Summary & Overview
HCPCS G0078: Moderate Care Management Home Visit for New Patient
HCPCS Level II code G0078 denotes a moderate-intensity (45-minute) care management home visit for a new patient, authorized only within Medicare-approved CMMI models. Nationally, this code reflects a targeted effort to support comprehensive, in-person care management for vulnerable populations in non-clinic settings, addressing care coordination, assessment, and planning needs where patients reside. Its use signals emphasis on proactive management for patients who may have difficulty accessing office-based care.
Key payers in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Medicare is the controlling payer given the CMMI model restriction, while large commercial payers are included for benchmarking and policy context where applicable.
Readers will find concise benchmarks, policy context, and clinical interpretation relevant to the code: how the code defines service intensity and site, implications for care management programs, and how payers typically consider home-based moderate visits within value-based models. The publication summarizes billing considerations, common modifiers provided in the input, and gaps where data was not supplied. The focus is national — presenting the scope and operational meaning of G0078 for program planners, billing staff, and policy analysts.
Billing Code Overview
HCPCS Level II code G0078 describes a moderate (45 minutes) care management home visit for a new patient provided only within a Medicare-approved CMMI model. The service type is care management home visit (moderate intensity). The typical site of service is the beneficiary's home, domiciliary, rest home, assisted living facility, or nursing facility.
Data not available in the input.
Clinical & Coding Specifications
Clinical Context
A community-based nurse practitioner from a Medicare-approved CMMI (Center for Medicare & Medicaid Innovation) model conducts a first-time, moderate complexity care management home visit lasting approximately 45 minutes for a new beneficiary recently discharged from the hospital with multiple chronic conditions. The patient is an 78-year-old resident of an assisted living facility with heart failure, type 2 diabetes mellitus, and mild cognitive impairment. The clinician performs a comprehensive home assessment of the patient’s functional status, medication reconciliation, evaluation of wound or device sites if present, identification of social determinants affecting care adherence, coordination with the patient’s primary care physician and home health services, and development of a personalized care plan that includes follow-up appointments and community support referrals. Documentation includes start and end times, focused history and exam elements relevant to chronic disease management, medication list with changes, patient and caregiver education provided, goals of care discussion, and communication notes with other providers. Services are furnished within the patient’s residence (assisted living) and meet Medicare CMMI model requirements for a new beneficiary receiving moderate complexity home care management, billed with G0078.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
11 | Physician or other qualified health care professional as the primary provider of service |