services they deliver, facilitating accurate medical record-keeping and compliance with billing regulations.

By utilizing CPT codes, healthcare providers can enhance the efficiency and accuracy of their billing processes, leading to improved financial outcomes and streamlined administrative operations.

The evolving nature of the CPT code set

The CPT code set is continuously updated to reflect advancements in medical science and technology. The American Medical Association (AMA) and the CPT Editorial Panel regularly review and update the codes to ensure they remain relevant and comprehensive. These updates enable healthcare providers to accurately represent the services they offer in a changing healthcare landscape. Staying informed about these updates and incorporating them into billing practices is essential for healthcare providers to remain in compliance and maximize reimbursement.

Additional Resources for CPT Code 99204

For further research and information on CPT code 99204, healthcare providers can refer to additional resources. The American Medical Association (AMA) provides valuable resources, including the Current Procedural Terminology (CPT) manual and other coding authority. These resources offer guidance on coding guidelines, documentation requirements, and other relevant information related to CPT codes. Consulting these additional resources can enhance understanding and ensure accurate usage of CPT code 99204.

Using CPT Code 99204 for New Patient Office Visits

CPT code 99204 is specifically designed for new patient office visits that require a comprehensive evaluation and management. This level 4 code is used when the patient has a progressing illness or acute injury that requires medical management or potential surgical treatment.

When utilizing CPT code 99204, healthcare providers must meet the documentation requirements outlined for this code. Proper documentation is crucial to accurately bill for level 4 new patient office visits and ensure appropriate reimbursement.

To ensure compliance with the documentation requirements, healthcare providers should:

• Thoroughly document the patient’s medical history and current condition
• Perform a comprehensive physical examination that includes the evaluation of multiple organ systems or a single complex system
• Document the medical decision-making process, including the data reviewed, risk assessment, and management options considered

By meeting these documentation requirements, healthcare providers can accurately bill for level 4 new patient office visits using CPT code 99204. This ensures that both the healthcare provider and the patient receive the appropriate reimbursement and necessary care.

The Future of CPT Codes

As medical knowledge and technology continue to advance, the CPT code set must adapt to the changing landscape of healthcare. The CPT Editorial Panel, in collaboration with practicing physicians, ensures that the code set evolves to reflect the coding demands of a modern healthcare system. The continued relevance and accuracy of CPT codes are vital in maintaining effective communication between healthcare providers and payers.

Evolution of CPT Codes

The evolution of the CPT code set ensures that it remains aligned with the language of medicine and captures the intricacies of medical procedures and services. By staying up-to-date with the latest code set updates, healthcare providers can accurately document and communicate the care they provide, enabling effective reimbursement processes.

The 99204 CPT code is a crucial element in healthcare reimbursement and proper medical billing. Understanding the essentials of this code is essential for healthcare providers to ensure accurate reimbursement for the services they provide. By partnering with reputable medical billing services, such as Medical Bill Gurus, healthcare providers can streamline their billing process and navigate the complexities of medical coding and billing more effectively.

Accurate coding and documentation are key to delivering quality care to patients while ensuring appropriate reimbursement. By adhering to the guidelines and requirements of the 99204 CPT code, healthcare providers can effectively communicate the services they have provided and ensure accurate payment from insurance companies and other third-party payers.

At Medical Bill Gurus, we understand the importance of accurate medical billing and reimbursement. Our team of experts can provide the necessary support and guidance to help healthcare providers maximize their reimbursement while maintaining compliance with coding standards. With our services, healthcare providers can focus on delivering quality care to their patients, knowing that their billing needs are in capable hands.

What is the 99204 CPT code?

Why are cpt codes important.

CPT codes provide a standardized way to bill for medical services, ensuring clear communication between healthcare providers and insurance companies for accurate reimbursement.

What does CPT code 99204 represent?

CPT code 99204 represents an office or other outpatient visit for the evaluation and management of a new patient, requiring a comprehensive history, physical examination, and moderate medical decision-making.

What are the documentation requirements for CPT code 99204?

Proper documentation should include a comprehensive patient history, a detailed physical examination, and a well-documented medical decision-making process.

What are the benefits of using CPT code 99204?

Using CPT code 99204 allows for more comprehensive care, flexibility in time spent with patients, and the potential for higher reimbursement due to the level of service provided.

What are common mistakes to avoid with CPT code 99204?

