home visit pos 12

Place of Service 12

Place of Service 12 in Medical Billing:

Place of Service 12 is also called as POS 12 in Medical billing. Place of Service 12 indicated when the patient receives the medical services in patients “Home”.

POS 12 Description:

POS 12 is a place other than a facility or hospital, where the patient receives health care services in a private residence.

Frequently asked questions on place of service 12 :

• When billing for medical services provided at place of service- patient’s home (POS 12), which address we need to report in block# 32? Do you put the patient’s home address or provider’s office address? Or is there a guideline that states that when you bill a service for patient’s home visit, you must have their home Address or patient address on the block# 32 on the claim form?

Answer: When you bill a home visit for a patient, then the claims need to be reported with place of service 12 in the block# 24B and provider’s office (practice) address at the bottom (Block# 32)

2) Patient’s exam for sleep concerns in the wellbeing of their home, which place of service needs to be reported?

Answer: If the Health Sleep Test device is shipped to the patient’s home, the place of service 12 needs to be reported.

3) When billing for Durable Medical Equipment, which place of service to be used?

Answer:  Patients uses the Durable Medical Equipment at home (Either Rental or purchased items), place of service 12 is to be indicated on claim form when billing Durable Medical Equipment codes.

4) When billing the services provided at the patient’s home we use place of service 12. Do we need to use the patient’s home address at the bottom on HCFA Claim form?

Answer: Place of Service 12 indicates the services rendered at patient home. So the practice address to be mentioned at the bottom of HCFA Claim form, because place of service is enough for insurance to direct to the patient’s home address (Which will be on top of the HCFA claim form).

5) Does Insurance pay home visits claims billed with office visit E/M Codes 99201-99215 with place of service 12?

Answer: No.

Insurance will never pay the claim and they will deny the claim when office visit codes (99201-99215) billed with place of service 12.Because the services performed in home, but claim billed with an incorrect E/M office visit codes which is an incorrect.

Some providers even do fraudulent for getting paid, for example:

When insurance company will deny the claim submitted with place of service 12 and E/M office visit codes (99201 through 99215), some providers may even try to bill the home visit claim with place of service 11 for E/M office visit codes (99201-99215) in order to get paid. But this is totally fraudulent, because the services are performed in a home and billing the claim as an office visit is fraud.

According to me home visit E/M code should be billed with either new patient codes (99341-99345) or established codes (99347-99350) along with place of service 12.

• Place of Service 24
• Place of Service 31 and Place of Service 32

Place of Service Codes (CMS1500 box 24b)

List of place of service codes, other special considerations.

05-08 Special Considerations Medicare does not currently use the POS codes designated for these settings. Follow the instructions you have received regarding how to process claims for services rendered in IHS and Tribal 638 settings. If you receive claims with these codes, you must initially accept them in terms of HIPAA compliance. However, follow your "return as unprocessable" procedures after this initial compliance check. Follow your "return as unprocessable" procedures when you receive paper claims with these codes. (Note that while these codes became part of the National POS code set effective January 1, 2003, Medicare contractors received instructions regarding how to process claims with these codes effective October 1, 2003, so that Medicare could be HIPAA compliant by October 16, 2003).

When a physician/practitioner furnishes services to a registered inpatient, payment is made under the PFS at the facility rate. To that end, a physician/practitioner/supplier furnishing services to a patient who is a registered inpatient, shall, at a minimum, report the inpatient hospital POS code 21 irrespective of the setting where the patient actually receives the face-to-face encounter. In other words, reporting the inpatient hospital POS code 21 is a minimum requirement for purposes of triggering the facility payment under the PFS when services are provided to a registered inpatient. If the physician/practitioner is aware of the exact setting the beneficiary is a registered inpatient, the appropriate inpatient POS code may be reported consistent with the code list annotated in this section (instead of POS 21). For example, a physician/practitioner may use POS 31, for a patient in a SNF receiving inpatient skilled nursing care, POS 51, for a patient registered in a Psychiatric Inpatient Facility, and POS 61 for patients registered in a Comprehensive Inpatient Rehabilitation Facility.

