Practice Management Alert

Here’s one RAC that could show you problem areas.

Practices whose physicians perform evaluation and management (E/M) services for skilled nursing facility (SNF) patients present a coding challenge, as it’s often difficult to figure out which codes to report and how to document the service.

Help’s here: Region A RAC [recovery audit contractor] 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: 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.

You can ensure you’re coding correctly for all your SNF patients by following the expert advice in this SNF coding FAQ:

Tally E/M Accurately

Question: Our physician met a patient in a nursing facility in June 2015 and then saw the patient again in January 2016 at the same nursing facility. During the June visit, she evaluated the patient for a new problem and documented 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; an components: a detailed interval history; a detailed examination; medical decision making of moderate complexity…), you should report a problem-oriented code.

“In this case it was a sick visit not an annual visit,” explains Laureen Jandroep, CPC, COC, CPC-I, CPPM, founder/CEO Certification Coaching Organization, LLC in Oceanville, N.J. “That changes the codes you would consider. So in this scenario 99318 would not be appropriate. A code from the range 99307 to 99310 would be considered for ‘subsequent nursing facility care visits.’ A ‘DDM’ or detailed history, detailed exam, and moderate medical decision making would equate to a 99309.”

Get Timing Right

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. “According to the descriptions, there is a time element so you may code based upon that,” says Sarah L. Goodman, MBA, CPC-H, CCP, FCS, president/CEO and principal consultant at SLG, Inc., in Raleigh, N.C.

That said, in order for you to bill these visits based on counseling and coordination of care time, the patient must be present during the visit (a face-to-face encounter), and you must document the exact amount of time spent in counseling, Goodman says.

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. Here too, educating the physician to only use his documentation and only the review of systems and past, family, and social histories from any other provider at the facility.