One day last year, the daughter and caretaker of one of my patients called to ask whether I could arrange for a home nurse to come see her mother, who was chronically ill. She was concerned about her mom’s breathing and didn’t feel like she could get her to my office. I knew the family lived nearby, and I was going to be leaving the office within the hour, so I offered to come over and see her mother myself when I left for the afternoon. As her condition deteriorated over the next few months, I found myself making visits to their home almost weekly. When she died, I ran over between patients to pronounce her and comfort her family. I have a great sense of satisfaction when I think about those months because I was able to extend myself beyond the confines of my office to help a patient and her family through a very difficult time.
Old-fashioned house calls are seldom discussed or thought of in today’s world of high-tech, expensive health care. However, they can easily be incorporated into a physician’s everyday practice, and they can benefit both patients and physicians in many important ways.
Advantages to the patient
Some patients could access medical care much more readily if the physician came to their home. Elderly patients and patients with physical disabilities may have difficulties getting to a physician’s office. Patients who are blind or cannot drive for other reasons may also benefit from the convenience of home visits. During winter months, patients who could normally get to the office may have more trouble.
For some patients, the physician may be able to do a better examination in their home than in the office. I have one patient, for example, who is morbidly obese and can’t get onto my exam table without a lot of help. When she called one day complaining of abdominal pain, I offered to come to her house, where I knew she could easily lie down on her bed for me to examine her. Similarly, with a wheelchair-bound patient, I was able to do a much more thorough examination in her home than I had ever done in previous visits in the office.
Patients also benefit from their physician seeing the location and conditions in which they live. Cleanliness and hygiene can be appreciated, as can the layout of the house. With this information, a physician may be able to identify problems and make suggestions for improvement – suggestions that would never be considered had the physician not been to the patient’s home.
Advantages to the physician
The reimbursement for home visits for Medicare and most other insurance carriers is usually considerably more than the same visits done in the office (see “Billing for house calls”). Doing home visits can also increase your income by generating goodwill. Patients today don’t expect their physicians to do house calls; therefore, they appreciate a physician who is willing to come to their home and are quick to tell their friends and neighbors what a wonderful physician they have. This invariably leads to new patients for the physician.
Perhaps the biggest benefit to the physician is that it makes you feel good to do home visits. It is gratifying to do a little extra for someone who needs it and can lead to a great sense of professional satisfaction. In my practice, I care for a couple who are both over 90 years old. Last winter, they both became quite ill and neither could drive to my office. I managed their conditions through home visits and phone calls and got them back to being able to plant their garden this spring. This couple is a perfect example of what can happen when a physician uses house calls to go a little beyond the expected.
How to do house calls
The hardest part is selecting patients. I suggest not advertising the service. Instead, pick the patients to whom you offer house calls based on criteria that you determine. Criteria should include patients’ needs as well as their proximity to your office. I have managed to incorporate home visits into my day as I pass from the hospital to the office or from my office to pick up my children at school. Traveling out of the way or long distances to do home visits would have high “opportunity costs” – that is, I would be making less on these house calls than the revenues I could have been generating seeing patients in the office during the same time. By limiting home visits as much as possible to only convenient and practical locations, you will fully reap the benefits of the higher reimbursement.
It also helps to have a prepared home-visit bag stocked with a stethoscope, sphygmomanometer, thermometer, otoscope/ophthalmoscope, gauze, tape and scissors. You may also want to include urine dipsticks and even blood drawing supplies.
As you do more house calls, you may find more patients wanting or expecting them. Be careful not to let it get out of control. If you take on too many home-visit patients at too great a driving distance, you can significantly reduce the financial rewards of the experience, although the emotional rewards would remain.
It is important to set ground rules for home visits so that patients do not expect services you cannot provide. For instance, I explain to patients that I can only come to their home when my schedule allows. I also remind patients that if they can come to my office, that would be preferable in most cases. Additionally, I tell patients that, while I am willing to do house calls, my partners may not always be; this keeps them from being disappointed when I am not the physician on call.
Truly an art
For the right patients, house calls can result in superior care that is easier to access. For physicians, house calls can bring financial rewards in the form of improved reimbursement and free word-of-mouth marketing. But perhaps more important than these benefits are the intangible rewards. House calls represent a return to a simpler time, when medicine was truly an art. In today’s complicated health care environment, they can provide great comfort to both the patient and the physician.
BILLING FOR HOUSE CALLS
House calls are reimbursable visits with most payers, including Medicare. To be reimbursed by Medicare, you must document the reason a house call was necessary; for example, an office visit would require ambulance transport or excessive physical effort or cause pain, or the patient is home-bound. (To understand Medicare’s definition of homebound, see “Defining ‘Confined to the Home,’” FPM, March 2003, page 20.)
To bill for house calls, document the visits thoroughly and use the appropriate CPT code from the table shown below.
|House call CPT code||Requirements||Average time|
|99341||Problem-focused history and exam Straightforward medical decision making||20|
|99342||Expanded problem-focused history and exam Medical decision making of low complexity||30|
|99343||Detailed history and exam Medical decision making of moderate complexity||45|
|99344||Comprehensive history and exam Medical decision making of moderate complexity||60|
|99345||Comprehensive history and exam Medical decision making of high complexity||75|
|99347||Problem-focused interval history and exam Straightforward medical decision making||15|
|99348||Expanded problem-focused interval history and exam Medical decision making of low complexity||25|
|99349||Detailed interval history and exam Medical decision making of moderate complexity||40|
|99350||Comprehensive interval history and exam Medical decision making of moderate to high complexity||60|