When a physician/practitioner furnishes services to an outpatient of a hospital, payment is made under the PFS at the facility rate. Physicians/practitioners who furnish services to a hospital outpatient, including in a hospital outpatient department (including in a provider-based department of that hospital) or under arrangement to a hospital shall, at a minimum, report the outpatient hospital POS code 22 irrespective of the setting where the patient actually receives the face-to-face encounter. In other words, reporting the outpatient hospital POS code 22 is a minimum requirement for purposes of triggering the facility payment amount under the PFS when services are provided to a registered outpatient. If the physician/practitioner is aware of the exact setting the beneficiary is a registered hospital outpatient, the appropriate outpatient facility POS code may be reported consistent with the code list annotated in this section (instead of POS 22). For example, physicians/practitioners may use POS code 23 for services furnished to a patient registered in the emergency room, POS 24 for patients registered in an ambulatory surgical center, and POS 56 for patients registered in a psychiatric residential treatment center.

NOTE: Physicians/practitioners who perform services in a hospital outpatient department shall use, at a minimum, POS code 22 (Outpatient Hospital). Code 22 (or other appropriate outpatient department POS code as described above) shall be used unless the physician maintains separate office space in the hospital or on the hospital campus and that physician office space is not considered a provider-based department of the hospital as defined in 42. C.F.R. 413.65. Physicians shall use POS code 11 (office) when services are performed in a separately maintained physician office space in the hospital or on the hospital campus and that physician office space is not considered a provider-based department of the hospital. Use of POS code 11(office) in the hospital outpatient department or on hospital campus is subject to the physician self-referral provisions set forth in 42 C.F.R 411.353 through 411.357.

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April 25, 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

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Last revised April 8, 2024 - Betsy Nicoletti Tags: office and other E/M

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U.S. Dept. of Health & Human Services

CMS Place of Service Code Set

Guidance for place of service codes and descriptions for professional claims.

Issued by: Centers for Medicare & Medicaid Services (CMS)

Issue Date: February 11, 2020

Place of Service Codes for Professional Claims

Database (updated september 2023).

Listed below are place of service codes and descriptions. These codes should be used on professional claims to specify the entity where service(s) were rendered. Check with individual payers (e.g., Medicare, Medicaid, other private insurance) for reimbursement policies regarding these codes.  

NOTE :  Please direct questions related to billing place of service codes to your Medicare Administrative Contractor (MAC) for assistance.

*      Revised, effective April 1, 2004.

**    Revised, effective October 1, 2005  

HHS is committed to making its websites and documents accessible to the widest possible audience, including individuals with disabilities. We are in the process of retroactively making some documents accessible. If you need assistance accessing an accessible version of this document, please reach out to the [email protected] .

DISCLAIMER: The contents of this database lack the force and effect of law, except as authorized by law (including Medicare Advantage Rate Announcements and Advance Notices) or as specifically incorporated into a contract. The Department may not cite, use, or rely on any guidance that is not posted on the guidance repository, except to establish historical facts.

CAITLYN M. RERUCHA, MD, MSEd, RUBEN SALINAS, JR., MD, JACOB SHOOK, DO, AND MARGUERITE DUANE, MD, MHA

Am Fam Physician. 2020;102(4):211-220

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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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.

American Academy of Family Physicians. Direct primary care. Accessed December 19, 2019. https://www.aafp.org/about/policies/all/direct-primary.html

American Academy of Family Physicians. The direct primary care model: how it works. Accessed December 19, 2019. https://www.aafp.org/practice-management/payment/dpc.html

American Academy of Family Physicians. Direct Primary Care Member Interest Group. Poll of group members. Conducted on August 20, 2018, and June 21, 2019. Accessed July 14, 2020. https://www.aafp.org/membership/involve/mig/dpc.html

American Academy of Family Physicians Insurance Program. Direct primary care vs. concierge medicine: which is right for you? March 21, 2016. Accessed December 19, 2019. https://www.aafpins.com/2016/03/direct-primary-care-vs-concierge-medicine-which-is-right-for-you/

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Evaluation and management (e/m) services - domiciliary or rest home environment, domiciliary, rest home, or custodial care services cpt codes 99324 - 99337.

These codes are also used to report E/M services in an assisted living facility. The facility’s services do not include a medical component.

