Part B Insider (Multispecialty) Coding Alert

3 FAQs can help you avoid running afoul of the law.

Do your physicians meet with patients at skilled nursing facilities (SNFs) and perform E/M services for those visits? If so, you’ll want to keep an eye on which codes you report—and double check medical necessity to ensure that you could pass any audit.

Why? Region A RAC Performant Recovery, which handles the audits for five states, identified the following issue on its website as being under review as of Sept. 10, 2015:

Evaluation and management coding in skilled nursing facilities: When you provide E/M services to SNF patients, you should report codes 99304-99318, the RAC says in its recent announcement. “It is inappropriate to report hospital inpatient care codes (99221-99223, 99231-99233, 99238 and 99239) for SNF E/M services,” Performant adds. The RAC will be looking at claims for these services that have been performed over the past three years.

If you report E/M services for SNF patients on a regular basis, get to know these three FAQs that can ensure you’re coding correctly.

Know How to Tally E/M

Question: Our physician met a patient in a nursing facility in March and then saw the patient again in June at the same nursing facility. During the June visit, she evaluated the patient for a new problem and documented a detailed history and examination with medical decision making (MDM) of low complexity. Should I report 99318?

Answer: You need to understand the intent of the provider’s encounter with the patient to determine the correct coding. 

Because the doctor saw the patient for a problem-oriented visit, rather than an annual assessment, 99318 (Evaluation and management of a patient involving an annual nursing facility assessment, which requires these 3 key components: a detailed interval history; a comprehensive examination; and medical decision making that is of low to moderate complexity) is not the correct code for the June E/M service.

Instead, since the history and exam meet the requirements for two of the key components, you will choose 99309 (Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: a detailed interval history; a detailed examination; Medical decision making of moderate complexity).

Nail Down Timing

Question: Can we code based on time when using the SNF E/M codes such as 99309?

Answer: Ever since 2008, CPT^® has published average time spent on the nursing facility codes, allowing you to report them based on time. However, in order for you to bill these visits based on counseling and coordination of care time, the patient must be present during the visit, and you must document the amount of time spent in counseling.

Documentation must include time spent face-to-face (or on the floor/unit) counseling and/or coordinating care, as well as the total time of the encounter. For 99309, the “typical time” cited by CPT^® is 25 minutes, while you’ll need to spend 35 minutes to justify reporting 99310.

If you don’t have the appropriate documentation to code based on time, you’ll have to revert to the standard coding regulations. For 99309, you’ll need to document two of these three requirements: A detailed interval history, detailed exam, and moderate medical decision making.

If your doctor visits a large number of nursing home patients on the same date (which is common), he may not be documenting enough for each patient to meet these high-level codes. Make sure he takes the time after each patient to thoroughly document the record to support the codes he plans to report.

Rules Should Stay the Same for Specialists

Question: Our doctors were asked to consult at a nursing home. They have never gone before, and I’m not sure what codes to use. When I looked in the book, the codes 99304-99310 for nursing facility visits state they are for the admitting physician, initial care, and subsequent care. Since we are specialists, can we use these codes as well?

Answer: Specialists may report the nursing facility codes you mention. You also want to be sure you use the appropriate place of service code. For more details, check out Medicare Claims Processing Manual, Chapter 12, Section 30.6.13, at www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf.

In the manual you’ll find helpful information such as how the use of modifier AI (Principal physician of record) distinguishes the principal physician’s claim from those of other specialty care physicians: “The principal physician of record must append the modifier ‘-AI’, (Principal Physician of Record), to the initial nursing facility care code. This modifier will identify the physician who oversees the patient’s care from other physicians who may be furnishing specialty care. All other physicians or qualified NPPs who perform an initial evaluation in the NF or SNF may bill the initial nursing facility care code.”

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