Common mistakes include failing to document all three critical components required for a level 4 visit, downcoding without proper documentation, and billing for an established patient visit instead of a new patient visit.

What tips can help with proper coding using CPT code 99204?

Healthcare providers should thoroughly review documentation, invest in coding resources, double-check work, and cross-check coding to ensure accuracy.

What is the role of CPT codes in medical billing?

CPT codes facilitate accurate reimbursement for healthcare providers by providing a standardized language for recording and billing medical services.

How does using CPT code 99204 impact healthcare reimbursement?

Accurately using CPT code 99204 ensures appropriate reimbursement for level 4 new patient office visits by following billing guidelines and meeting documentation requirements.

What is the role of CPT code 99204 in patient care?

CPT code 99204 allows for a comprehensive evaluation and management of new patients, leading to better patient outcomes and treatment planning.

Why are CPT codes relevant in healthcare billing?

CPT codes provide a standardized coding system that reflects current medical practice, ensuring effective communication between healthcare providers and payers.

Are there additional resources available for CPT code 99204?

Healthcare providers can consult resources provided by the American Medical Association (AMA) for guidance on coding guidelines, documentation requirements, and other relevant information.

How is CPT code 99204 used for new patient office visits?

CPT code 99204 is used when providing a level 4 new patient office visit, requiring a comprehensive evaluation and management of the patient’s healthcare needs.

What is the future of CPT codes?

CPT codes continue to evolve to reflect advances in medical knowledge and technology, ensuring their relevance and accuracy in the ever-changing healthcare landscape.

What is the significance of healthcare reimbursement using CPT code 99204?

Accurate coding and documentation using CPT code 99204 ensure appropriate reimbursement for healthcare providers, allowing them to receive fair compensation for their services.

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How to bill for a house call visit

More physicians are seeing the benefits of house calls , but at-home visits come with specific reimbursement and practical considerations. Here’s a quick overview of tips and CPT codes for the next time you bill for a house call visit.

Consider this when you bill for a house call

Medicare reimburses providers for home visits only if they are medically necessary. Healthcare.gov defines medically necessary services as “services or supplies that are needed to diagnose or treat a medical condition and that meet accepted standards of medical practice.”

In the case of house calls , physicians need to document that the home visit was medically necessary. In other words, you must present a medical rather than practical reason for visiting a patient outside the office. 

Here are a few reminders to consider before you bill for a house call:

• Providers need to document if the home visit is based upon a one-time, ongoing, or permanent need.
• Your documentation should prove that the patient is not physically capable of traveling to the office. You may base this assessment on physical or mental issues, not financial or personal matters.
• You can’t provide home services for your convenience as the physician.
• Patients receiving care under Medicare’s home health benefit must be confined to the home. However, patients don’t need to be home-bound for physicians to provide services billed under CPT codes 99341 through 99350.

The Office of Inspector General (OIG) and many CMS contractors regularly audit home services billed to Medicare. Always provide appropriate documentation showing that the house call was medically necessary.

“In other words, you must present a medical rather than practical reason for visiting a patient outside the office.” 

CPT Home Services Codes

Physicians use a limited set of CPT codes to bill for house calls. These codes apply to evaluation and management (E/M) services provided in a patient’s home. “Home” can include a private residence, temporary lodging, or short-term accommodation. 

As of January 2023, providers should also use these codes to bill for medical services delivered in assisted living facilities and other places where only minimal health care is provided. 

New patient CPT codes

99341 – Home visit for the evaluation and management of a new patient. This visit requires the following three components:

• A problem-focused history
• A problem-focused exam
• Straightforward medical decision making

Here’s a typical description for this code:

Counseling and/or coordination of care with other physicians, other qualified health care professionals, or other agencies are provided consistent with the nature of the problem(s) and the patients’ and/or family’s needs.

Usually, the presenting problem(s) are of low severity. Typically, the physician spends 20 minutes face-to-face with the patient and/or family.

99342 – Same as above, but this is a moderate severity problem requiring 30 minutes.

(CPT deleted code 99343 as of January 2023.)

99344 – Moderate to high severity problem, or at least 60 minutes total time.

99345 – Patient unstable or has a significant new problem requiring immediate attention (75 minutes).

Established patient CPT codes

99347 – Home visit for evaluating and managing an established patient. The visit requires at least two of these three key components.