A home or domiciliary visit includes a patient History, Physical Examination and Medical Decision Making in various levels depending upon a patient’s needs and diagnosis. 

The visits may also be performed as counseling and/or coordination of car, when medically necessary outside the office environment and are an integral part of a continuous of the patient's 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 exacerbation of medical conditions, resulting in less frequent trips to the Hospital or Emergency services.

The home-based health care is rapidly expanding and growth in hospital-based house call programs. 

The Physicians and qualified non-physician practitioners (NPPs) are required to oversee or directly provide progressively more involving a great deal of worldly experience and knowledge of fashion and culture for home visits. 

A Patients must understand the nature of a pre-arranged visit and consent to treatment in the home or domiciliary care facility. There is no requirement that the patient must be homebound. 

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.

If laboratory and diagnostic tests are performed during the course of home or domiciliary care visits, they must be documented in the medically necessary reason.  Medical reasons for repeat testing must be clearly documented.

Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). 

The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.

Many elderly patients have chronic conditions, such as hypertension, diabetes, orthopedic conditions, and abnormalities of the toenails. 

Required Criteria

• A home or domiciliary care visit must meet all of the following criteria.
• Chief complaint or a specific, reasonable, and medical necessity is required for each visit.
• A payable diagnosis alone does not support medical necessity of ANY service.
• Medical necessity must exist for each individual visit.
• Visit will be regarded as a social visit unless medical record clearly documents medical necessity for every visit.
• Service/visit must be medically reasonable and necessary and not for physician or qualified NPP convenience.
• Service must be of equal quality to a similar service provided in an office.
• 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 frequency of visits for any given medical problem addressed in home setting will not exceed that of an office setting, except on rare occasion.
• Training of domiciliary staff is not considered medically necessary.
• 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).

Acceptable Location 

Home based services are provided services which are performed in,.

• Private Residence - Home, apartment, town-home etc.
• Domiciliary Care Facility - A home providing mainly custodial and personal care for persons who do not require medical or nursing supervision, but may require assistance with activities of daily living because of a physical or mental disability. This may also be referred to as a sheltered living environment.
• Rest Home - A place where people live and are cared for when they cannot take care of themselves.
• Custodial Care Services - Custodial care is non-medical assistance, either at home or in a nursing or assisted-living facility with the activities of daily life (such as bathing, eating, dressing, using the toilet) for someone who's unable to fully perform those activities without help.
• Residential Substance Abuse Facility - A facility which provides treatment for substance (alcohol and drug) abuse to live-in residents.

Place of Service (POS) Codes

• 13 - Assisted Living Facility (adult living facility)
• 14 - Group Home
• 33 - Custodial Care Facility
• 55 - Residential Substance Abuse Facility

Domiciliary, Rest Home, or Custodial Care Services Listing -CPT 99324 to 99337

Cpt   code description.

99324 Level 1 new patient domiciliary, rest home, or custodial care visit  

99325 Level 2 new patient domiciliary, rest home, or custodial care visit

99326 Level 3 new patient domiciliary, rest home, or custodial care visit

99327 Level 4 new patient domiciliary, rest home, or custodial care visit

99328 Level 5 new patient domiciliary, rest home, or custodial care visit

99334 Level 1 established patient domiciliary, rest home, or custodial care visit

99335 Level 2 established patient domiciliary, rest home, or custodial care visit

99336 Level 3 established patient domiciliary, rest home, or custodial care visit

99337 Level 4 established patient domiciliary, rest home, or custodial care visit

Home Visits Listing - CPT codes 99341 - 99350

• The Home Services codes, are used to report E/M services furnished to a patient residing in his or her own private residence. 
• The Private residence considered following, Private home, an apartment, or town home.

CPT    Code Description

99341 Level 1 new patient home visit

99342 Level 2 new patient home visit

99343 Level 3 new patient home visit

99344 Level 4 new patient home visit

99345 Level 5 new patient home visit

99347 Level 1 established patient home visit

99348 Level 2 established patient home visit

99349 Level 3 established patient home visit

99350 Level 4 established patient home visit

Refer New Patient vs. Established Guidelines

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Medical Billing Services for Home-Based Patients: POS 12 Explained

• Medical Billling Services

Touseef Riaz

February 6, 2024.

