EM Coding Alert
Assign a Physician, Not PA, for Initial NF Visits
Question: I am receiving denial C0-170 (Payment is denied when preformed/billed by this type of provider) from Medicare when I bill for an initial nursing facility visit our physician assistant (PA) did. I am using place of service code 31 (Skilled Nursing Facility) and provider type 38 (Physician assistant). Why am I getting this denial?
Answer: Per Medicare rules, you cannot bill an initial visit in a skilled nursing facility (SNF) or nursing facility (NF) using 99304-99306 (Initial nursing facility care, per day, for the evaluation and management of a patient ...) under a physician assistant, (PA). Medicare says that a physician must perform this type of service, per 42 Code of Federal Regulations (42 C.F.R. 483.40 [c] [4]).
According to CMS, the Social Security Act states in Section 1819(b)(6)(A) that “the medical care of every resident must be provided under the supervision of a physician.” This means non-physician practitioners, including PAs, cannot perform the initial comprehensive visit in SNFs.
Remember: CMS defines the initial visit as “the initial comprehensive assessment visit during which a physician completes a thorough assessment, develops a plan of care and writes or verifies admitting orders for the nursing facility resident.”
Additionally, per the Long Term Care regulations (42 CFR 483.40 [c][4] and [e][2]), the physician may not delegate a task that the physician must personally perform. Therefore, the physician may not delegate the initial visit in a SNF to your PA.
Keep in mind: This rule also applies to the NF (POS 32) with one exception: A qualified NPP, who is not employed by the facility, may perform the initial visit in the NF setting when the state law permits.
Learn more: You can read more about Medicare’s billing regulations for NPPs in the SNF and NF setting by reading the Medicare Claims Process Manual, Chapter 12, Section 30.6.13 (www.cms.gov/manuals/downloads/clm104c12.pdf) or MLN Matters article SE0418 (www.cms.gov/MLNMattersArticles/downloads/SE0418.pdf).
Wyoming Subscriber
EM Coding Alert
- Key Elements:
Choose the Right Physical Exam Guidelines Every Time to Ensure Top Payment + Compliance
Hint: You don’t have to choose 1995 or 1997 and stick with it. Having two [...] - Modifiers:
Follow 3 Steps to Solidify Your Modifier 25 Use, Before Your Payers Come Knocking
Don’t confuse 25 and 57; look to the global period. Payers are scrutinizing and denying [...] - Modifier 25 vs. Modifier 57
Your modifier 25 claims should meet all of the following criteria: The E/M occurs on [...] - You Be the Coder:
Don't Automatically Combine ER and Office Visits
Question: If a patient was seen for an office visit (99214) first and then later [...] - Clip and Save:
Keep This Chart Handy to Help Quickly Calculate Exam Levels
Be sure you choose the guidelines that will be most advantageous to your coding. With [...] - Reader Question:
Stress Time Documentation Requirement for Discharge Coding
Question: The doctor admitted a patient and then discharged the patient five days later. Before [...] - Reader Question:
Include Phone Work in Next E/M Code
Question: From his office an oncologist reviews lab test results and, by telephone, orders additional [...] - Reader Question:
Check for Bundling Before Attaching Modifier
Question: Sometimes I cannot find the two codes I intend to bill in the CCI [...] - Reader Question:
ICU Does Not Automatically Support 99291-99292
Question: After a patient with chest pain “coded” in the ER and was admitted to [...] - Reader Question:
Identify 3 'Vitals' Before Adding to Exam
Question: Would you please explain how taking the vital signs contributes to determining the E/M [...] - Reader Question:
Assign a Physician, Not PA, for Initial NF Visits
Question: I am receiving denial C0-170 (Payment is denied when preformed/billed by this type of [...]