• A problem-focused interval history
• A problem-focused examination

Here’s the typical description for this code:

Usually, the presenting problem(s) are self-limited or minor. Typically, you spend 15 minutes face-to-face with the patient and/or family.

99348 – Same as above, but this problem is low to moderate severity, requiring at least 30 minutes face-to-face.

99349 – Moderate to high problem requiring 40 minutes.

99350 – Patient unstable or has a significant new problem requiring immediate physician attention (60 minutes).

When making a house call, you may offer additional services such as advanced care planning, diagnosis services, or other minor procedures. These can be documented and billed in addition to the visit code.

How to select house call CPT codes

These tips from the AAFP will help you choose the correct codes:

• Select codes based on either your level of medical decision making (straightforward to complex) or the total time of the encounter. This is similar to selecting codes for office visits.
• When the total encounter time exceeds the threshold for code 99345 or 99350 by at least 15 minutes, you can add code 99417 to report prolonged services. However, if you saw a Medicare patient, report prolonged services with code G0318 in addition to 99345 (more details here ). 
• CPT deleted E/M codes specific to domiciliary, rest home, or custodial care (99324-99238, 99334-99337, 99339, and 99340). For those types of visits, use the codes above instead. 
• For services in facilities where significant medical or psychiatric care is available, use codes 99304-99310 .

2023 Updates to CPT Codes for House Call Visits

The CPT codes above reflect 2023 updates that combined two previously distinct E/M visit families: “Domiciliary, Rest Home (Boarding Home), or Custodial Care services” and “Home services.” These visit types are now collectively called “Home or Residence services” and are used to report E/M services provided to patients in their home/residence, assisted living facilities, group homes, custodial care facilities, and residential substance abuse treatment facilities. 

There are no changes to the care settings for the current code families. You can learn more about the recent updates in CMS’ Evaluation and Management Services Guide .

House calls: further reading

Here are some recommended articles for those interested in learning more about house calls:

• House calls are making a comeback
• The benefits of house calls for patients and providers
• 7 ways to easily document house calls on the go
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Related Blog: Guest Post: Providing House Calls During the COVID-19 Pandemic

The demand for house calls is increasing because of the aging U.S. population, an increase in patients who are homebound, and the acknowledgment of the value of house calls by the public and health care industry. Literature from current U.S. home-based primary care programs describes health care cost savings and improved patient outcomes for older adults and other vulnerable populations. Common indications for house calls are management of acute or chronic illnesses, coordination of a post-hospitalization transition of care, health assessments, and end-of-life care. House calls may also include observation of activities of daily living, medication reconciliation, nutrition assessment, evaluation of primary caregiver stress, and the evaluation of patient safety in the home. Physicians can use the INHOMESSS mnemonic (impairments/immobility, nutrition, home environment, other people, medications, examination, safety, spiritual health, services) as a checklist for providing a comprehensive health assessment. This article reviews key considerations for family physicians when preparing for and conducting house calls or leading teams that provide home-based primary care services. House calls, with careful planning and scheduling, can be successfully and efficiently integrated into family medicine practices, including residency programs, direct primary care practices, and concierge medicine.

House calls, also referred to as home visits, are increasing in the United States. 1 Approximately 40% of patient visits in the 1930s were house calls. 1 , 2 By 1996, this decreased to 0.5% because insurance reimbursements for house calls decreased. 1 , 2 The pendulum in the United States is swinging again to house calls because of the need to develop care models for the growing aging population. 1 , 3 , 4 The proportion of house calls to outpatient clinic visits conducted by family physicians in the United States is unlikely to reach the 1930s levels; however, the number of house calls conducted from 1996 to 2016 doubled. 3 Medicare Part B billing and reimbursement for house calls are also increasing, with nearly 2.6 million house calls paid in 2015. 5

WHAT'S NEW ON THIS TOPIC

House Calls

There were more than 1,100 direct primary care practices in the United States in 2019, and 68% of these practices offered house calls, including eight practices that were completely mobile (i.e., had no actual office).

A systematic review of nine studies (N = 46,156) evaluating home-based primary care outcomes for homebound older adults reported fewer hospitalizations, hospital bed days of care, emergency department visits, long-term care admissions, and long-term bed days.