• ucontrolbilling

For healthcare professionals venturing into home-based care, deciphering the complexities of POS 12 medical billing services is paramount. It’s the key to accurate reimbursement, smooth patient care, and navigating the ever-evolving landscape of healthcare regulations. Worry not, fellow medical experts! This comprehensive guide is your ultimate tool to master the intricacies of POS 12 billing with confidence.

What is POS 12?

POS 12 stands for “Home Location,” signifying medical services rendered in a patient’s private residence, not a traditional healthcare facility. This encompasses a diverse spectrum of care, from routine check-ups and medication management to complex wound care and specialized procedures. Mastering POS 12 billing ensures proper claim coding, maximizes reimbursement, and minimizes the dreaded denials that can disrupt provider and patient workflows.

Why Does POS 12 Billing Matter?

Accurate POS 12 billing goes beyond mere paperwork. It’s about ensuring patients receive the vital care they need in the comfort of their own homes while simultaneously guaranteeing appropriate financial recognition for providers. Think of it as the bridge between delivering quality care and sustaining a thriving practice. Incorrect coding can lead to a cascade of issues, including:

• Claim denials: This translates to delayed or no reimbursement, impacting the provider’s financial stability and the patient’s access to crucial care.
• Administrative headaches: Dealing with denials and appeals consumes valuable time and resources that could be better directed towards patient care.
• Compliance concerns: Inaccurate coding can trigger audits and potential penalties, jeopardizing your reputation and practice.

Mastering the Maze: Key Pointers for POS 12 Billing Success

• Documentation is King: Detailed medical records are your shield against denials. Document the medical necessity for home-based care, including visit summaries, progress notes, and justifications for specific procedures.
• Eligibility Verification: Before embarking on any home visit, confirm the patient’s eligibility for home-based services through their insurance plan. This proactive step prevents wasted effort and potential claim denials.
• Modifier Magic: Remember to underestimate the power of modifiers! Utilize appropriate modifiers like “QW” for home visits to accurately portray the service location and ensure proper claim processing.
• Compliance Compass: Stay abreast of payer-specific rules and regulations regarding POS 12 billing. These guidelines evolve frequently, so regular updates are crucial to avoid compliance pitfalls.

Beyond the Basics: Advanced Strategies for POS 12 Billing Mastery

• Embrace Technology : Invest in robust billing software specifically designed to handle the complexities of POS 12 billing. These tools automate tasks, streamline processes, and minimize errors, freeing up your time for what matters most – patient care.
• Seek Expert Guidance: Consider partnering with specialized POS 12 billing services . Their in-depth knowledge and experience can provide comprehensive support, handle the heavy lifting of claim submissions and appeals, and offer invaluable peace of mind.
• Continuous Learning: The healthcare landscape is constantly shifting, and so should your knowledge. Remain informed about evolving regulations, coding updates, and best practices to optimize your POS 12 billing strategies and stay ahead of the curve.
• Stay Informed: Keep abreast of evolving regulations and coding updates to optimize your billing practices.

POS 12 Medical Billing Reimbursement: A SWOT Analysis

POS 12 medical billing reimbursement refers to the financial compensation healthcare providers receive for services rendered in a patient’s home. This encompasses a wide range of care, from routine check-ups to complex procedures, all delivered in the comfort of the patient’s private residence. To navigate this constantly evolving landscape efficiently, healthcare providers must comprehend the strengths, weaknesses, opportunities, and threats associated with POS 12 reimbursement.

• Increased access to care: POS 12 enables care for patients who may have difficulty travelling to traditional healthcare facilities due to mobility limitations, chronic illnesses, or geographical constraints. This expands access to essential medical services and improves patient outcomes.
• Enhanced patient satisfaction: Home-based care offers a personalized and convenient patient experience, leading to higher satisfaction and improved engagement with healthcare providers.
• Potential for higher reimbursement rates: Certain POS 12 services may qualify for higher reimbursement rates than traditional facility-based care, particularly for complex procedures or patients with chronic conditions requiring ongoing care.
• Providers can save money by eliminating physical infrastructure and overhead expenses.

