Your grandmother can’t drive anymore. Getting her to the doctor’s office means arranging transportation, dealing with her walker, and spending half the day on what should be a 20-minute checkup. So her doctor comes to her instead. When that happens, the visit gets coded as 99349 – if it meets certain requirements.
Medical billing codes are basically price tags for everything doctors do. Insurance companies created this system because they got tired of doctors writing “visited patient” and billing random amounts. CPT Code 99349 is one specific price tag for home visits that are more involved than a basic check but not quite emergency-level complex.
What CPT Code 99349 Actually Means
CPT code 99349 is used for home visits with established patients that involve moderate medical decision-making or about 40 minutes of face-to-face care. Unlike office visits, these services must be documented to show the time spent, the complexity of care, and the reason a home visit was necessary. Accurate records are essential for meeting the 99349 CPT code description time and ensuring claims are accepted.
Key requirements for using 99349:
- You’ve seen this doctor before (not your first meeting)
- The visit happens at your actual home, not a facility
- Your medical situation involves multiple problems or moderate complexity decisions
- The doctor spends 40-54 minutes on your case (not just face-to-face time)
- The doctor documents why you couldn’t come to the office
The “established patient” part matters. If this is your first time seeing this doctor, they use completely different codes (99344 instead of 99349), and insurance pays differently.
Breaking Down the Home Visit Levels
Medicare recognizes five levels of home visit complexity for established patients. Each level pays differently, requires different documentation, and covers different medical scenarios.
Level 1 – CPT Code 99347 (Straightforward)
This is your basic check-in visit. Maybe the doctor’s confirming you’re taking medications correctly or checking a simple rash. Usually takes about 15 minutes total.
Typical payment: $85-100 Documentation needed: Problem-focused history and exam Example: Checking blood pressure for stable hypertension patient
Level 2 – CPT Code 99348 (Low Complexity)
Still pretty simple but requires more time and evaluation. The doctor might adjust one medication or address a new minor problem.
Typical payment: $120-140 Documentation needed: Expanded problem-focused history and exam Example: UTI symptoms in elderly patient with diabetes
Level 3 – CPT Code 99349 (Moderate Complexity)
This is where things get more involved. Multiple chronic conditions need attention, or there’s a new problem complicating existing conditions. The doctor’s making several medical decisions.
Typical payment: $170-230 Documentation needed: Detailed history and exam OR moderate complexity decision-making Example: Adjusting medications for patient with diabetes, heart failure, and new swelling in legs
Level 4 – CPT Code 99350 (High Complexity)
Serious medical situations that almost need hospital-level care. Multiple unstable conditions or significant risk of complications.
Typical payment: $230-300 Documentation needed: Comprehensive history and exam OR high complexity decision-making Example: Managing end-stage COPD patient with multiple medication changes and oxygen adjustment
Level 5 – CPT Code 99345 (Very High Complexity)
Reserved for the most complex cases. These patients are seriously ill and require extensive management. Often involves end-of-life care or multiple failing organ systems.
Typical payment: $300-370 Documentation needed: Comprehensive evaluation with high complexity decision-making Example: Terminal cancer patient with pain crisis and multiple symptom management needs
Who Qualifies for Home Visit Billing
Accurate coding for house calls hinges on clear, detailed documentation that reflects the patient’s condition, the provider’s decision-making, and the care delivered. For CPT code 99349, records must justify the visit’s complexity and necessity, such as the patient’s inability to travel or other compelling circumstances.
Not everyone who wants their doctor to come to their house qualifies for these codes. Insurance companies have specific rules about who gets covered home visits.
Medical necessity is the big requirement. The doctor has to document why you can’t reasonably get to the office. Common qualifying reasons include:
- Severe mobility limitations (can’t walk, wheelchair-bound, severe arthritis)
- Cognitive impairment that makes travel dangerous or impossible
- Multiple chronic conditions making transport risky
- No available transportation and medical need is urgent
- Recent hospital discharge with mobility restrictions
- Terminal illness requiring comfort care at home
Age alone doesn’t qualify you. Plenty of 90-year-olds drive themselves to appointments. But a 60-year-old with severe MS who can’t transfer from bed to car? They qualify.
Geographic limitations also apply. Some insurance plans only cover home visits within certain mile radius from the doctor’s office. Rural areas might have different rules than cities.
How the Billing Process Works
The journey from doctor visit to payment involves more steps than most patients realize. Understanding this process helps explain why some doctors don’t offer home visits anymore.
Step 1: Pre-Visit Planning Before leaving the office, the doctor reviews your medical history, recent test results, and medications. This prep time counts toward the total time for billing but isn’t face-to-face time.
Step 2: The Actual Visit Doctor examines you, discusses problems, adjusts treatments. They’re mentally tracking what body systems they’ve examined and what level of decision-making they’re doing – this determines the billing level.
Step 3: Documentation Marathon After leaving your home, the doctor documents everything. Which body systems examined, what conditions they managed, what decisions they made, why the visit was necessary. Miss any element, claim gets denied.
Step 4: Coding and Submission Medical coder reviews the documentation, assigns 99349 (or different level if appropriate), submits to insurance. This happens days or weeks after your visit.
