Primary Care Coding Alert

Question: Our physician sees patients in a nursing home, and while he is making rounds, patients from a rest home next door walk over to the nursing home waiting room and are seen by the doctor. We billed this as an office visit because the doctor is using the waiting room as his office, but Medicare denies it. What are we doing wrong?

California Subscriber

 
Answer: You cannot bill this as an office visit because the physician is not seeing patients in the office. The E/M office visit codes can only be used in the office, or in an outpatient facility or other ambulatory facility. In your case, the doctor is seeing patients in a nursing home, but some of the patients he sees are from a rest home, or domiciliary. A nursing home and a rest home differ in that the nursing home has on-site medical care but the rest-home services do not include a medical component.
 
First, you need to choose the correct E/M code. For the patients residing in the nursing home, use 99301-99303 (evaluation and management of a new or established patient involving a nursing facility assessment) or 99311-99313 (subsequent nursing facility care, per day, for the evaluation and management of a new or established patient). For the patients from the rest home, use 99321-99323 (domiciliary or rest home visit for the evaluation and management of a new patient) for new patients and 99331-99333 (... an established patient) for established patients.
 
Medicare is probably denying the claim because you are using the place-of-service code that does not correspond to the E/M code. The place-of-service code for the nursing facility is 32, and the place-of service-code for the domicile facility is 33. Using the place-of-service code 32 for a nursing home with the E/M code for a domiciliary may confuse payers and cause them to deny. Because the patients are walking over from the rest home out of their own convenience, bill those patients with the correct domiciliary E/M codes and 33 as the-place-of service code. Even though you are not technically in the domiciliary, use it as the place of service because the patients are from there.