Weaknesses:

• Complex coding and documentation requirements: Accurate POS 12 billing requires meticulous documentation and proper coding to ensure claim approvals and maximize reimbursement. Mastering the nuances of POS 12 coding can be challenging for some providers.
• Increased risk of claim denials: The intricacies of POS 12 billing can lead to a higher risk of claim denials if documentation or coding errors are present. This can result in financial losses and administrative headaches for providers.
• Limited payer coverage: Not all insurance plans offer comprehensive coverage for POS 12 services. Providers must stay updated on specific payer policies and eligibility requirements to avoid patient surprise bills and potential financial disputes.
• Dependence on patient cooperation: Successful POS 12 care hinges on patient cooperation and adherence to treatment plans. This can be more challenging than a controlled facility environment, potentially impacting outcomes and reimbursement if patients need help with medication adherence or appointment scheduling.

Opportunities:

• Technological advancements: Advancements in healthcare technology, such as telehealth and remote monitoring tools, can enhance the efficiency and effectiveness of POS 12 care, potentially expanding service offerings and attracting new patient populations.
• Growing ageing population: With the ageing population increasing globally, the demand for home-based care is expected to rise significantly. Providers who adapt and excel in POS 12 billing can capture this growing market and secure a thriving practice.
• Policy changes and advocacy: Ongoing efforts to advocate for improved POS 12 coverage and streamlined regulations can pave the way for better patient access to home-based care and increased provider financial stability.
• Collaboration and partnerships: Partnering with other healthcare organizations, community agencies, and technology companies can broaden access to POS 12 services, optimize care coordination, and enhance patient outcomes.
• Competitive landscape: The increasing popularity of POS 12 care attracts new providers entering the market, potentially intensifying competition and impacting reimbursement rates.
• Regulatory changes: Evolving regulations and coding requirements can pose challenges for providers needing to adapt their practices continuously. It is critical to comply with updated rules to avoid penalties and financial losses. It is important to remember that not taking necessary actions can adversely affect both individuals and organizations. It is essential to keep pace with the latest regulations and take all the steps required to comply.
• Economic pressures: Economic downturns and changes in reimbursement policies can negatively impact the financial viability of POS 12 services. Providers must be adaptable and explore alternative revenue streams to navigate potential economic challenges.
• Workforce challenges: Recruiting and retaining qualified healthcare professionals trained in POS 12 care can be a challenge, particularly in rural areas or for specialized services.

POS 11 in Medical Billing

In medical billing, POS 11 stands for Office location, which must not be a hospital, SNF, military treatment facility, community health centre, public health clinic, or ICF. It means the service was provided in a physician’s office, not the facilities above.

Here’s why POS 11 is necessary:

• Accurate claim processing: The correct POS code ensures that claims are submitted and processed correctly. This helps to ensure timely reimbursement and potential denial.
• Proper reimbursement rates: Different POS codes may have different reimbursement rates. Using POS 11 ensures the provider receives the correct reimbursement amount for services.
• Hey there! Did you know that healthcare providers must follow federal and state laws? It’s essential to ensure they comply with regulations to provide the best possible care to patients. Using the correct POS code is one way to ensure compliance.
• Data analysis: POS codes are used to track and analyze healthcare data. This data can be used to improve care quality, identify cost savings areas, and develop new healthcare programs.

Here are some additional things to keep in mind about POS 11:

• It is used for services provided in a physician’s office, but it can also be used in other outpatient settings, such as a clinic or laboratory.
• It is essential to document the location of the service in the medical record. This will help to ensure that the correct POS code is used when billing the claim.
• If you need help determining which POS code to use, contact your billing software provider or insurance company for clarification.

POS 22 in Medical Billing

POS 22 stands for “On-Campus Hospital Outpatient.” This means it signifies services provided within a hospital’s dedicated outpatient department on the same campus. Think of it as a separate clinic within the hospital walls, offering specialized care to non-admitted patients.

So, why is POS 22 necessary?