The increasing popularity of and call for home-based care have led to an increased need to study the outcomes and design of home-based primary care models in the United States. The two largest home-based primary care studies are the Centers for Medicare and Medicaid Services Independence at Home Demonstration and the U.S. Department of Veterans Affairs home-based primary care program. 6 , 7 The Independence at Home program demonstrated a 23% reduction in hospitalizations, a 27% decrease in 30-day readmissions, and a cost savings of $111 per beneficiary per month, which is a $70 million savings over three years. 7 – 10 Similarly, a large systematic review (N = 46,154; nine studies) evaluating home-based primary care outcomes for homebound older adults reported fewer hospitalizations, hospital bed days of care, emergency department visits, long-term care admissions, and long-term bed days of care. 11 The U.S. Department of Veterans Affairs home-based primary care study of chronically ill, frail adults (N = 179) in urban populations also found fewer hospital admissions and bed days of care, but no change in emergency department use. 12

House calls benefit patients post-hospitalization by reducing readmission rates, associated health care costs, and errors related to transitions of care. 13 , 14 There is an increased need for home-based care for the most vulnerable populations because of the recent shift in the United States toward value-based health care. 1 , 3 In 2011, there were 2 million homebound people in the United States, of which only 12% reported receiving home-based primary care. 15 This number is expected to increase to 4 million by 2030. 1

House calls also benefit patients with socioeconomic barriers to care, including pregnant patients and children who are at high risk of abuse. 16 Nurse- or social worker–led home visiting programs have reduced child maltreatment, decreased child health care overutilization, and improved cognitive skills of children born to a low income household with limited psychological resources. 16 – 18 Outcome data for physician-led house calls are limited for younger populations because most data are from studies on older adults. A meta-analysis of 51 studies of home-based family care reported small, statistically significant improvements in child cognitive outcomes, maternal life outcomes, and parental behaviors and skills. 19 Additionally, a Cochrane review of 11,000 newly postpartum patients receiving frequent in-home visits from interdisciplinary teams showed a decrease in infant health service utilization and an increase in maternal interest in exclusive breastfeeding. 20

Historically, family physicians have been the workforce that meets the critical needs of the United States' most vulnerable populations. Family physicians need to learn how to incorporate house calls into their practices. The Accreditation Council for Graduate Medical Education requires family medicine residents to conduct house calls. 21 Varying the type of calls and including patients with complex needs of all ages add training value that is consistent with the American Academy of Home Care Medicine clinical competencies. 22 House calls, with careful planning and scheduling, can be successfully integrated into a busy office-based practice or residency program. Portable technologies, including electronic health records, battery-powered examination equipment, and point-of-care diagnostic testing, enable health care teams to bring office capabilities to patients' homes. 1 This article provides tools for conducting house calls and reviews strategies for implementing house calls into a variety of outpatient practices, including residency programs, direct primary care (DPC), and concierge medicine models.

Conditions for the Initiation of House Calls

House calls may be needed for acute reasons because of a change in health status, serial visits for chronic conditions, or a one-time visit requested by caregivers or the physician to evaluate for a specific concern. The type of house call guides the goals and objectives for each patient encounter 18 ( Table 1 18 , 21 , 23 , 24 ) . For older adults, consider assessing for geriatric syndromes (e.g., recurrent falls, polypharmacy, frailty, memory loss). Evaluation for suspected elder abuse, neglect, or self-neglect may provide valuable information. Illness or injury prevention house calls for frail, older, homebound adults should focus on preventing functional loss and avoiding hospitalization. 18

A patient who is enrolled in Medicare must meet two criteria to be considered homebound ( Table 2 ) . 25 Most patients who are homebound have chronic medical conditions including heart failure, chronic obstructive pulmonary disease, renal failure, or advanced dementia. The goal of the house call for patients who have a chronic illness is to ensure safety at home, prevent exacerbation of symptoms, and evaluate caregiver burden and ability to care for the patient. 18 Patients enrolled in Medicare who do not meet homebound criteria for home health care may be eligible for home-based primary care services. These services include hospital-based, veterans affairs–based, or freestanding home-based primary care that provides acute and chronic management of medical conditions, polypharmacy management, improved access to durable medical equipment, community resources for the patient and caregivers, and symptom management in end-of-life care. 3 Medical necessity should be documented (i.e., frequently missed appointments, poor medication adherence, high use of emergency department services, or a need to assess function in the home environment). 3

