Primary Care Coding Alert

Question: How do I bill if our physician went to the nursing home to see Medicare patients for consultations, but did not meet all three requirements to charge an initial nursing facility visit. Would I use 99307?

New York Subscriber

Answer: The codes for initial nursing home visits are 99304-99306 (Initial nursing facility care, per day, for the evaluation and management of a patient ...). However, these codes do require that all three key components be met. Since the physician did not meet the three components, you cannot bill these codes.

Under these circumstances some Medicare carriers may require unlisted code 99499 (Unlisted evaluation and management service) and request to see all of your physician's documentation. Then, the carrier will pay as they see fit based on your documentation.

Other Medicare carriers and commercial and private carriers might allow you use 99307 (Subsequent nursing facility care per day, for the evaluation and management of a patient ...) as you suggested. For example, the WPS Medicare website states that you can bill a subsequent nursing facility code "if documentation and medical necessity do not meet the requirement for billing an initial nursing facility care code."