Medicare Compliance & Reimbursement

Tip: Your reimbursement hinges on reporting the POS correctly.

If you hope to secure reimbursement and stay compliant, choosing the appropriate code for encounters between patients and physicians or mid-level providers in a skilled nursing facility (SNF) or a nursing facility (NF) is a must. 

Key: Coding for initial nursing facility care — in either a SNF or a NF — starts with becoming familiar with what is meant by “initial” and knowing that state law has its paws in the mix. Read on to get the tools you need to choose correctly every time.

Unscramble What is Said From What is Meant

CMS describes CPT® nursing care codes as initial (99304-99306, Initial nursing facility care, per day, …) and subsequent (99307-99310, Subsequent nursing facility care, per day, …). Saying “initial” is misleading. Initial doesn’t necessarily mean “first.”

“Under Federal law the initial comprehensive visit, during which the physician completes a thorough assessment and develops the plan of care for the patient’s overall nursing facility stay, must take place within 30 days of admission,” says Joan Gilhooly, MBA, CPC, CPCO, president and consultant for Medical Business Resources, LLC in Lebanon, Ohio. “However, if the physician is in a group practice that includes midlevel providers, this visit may not be the first care the patient receives from the practice. If medically necessary care is needed to continue the treatment the patient was receiving in the acute care (hospital) setting, and the medically necessary care is provided by the practice’s midlevel provider rather than the admitting physician, the admitting physician’s initial comprehensive visit may actually occur at a visit after the first visit provided by the midlevel provider.”

Identify Your Physician as the Principal Physician of Record

In order to bill for E/M visits in a SNF, the patient must be receiving services for medically complex care after having been discharged from an acute care facility and the visits must be reasonable and medically necessary and documented in the medical record. Patients in an NF must be receiving either skilled nursing, rehabilitation, or long-term care in order to report nursing facility visit E/M codes.

You should report 99304-99306 for your physician’s first initial nursing facility care encounter along with a modifier.

“Modifier AI (Principal physician of record) will be reported by the official attending physician of record on her initial visit,” explains Dorothy Steed, CCS, CPC-H, CPCO, CPUM, CPUR, CPHM, CPMA, ACS-OP, CCS-P, RCC, RMC, CEMC, CPC-I, CFPC, PCS, FCS, CPAR, CDIP, AHIMA approved ICD-10 trainer and ambassador, independent consultant, auditor, and educator in Atlanta, Ga. This modifier will identify the physician who oversees the patient’s care from other physicians who may be furnishing specialty care. The official attending physician of record “will be the physician who has initiated the admission and whose name appears on the admission documents as the admitting physician,” continues Steed.

Take Note That the Physician Performs Initial Comprehensive Visit in a SNF

A physician may not delegate the initial comprehensive assessment visit in a skilled nursing facility (SNF) when the Code of Federal Regulations (CFR) specify that the physician must perform the task personally or when the delegation is prohibited under state law or by the facility’s own policies.

The physician performs the comprehensive visit but that visit does not have to be the first visit with the patient.

Gilhooly offers this example: A patient is admitted to a SNF with pneumonia to continue antibiotics and to build up stamina in order to return to a community setting of care (such as the patient’s home or a family member’s home). After admission on day one, the nurse practitioner (NP) sees the patient and she checks the patient’s lungs for any improvement. The patient’s physician, who’s from the same practice as the NP, comes in on day three to do the initial comprehensive assessment and medically necessary care. On day five, the NP evaluates the recovery from pneumonia and rebuilding of stamina. The physician returns on day seven to reevaluate the patient’s recovery and the rebuilding of stamina.

In this case, the comprehensive visit with the physician which occurred on day 3 would be coded as the “initial” visit even though it was not the first visit with the patient.

Code it: You would code these encounters in the following way, according to Gilhooly:

• Day 1 — 99307-99310, NP performs medically necessary care
• Day 3 — 99304-99306, Physician performs initial comprehensive assessment and medically necessary care
• Day 5 — 99307-99310, NP performs medically necessary evaluation of recovery and rebuilding of stamina
• Day 7 — 99307-99310, Physician performs medically necessary evaluation of recovery and rebuilding of stamina

Tip: Medically necessary can be defined as a covered health service or treatment that is mandatory to protect and enhance the health status of a patient, and could adversely affect the patient’s condition if omitted, in accordance with accepted standards of medical practice.

Check Your State Laws for NPP Limits

In a nursing facility (Part B admission) setting, a qualified NP, physician assistant, or clinical nurse specialist who isn’t employed by the facility may perform the Initial Comprehensive Assessment visit when the state law permits and they must collaborate with the physician. If state law doesn’t permit these non-physician practitioners (NPP) to perform this comprehensive service, then physicians must perform that service, the same way they do for a SNF (Part A) admission.

NPPs may provide and report other medically necessary E/M visits prior to and after the initial visit if there is medical necessity for the visit. You’ll report these visits with the subsequent nursing facility care codes (99307-99310).

Exception: If you’re working in one of the few states that allow mid-level health care professionals perform the “initial” visit, you are the exception to the rule.

Choose the Appropriate POS

According to the Medicare Claims Processing Manual (MCPM), chapter 12, 20.4.2, initial nursing facility care should be reported with one of two places of service:

• 31 (Skilled nursing facility)
• 32 (Nursing facility).

For more details, check out www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf.

Important: Medicare uses processing edits that may prevent you from receiving reimbursement if you list an incorrect place of service.