For patients reaching the end of life, care focusing on comfort (rather than function or longevity) is a common reason for house calls. Most patients with terminal cancer want to die at home; therefore, home care is a valuable service that helps reduce the likelihood of death in the hospital. 18 , 26 – 28 House calls made by family physicians for patients who are dying are primarily to provide symptom management such as pain relief for patients not using hospice services, and to provide psychosocial support to the patient and caregivers before death, and to family members and caregivers after the patient's death. 29

Preparing for and Conducting House Calls

Previsit planning is essential to ensure the patient's maximum benefit from a house call. A member of the care team should call the patient in advance of arrival to verify the patient's availability and home address. Physicians should review the patient's medical record and medication list in advance, and bring a copy of the most recent information to the house for reconciliation during the visit. Once the physician is at the home, it is important to follow safety precautions ( Table 3 30 ) to prevent personal injury or infection. 18 , 30 Table 4 18 , 31 and Table 5 18 , 29 , 32 list recommended supplies for house calls.

If needed, a house call checklist, such as the INHOMESSS mnemonic (impairments/immobility, nutrition, home environment, other people, medications, examination, safety, spiritual health, services; Figure 1 ), can be used as a guide for performing a complete geriatric assessment. 18 A typical approach begins with observing how the patient enters their home and evaluating for transitions of flooring in entryways and the need for extra grab handles, ramps, or rails. Once inside the home, begin by addressing any urgent patient concerns, then shift the conversation to focus on the items found on the checklist if time permits. This process typically takes 45 to 90 minutes, and frequent breaks are common.

Allocate time to review the patient's prescribed medications, herbs or supplements, and over-the-counter medications. The patient or caregiver should show the physician where these medications are kept and organized to provide further insight into medications that may not have been mentioned, issues with compliance, and identification of stockpiles of old or expired medications. Laying out the medications is recommended to perform true medication reconciliation, in addition to checking for drug-drug interactions.

While the patient is still seated, check vital signs, and perform a focused examination. Once that is completed, the physician should observe the patient as they stand and note if they have difficulty changing positions, need an assistive device to stand (e.g., chair with arms, cane), and how they move around the house (e.g., with a walker, cane, grasping onto furniture). Ask permission to follow the patient through the most frequented areas of the house while observing the patient's gait and noting any balance issues. Looking for transitions in flooring; stairwells; rug placement; pathway obstructions; height of chairs, bed, and toilet; type of showers (walk-in vs. tub); and location of smoke detectors, fire extinguishers, and firearms helps provide an understanding of the patient's functional status and identify potential patient safety and fall hazards ( Table 6 ) . 18

Provide written safety recommendations to the patient and caregiver addressing all urgent concerns and provide additional comments based on findings from the completed checklist. Some durable medical equipment recommendations, such as hospital beds, may be covered by insurance, including Medicare Part B; however, other equipment, such as grab bars or shower chairs, is not typically covered by insurance. The use of assessment tools ( Figure 1 18 ) can be incorporated into the house call based on the complexity of the patient's condition, the time allowed, and the purpose of the visit. Having an in-depth discussion of end-of-life care choices, guided by the patient's goals, may be appropriate, even if they have already been addressed in a clinic or hospital setting. End-of-life care choices should be confirmed or readdressed as the patient's health care situation changes. Providing prescriptions, supplies, handouts with helpful websites, or local resources communicates further support to the patient and caregivers.

Incorporating House Calls into Office-Based Practice

The benefits of house calls are substantial for physicians and their patients. Physicians experience a change of pace from typical clinic appointments, and house calls can provide additional important information about the patient, including insight into a patient's actual home situation, medication management, diet, and overall lifestyle. Patients report experiencing peace of mind, increased respect and trust in their physicians, and better access to care after a house call. 2 , 4 , 33

However, integrating house calls into office-based practice is challenging. Barriers include geography, travel time, and perceived loss of revenue. 18 Grouping house calls together within a half-day, grouping locations, and conducting the visits after the conclusion of a clinic day may minimize this barrier. A multidisciplinary strategy for house calls can help decrease physician burden and improve care. The care team commonly includes a customized combination of a physical therapist, occupational therapist, speech therapist, dietician, licensed social worker, clinical pharmacist, licensed practice/vocational nurse, registered nurse, psychiatric nurse, wound care nurse, and nurse practitioners or physician assistants. With a multidisciplinary team, improved tracking and scheduling of patients can optimize time management, allowing for greater spacing and efficiency of physician visits, and can decrease loss to follow-up.

