General Surgery Coding Alert

Question: How do I bill if our surgeon went to the nursing home to see a Medicare patient for a consultation, but did not meet all three requirements to charge an initial nursing facility visit. Would I use 99307?

Texas Subscriber

Answer: The codes for initial nursing home visits are 99304-99306 (Initial nursing facility care, per day, for the evaluation and management of a patient ...). However, these codes do require that the physician meet all three key components. Since the surgeon did not meet the three components, you cannot bill these codes.

Under these circumstances, some Medicare payers may require unlisted code 99499 (Unlisted evaluation and management service) and request to see all of your physician's documentation.

Other Medicare payers and commercial and private insurers might allow you use 99307 (Subsequent nursing facility care per day, for the evaluation and management of a patient ...) as you suggested. For example, the WPS Medicare website states that you can bill a subsequent nursing facility code "if documentation and medical necessity do not meet the requirement for billing an initial nursing facility care code."