Coding Corner: Coding For Assisted Living Facilities

On January 1, 2023, CPT codes 99324-99343 for domiciliary, rest home, or custodial care services were eliminated. This caused us to change how we bill for Evaluation and Management (E/M) services provided in assisted living facilities.

Clarifying "Home"

To bill for “home visit codes” effectively, the provider must document that the patient was seen in the home (in a private residence) and not in the office. The CPT definition of "home" includes a wide range of locations. The official coding definition of the Home and Residence services states: “Home may be defined as a private residence, temporary lodging, or short-term accommodation (e.g., hotel, campground, hostel, or cruise ship)”

What Codes to Use Now?

To accurately bill for E/M services performed in assisted living facilities, you must now use the appropriate E/M codes:

• 99341-99345 for new patients
• 99347-99349 for established patients

Select the level based on the complexity of your service and documentation. These codes should always be matched with the appropriate place of service (POS) code.

After January 1^st, 2023, the appropriate codes to bill for evaluation and management of a member in the assisted living facility are:

• 99341- Home or residence visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 15 minutes must be met or exceeded.
• 99342- Home or residence visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded.
• 99344- Home or residence visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 60 minutes must be met or exceeded.
• 99345- Home or residence visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 75 minutes must be met or exceeded.
• 99347- Home or residence visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded.
• 99348- Home or residence visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded.
• 99349- Home or residence visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded.

Understanding Place of Service (POS) Codes

Correctly identifying the POS code is critical, and the key is specifying that the service occurred in an assisted living setting, not in a home or another health care facility. These POS codes all apply to the 99341-99349 code sets:

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

Accurate coding helps ensure your claims are processed timely and successfully.

Source:

The CPT^® 2023 Professional Edition codebook. Evaluation and Management (E/M) Services. Home and Residence services.