A travel bag, dedicated house call vehicle, and a mobile office are tools that help keep house calls organized. Besides regular office equipment needed for a focused examination and gathering vitals, an emergency supply kit ( Table 5 18 , 29 , 32 ) may be useful. House calls for dying patients are unique because of the symptoms and treatment needs specific to that population. American Family Physician has previously published an article on managing common symptoms in end-of-life care. 29 Additional specialized equipment may be necessary based on the patient's needs ( Table 4 18 , 31 ) . It is important to have a good understanding of patients' individualized needs and commit to goals for the visit in advance. When applicable, physicians should provide educational materials, medication reconciliation forms, do-not-resuscitate and do-not-intubate forms, out-of-hospital resuscitation forms, home health forms, and hospice-required documents. 18

Documentation for a house call is similar to that for an office visit. A note template can help with consistent documentation and serve as a checklist ( eFigure A ) . Recommendations for continued care and changes to the care plan should be included in the documentation with proper coding and billing information ( eTable A ) .

Direct Primary Care and Concierge Medicine House Calls

DPC is an innovative practice model that offers patients a variety of primary care services for a low, periodic membership fee. 34 , 35 Integrating house calls into this type of practice may be easier because the DPC model enables physicians to spend more time with patients, and DPC physicians typically have smaller panel sizes. According to Phil Eskew, DO, founder of DPC Frontier, there were more than 1,100 DPC practices in the United States in 2019, and 68% of these practices offered house calls, including eight practices that were completely mobile (i.e., had no actual office). House calls may be included as part of the membership, or DPC physicians may charge a flat rate or a variable amount based on travel time or mileage. 36

Although DPC physicians often provide house calls to older adults and to patients who are disabled, terminally ill, and to patients who are homebound, some physicians may also offer newborn visits and well-child examinations. Additionally, house calls are commonly made for sick visits and postoperative care. Large families or families with young children may benefit from house calls because of the convenience and comfort of seeing multiple members at once in a familiar and safe environment. DPC physicians report that offering house calls is useful for recruiting new patients, and families appreciate the home-based service.

Concierge practices also routinely offer house calls but charge higher membership fees and may continue to bill insurance for covered services. 37 Concierge practices may also provide hotel calls for travelers seeking more personal, convenient care.

This article updates a previous article on this topic by Unwin and Tatum . 18

Data Sources: A PubMed search was conducted using the key terms home visits, house calls, home-based primary care, post-hospitalization visits, homebound, and direct primary care. The search included systematic and clinical reviews, meta-analyses, reviews of clinical trials and other primary sources, and evidence-based guidelines. Also searched was the Cochrane database. References from these sources were consulted to clarify the statements made in publications. Search dates: April 2019, August 2019, December 2019, and March 2020.

The opinions and assertions contained herein are the private views of the authors and are not to be construed as the official policy or position of the Department of Defense or the U.S. government.

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Kitzman H, Olds DL, Knudtson MD, et al. Prenatal and infancy nurse home visiting and 18-year outcomes of a randomized trial. Pediatrics. 2019;144(6):e20183976.

Easterbrooks MA, Kotake C, Fauth R. Recurrence of maltreatment after newborn home visiting: a randomized controlled trial. Am J Public Health. 2019;109(5):729-735.

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Filene JH, Kaminski JW, Valle LA, et al. Components associated with home visiting program outcomes: a meta-analysis. Pediatrics. 2013;132(suppl 2):S100-S109.

Yonemoto N, Dowswell T, Nagai S, et al. Schedules for home visits in the early postpartum period. Cochrane Database Syst Rev. 2017(8):CD009326.

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American Academy of Home Care Medicine. Clinical competencies. Accessed December 20, 2019. https://cdn.ymaws.com/www.aahcm.org/resource/resmgr/homepage/homecaremedicinecomptencies_.pdf

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Yang M, Thomas J, Zimmer R, et al. Ten things every geriatrician should know about house calls. J Am Geriatr Soc. 2019;67(1):139-144.

Giovino JM. House calls: taking the practice to the patient. Fam Pract Manag. 2000;7(6):49-54.Accessed July 14, 2020. https://www.aafp.org/fpm/2000/0600/p49.html

Hayashi J, Christmas C, Durso SC. Educational outcomes from a novel house call curriculum for internal medicine residents: report of a 3-year experience. J Am Geriatr Soc. 2011;59(7):1340-1349.

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