• Accuracy and Clarity: Using the correct code ensures your claims reach the right ears, avoiding confusion and unnecessary delays. By clearly stating “On-Campus Outpatient,” you prevent your services from being mistakenly billed as in-hospital procedures, which attract different reimbursement rates and regulations.
• Fair Reimbursement: Different settings, different notes! POS 22 ensures you receive the correct financial rhythm for your services in a dedicated outpatient department. Forget the hospital code’s lower melody; POS 22 plays the tune that rightly compensates for your expertise in this setting.
• Compliance Harmony: Just like an orchestra adheres to the conductor’s rules, healthcare providers must follow regulations. POS 22 acts as your compliance guide, demonstrating you’re playing by the hospital’s billing rules and reducing the risk of audits and fines.
• Data Symphony: Healthcare, like music, thrives on information. POS 22 joins the data chorus, adding its voice to track trends, understand resource allocation within the hospital, and inform future decisions about outpatient services.

Remember, POS 22 isn’t just a code; it’s a tool for:

• Efficient and accurate billing for your on-campus outpatient services.
• Securing fair reimbursement for your expertise in this specific setting.
• Maintaining compliance with hospital-specific regulations and avoiding administrative headaches.
• Contributing valuable data to the hospital’s overall understanding of resource allocation and service needs.

In medical billing, POS 99 is a catch-all code for “Other Place of Service.” This category encompasses any service location not specified by the other existing POS codes (ranging from 11 to 21 and beyond). It essentially signifies that the service was rendered in a setting that doesn’t have a dedicated code assigned to it.

POS 21 stands for “Inpatient Hospital.” This code indicates that the service was provided to a hospital inpatient. From routine check-ups to complex surgeries and specialized procedures, a wide range of services are provided within the hospital setting.

Why is POS 21 Important?

• Accurate Claim Processing: Using the correct code ensures your claims reach the right reimbursement pathway. For inpatient services, this means accessing the specific rates and regulations related to hospital admissions. An incorrect code, like an outpatient code for an inpatient stay, can lead to claim denials and financial losses.
• Proper Reimbursement Rates: Inpatient care generally attracts higher reimbursement rates than outpatient services. POS 21 ensures you receive the appropriate compensation for the intensive care and resources dedicated to hospitalized patients.
• Hey, do healthcare providers have to follow specific regulations regarding inpatient care? These regulations ensure patients receive the best care and treatment during their hospital stay. Healthcare professionals must stay up-to-date with these regulations to provide safe and effective patient care.POS 21 demonstrates adherence to these rules, reducing the risk of audits and fines.

In the digital era of healthcare, POS 02 might seem unassuming. Yet, within its two digits lies a powerful champion – Telehealth Provided Other than in Patient’s Home. This code unlocks a world of flexibility and convenience, enabling healthcare providers to deliver vital services beyond the traditional brick-and-mortar walls.

Conclusion:

POS 12 medical billing plays a crucial role in billing for home-based healthcare. U Control Billing understands the significance of accurate coding in medical billing. We help our clients navigate its intricacies. Our services ensure proper reimbursement and compliance and contribute to a growing healthcare model.

What is POS 12 on a claim?

POS 12 on a claim stands for “Home Location, other than a hospital or other facility.” It signifies that the service billed on the claim was provided to the patient in their private residence, not in a traditional healthcare setting like a hospital, clinic, or skilled nursing facility.

What is pos 13 in medical billing?

POS 13 stands for “Assisted Living Facility.” This code specifies that the service was provided to a patient in an assisted living facility (ALF).

What is POS in medical claims?

POS in medical claims stands for “Place of Service”. It’s a two-digit code used to indicate the location where the service billed on the claim was provided. This information is crucial for accurate claim processing, fair reimbursement, and compliance with healthcare regulations.

What is POS 22 on a medical claim?

This code specifies that the service billed on the claim was provided within a dedicated outpatient department located on the same campus as a hospital.

A couple of years ago, I executed the effective plan of creating a Medical billing and Coding company named U Control Billing. The company aims to bring revolutionary advancements to foster medical billing and coding revenues. As an official member of HIA-LI and MGMA, I feel honored in providing networking opportunities, problem-solving, and improving the revenue management cycle.

