Primary Care Coding Alert

Many family physician (FP) coders are eager to capture the extra $69.17 for a hospital discharge performed on the same day as a nursing home admission. Reimbursement for both services, however, hinges on documentation that reflects that the FP provided two distinct E/Ms.

Report Same-Day Discharge, SNF Admit

 Because CPT allows coding only one E/M service per day, you may think that billing 99238 (Hospital discharge day management; 30 minutes or less) or 99239 ( more than 30 minutes) with 99303 (Evaluation and management of a new or established patient involving a nursing facility assessment at the time of initial admission or readmission to the facility. The creation of a medical plan of care is required. Physicians typically spend 50 minutes at the bedside and on the patient's facility floor or unit) for the same date of service is inappropriate. But as long as the FP performs two distinct services, he or she should code both the discharge and the nursing facility admission, says Barbara E. Oviatt, CPC, CCSP, coding specialist at the Stuart, Fla.-based Martin Memorial Medical Group.

CPT guidelines make an exception to the normal E/M rules for nursing facility services. "The comprehensive nursing facility assessments notes indicate that you may separately report a discharge from either observation (99217, Observation care discharge day management ) or inpatient (99238, 99239) status and a nursing facility admission or readmission on the same date," Oviatt says.

Remember, though, that just because CPT accepts this coding method, individual carriers may have a different set of rules, Oviatt says. Section 15505.2B of the Medicare Carriers Manual instructs the carrier to pay both the inpatient discharge and the nursing home admission on the same day. "It is silent, however, on the subject of an observation discharge on the same date as a skilled nursing facility (SNF) admit," she says.

Coding Depends on Performing Both Services

The tricky part is making sure that your FP documents 99238-99239 and 99303 correctly to capture his or her entitled reimbursement for the discharge service: $69.17 for 99238, which has 1.88 relative value units (RVUs), and $93.81 for 99239, which has 2.55 RVUs. Some physicians do not want to spend the time writing separate notes for each service, says Genevieve Daley, CPC, president and owner of Procedural Coders Institute in Chula Vista, Calif. But if you look at the discharge and nursing facility assessment codes, they require different elements.

For instance, 99238-99239 include, as appropriate, final examination of the patient, discussion of the hospital stay, instructions for continuing care to all relevant caregivers, and preparation of discharge records, prescriptions and referral forms, according to CPT. On the other hand, nursing home facility assessment code 99303 requires a comprehensive history and examination and moderate- to high-complexity medical decision-making.

Because the history involved in the hospital stay is not the same as that required for the facility admission, the FP must redo the patient's history for the nursing home assessment, says Daley, who is also a professional medical coding curriculum American Academy of Professional Coders (AAPC) approved instructor at the Universities of California. "The nursing home staff performs the medical plan based on what the physician specifies in 99303."

Some SNFs will accept the hospital history and physical (H&P) or the discharge summary as an indicator of the patient's history, Oviatt says. Under these circumstances, "The physician should separately document the additional work to create a new plan of care and a separate set of admission orders.

"The doctor should also perform and document the comprehensive exam as part of the admission and not on his discharge summary," Oviatt adds. Remember, if the FP wants to bill for two services, he or she should perform each.

POS Rules Are Not Clear-Cut

You may also wonder if billing 99238-99239 and 99303 is appropriate when your FP does not go to the nursing home on the date he or she admits the patient. "Auditors do not agree on whether the physician has to be present at the SNF at least at some point during the admission, or if it is acceptable to perform all work from the hospital or office," Oviatt says.

The physician may initiate the SNF admission from the hospital, according to CPT's guidelines for nursing facility services. CPT also indicates that the services the physician reports should include those provided in other sites of service and that the doctor may perform a comprehensive assessment at one or more sites in the assessment process including the hospital.
  
But if the FP provides the assessment at the hospital, the place-of-service (POS) code will not match the procedure. For instance, the Medicare Carriers Manual restricts payment of SNF codes to POS 31 (SNF), 32 (Nursing facility), 54 (Intermediate care facility/mentally retarded) and 56 (Psychiatric residential treatment center). Consequently, if an FP discharges a patient from the hospital and also performs the assessment at the hospital, he will have to use POS 21 (Inpatient hospital) for both services. In this situation, "The POS and CPT link will not match up, which will certainly generate a denial," Oviatt says. This is part of the problem with the ongoing argument as to whether the FP has to go to the nursing home to bill the admission.