Step 5: Insurance Review Insurance company’s system (or sometimes a human reviewer) checks if documentation supports the code. They look for specific keywords, required elements, medical necessity.
Step 6: Payment or Denial If approved, payment arrives 30-90 days later. If denied, the practice can appeal, downcode to a lower level, or potentially bill the patient.
Insurance Coverage and Pricing Details
Different insurance types handle home visits differently, and the payment amounts vary significantly based on your location and specific plan.
Medicare Original (Part B) Pricing Table
| CPT Code | National Average Payment | Rural Area Adjustment | Urban Area Payment | Documentation Time Value |
|---|---|---|---|---|
| 99347 | $96.52 | +15% ($110.99) | $94.18 | 20 minutes |
| 99348 | $135.44 | +15% ($155.76) | $132.06 | 30 minutes |
| 99349 | $193.05 | +15% ($222.01) | $188.22 | 40 minutes |
| 99350 | $270.89 | +15% ($311.52) | $264.12 | 60 minutes |
| 99345 | $338.99 | +15% ($389.84) | $330.52 | 75 minutes |
Prices as of 2024 Medicare Physician Fee Schedule. Actual payments vary by geographic location.
Medicare Advantage Plans
These private Medicare plans often require prior authorization for home visits. They might pay less than Original Medicare or limit the number of covered visits per year. Some plans cap at 12 home visits annually, others at 24.
Commercial Insurance
Private insurance coverage is all over the map. Some plans don’t cover home visits at all. Others pay better than Medicare. Most require prior authorization and medical necessity documentation beyond Medicare’s requirements.
Medicaid
State-by-state variation is huge. California Medicaid might pay $140 for 99349 while Alabama pays $95. Some states require special enrollment as a home visit provider.
Direct Pay (No Insurance)
Doctors charging cash typically bill $250-500 for a 99349-level visit. Concierge practices might include unlimited home visits in their annual fee.
Common Documentation Mistakes That Get Claims Denied
Insurance companies deny about 15-20% of home visit claims initially. Most denials stem from documentation problems that seem minor but trigger automatic rejections.
The “Copy-Paste Special” Using the exact same documentation for every visit screams fraud to auditors. Even if you’re seeing the patient for the same conditions, something should be different each visit – vital signs, symptom descriptions, medication responses.
Missing the “Why Home” Justification Writing “patient homebound” isn’t enough. You need specifics: “Patient unable to ambulate beyond 10 feet due to severe COPD, requires continuous oxygen, becomes dyspneic with minimal exertion.”
Time Documentation Errors Saying you spent 45 minutes when your documentation shows a simple medication refill won’t fly. The complexity described must match the time claimed.
Wrong Setting Codes Billing 99349 for an assisted living facility visit is automatic denial. Those use different codes (99337-99340). Same with nursing homes – different codes entirely.
Upcoding Patterns If every single home visit gets billed as 99349, auditors notice. Real practice has a mix of levels. Some visits are simple, some complex.
Tips for Healthcare Providers
Since your client wants practical knowledge, here’s what actually helps practices get paid for 99349:
Template Smart, Not Hard Create templates for common scenarios but customize each note. Include prompts for required elements: mobility limitations, cognitive status, caregiver presence, specific reasons for home visit necessity.
Time Tracking Reality Start your timer when you pull the patient’s chart, not when you knock on their door. Document chart review time, travel time (separately), face-to-face time, and post-visit documentation time.
Photography Documentation With patient permission, photograph living conditions affecting medical care – mobility hazards, medication organization systems, wound healing progress. These support medical necessity and complexity.
Coordinate with Other Providers If home health nurses also visit, reference their notes. Shows comprehensive care coordination and supports higher-level billing.
Regular Audits Pull 10 random home visit claims monthly. Check if documentation supports the billed level. Better to catch problems yourself than during insurance audit.
When to Use 99349 vs Other Options
Sometimes 99349 isn’t the right code even when you think it should be. Knowing the alternatives prevents denials and audit flags.
Telehealth Instead? If the patient has video capability and the visit doesn’t require physical examination, telehealth codes (99213-99215) might work. Pays less but no travel time.
Annual Wellness Visits If doing Medicare’s annual wellness visit at home, that’s G0438 or G0439, not 99349. Different documentation, different payment, once per year limit.
Transitional Care Management Just discharged from hospital? First home visit might be part of TCM services (99495-99496). Pays more but has specific requirements about timing and follow-up.
Hospice Patients If patient’s on hospice, the hospice agency usually handles billing. Using 99349 for hospice patients often results in denials.
The Future of Home Visit Billing
Insurance companies are actually warming up to home visits after COVID showed that keeping people out of hospitals saves money. Some changes coming down the pipeline:
Value-based contracts are starting to reward home visits more generously, recognizing they prevent expensive ER visits and hospitalizations. Some Medicare Advantage plans now pay bonuses for home visit programs that reduce readmissions.
Technology integration means doctors can bill for remote patient monitoring alongside home visits. Smart scales, blood pressure cuffs, and glucose monitors feeding data between visits justify higher complexity coding.
New codes keep emerging. CMS is testing codes for extended home visits (over 90 minutes) and codes for home visits requiring multiple providers.
The catch? Documentation requirements keep getting stricter. Insurance companies want to see that home visits actually improve outcomes, not just convenience.