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Billing Instructions For Home Or Residence Services

Starting with claims for services on January 1, 2023, the 2 E/M visit families titled “Domiciliary, Rest Home (e.g., Boarding Home), or Custodial Care Services” and “Home Services” are now 1 E/M code family. The new family is titled “Home or Residence Services.” Use the codes in this family to report E/M services you provide to a patient in:

• Their home or residence
• An assisted living facility
• Group home (that isn’t licensed as an intermediate care facility for individuals with intellectual disabilities)
• Custodial care facility
• Residential substance abuse treatment facility

There are no changes to the included care settings from each respective family, rather the current care settings for each of the current families are in the new, merged family.

This change deletes CPT codes 99324-99337. The following place of service (POS) codes for CPT codes 99341-99350 show the merger of the domiciliary visit codes with the home visit codes:

• Home (POS 12)
• Assisted Living Facility (POS 13)
• Group Home (POS 14)
• Custodial Care Facility (POS 33)
• Residential Substance Abuse Treatment Facility (POS 55)

Source: U.S. Centers for Medicare & Medicaid Services (CMS)

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Place of Service Codes

If your claims are being denied, it is important to make sure the information on your claims is correct. One of the billing issues identified by the government as problematic has to do with coding for the location where services have been provided. Recently, the Centers for Medicare and Medicaid Services (CMS) revised instructions for what Place of Service (POS) codes to use for your claims, and the changes went into effect on November 2016.

These instructions, issued as a result of a report published by the Office of Inspector General (OIG) on improper coding practices by clinicians, are designed to reduce errors in POS coding. Specifically, they help clinicians determine how to assign POS codes when interpreting diagnostic tests outside of the office setting.

POS codes must be assigned based on the setting in which the beneficiary receives the face-to-face service. Because most services include a face-to-face component, this rule applies to the overwhelming majority of services. Where there is no face-to-face requirement, such as where an interpretation of a diagnostic test is performed remotely, you should use the POS code for the setting in which the beneficiary received the test (also referred to as the technical component (TC)) of the test.

This determination is generally made easily when distinguishing between a hospital and physician’s office. However, it becomes much more complex when services are provided in the hospital because a determination will still need to be made as to whether the patient is being treated as an inpatient or outpatient. When reporting POS, CMS instructs providers to pay more attention to the patient’s general inpatient or outpatient hospital status, rather than the precise inpatient or outpatient code. That said, if you know that a determination has been made regarding inpatient or outpatient status, that is what should be reported.

Previously, CMS had instructed practitioners to use the two-digit POS code that described where they were physically located when rendering the service.

A beneficiary receives a myocardial imaging study (78491) at an outpatient department of a hospital near their home. The hospital submits a claim that would correspond to the TC portion of the myocardial imaging study. The physician furnishes the PC portion of the patient’s myocardial imaging study from their office location. POS code 22 (outpatient hospital) should be used on the physician’s claim for the PC to indicate that the beneficiary received the TC, face-to-face portion of the study, at the outpatient hospital.

Place of Service Code Set – Complete https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set.html For the complete list of Place-of-Service Codes for Professional Claims, see the current year Current Procedural Terminology (CPT) Book.

Chapter 12 - Physicians/Nonphysician Practitioners 20.4.2 - Site of Service Payment Differential http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf

Chapter 13 - Radiology Services and Other Diagnostic Procedures 150 - Place of Service (POS) Instructions for the Professional Component (PC or Interpretation) and the Technical Component (TC) of Diagnostic Tests https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c13.pdf

Chapter 26 - Completing and Processing Form CMS-1500 Data Set 10.4 - Items 14-33 - Provider of Service or Supplier Information 10.5 - Place of Service Codes (POS) and Definitions 10.6 - Carrier Instructions for Place of Service (POS) Codes http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c26.pdf

CPT Book, Professional Edition https://catalog.ama-assn.org/Catalog/;jsessionid=B5YR30KIWYEFQCWBGOJVX5Q?_requestid=113916

MLN Matters: MM7631 http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM7631.pdf

OIG Report: http://oig.hhs.gov/oas/reports/region10/11000513.asp

Partial List of POS Codes

For the complete list of Place-of-Service Codes for Professional Claims, see the current year Current Procedural Terminology (CPT) Book.

Coding questions and comments may be sent to [email protected]

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