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Pulmonology Coding Alert

SNF Patients Seen in the Office:

Separate the Technical and Professional Components

Published on Fri Mar 01, 2002

Pulmonary physicians who see skilled nursing facility (SNF) residents in the office face tricky coding and billing scenarios. Because the Balanced Budget Act of 1997 requires SNFs to "consolidate" their billing for Medicare Part A-stay residents, all but a few services are excluded from the prospective payment system (PPS). Physicians who bill Medicare for services that are part of the all-inclusive PPS rate could be setting themselves up for payment recoupments and potential fraud and abuse investigations.
 
The first step in consolidated billing is to develop a "tickler system" or other mechanism to identify Part A SNF-stay patients seen in the office. "Many SNFs send a form or notice to the physician's office with the Part A-stay patient instructing the physician's office to bill the SNF for services subject to consolidated billing," says Rusti Bauman, RN, a nursing and reimbursement consultant with FD&R Healthcare Consulting in Deerfield, Ill.   

Consolidated Billing Scenario

The following example illustrates how to code for an SNF patient seen in the pulmonologist's office:
 
A 68-year-old Medicare beneficiary who has been followed by the pulmonologist for emphysema (492.8) presents to the office for evaluation of increasing episodes of wheezing. The pulmonologist is aware that the patient is receiving a short course of inpatient Part A skilled nursing facility care following a three-day hospitalization for uncontrolled diabetes mellitus (250.03) and influenza with pneumonia (487.0).
 
The doctor orders his office staff to perform a chestx-ray and a finger stick to obtain a white blood cell count, both of which are read as normal. He performs a focused exam, noting obvious wheezing upon chest auscultation. The pulmonologist asks the nurse to administer a nebulizer treatment for acute airway obstruction (94640). The patient's color improves following the treatment.
 
The pulmonologist calls the SNF geriatrician to provide an update on the patient's worsening asthma and suggests nebulizer treatments be provided in the SNF for wheezing episodes. The pulmonary physician bills the SNF for the following services:

 
  • The technical component of the x-ray (71010-71035) if he or she owned the equipment
     
  • The lab test if he or she analyzed the specimen, with modifier -TC (Technical component) appended to the appropriate code 
     
  • The nebulizer treatment (94640), which is considered respiratory therapy and covered by the SNF PPS. No modifier is needed.
     
    The pulmonologist bills the E/M services for the office visit to the carrier using 99213 (Established patient with two of three key components and low to moderate severity of presenting problem with 15 minutes typically spent face-to-face with the patient). The ICD-9 code for the visit is obstructive bronchitis, acute exacerbation (491.21).

    • Sleep Studies, Function Tests and Bronchoscopy
     
     
    The technical component of sleep studies and pulmonary function testing is also included in the SNF PPS rate. "The pulmonologist can only bill the technical component for a sleep study if he or she owns the equipment and pays the salaries of those performing the test," says Deborah Grider, CPC, CPC-H, CCS-P, a coding specialist and president, Medical Professionals Inc. in Indianapolis. "The technical costs include facility costs, that is, the equipment, facility and people who work with that facility or practitioner and are hired to operate the equipment."
     
    Similarly, a pulmonologist bills the technical component of pulmonary function testing using 94010-TC (Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation; technical component) to the SNF if the services are performed in the pulmonologist's pulmonary function lab, rather than a hospital or outside lab. The pulmonary physician also bills the carrier for interpretation of the spirometry using 94010-26, not arterial blood gas (ABG), because there is no charge for interpreting an ABG separately. 
     
    What about bronchoscopy? Consolidated billing excludes ambulatory surgical procedures that require use of an operating suite in an outpatient hospital setting. Therefore, a diagnostic bronchoscopy (31622) would be excluded from the SNF PPS  if it were performed in an outpatient hospital setting. "CMS also regards the use of an endoscopy suite as equivalent to the use of an operating room for purposes of this exclusion," Bauman says.

    E/M Services in SNFs

    Pulmonology physicians should be aware of what carriers view as "gang billing" or seeing multiple patients in an SNF on the same day. "While the physician can do this," Bauman says, "he or she must make sure to docu-ment the visit and write a progress note validating the level of E/M code billed. Same-day billing may be subject to an audit, so it's important for the physician to document the level of services performed."
     
    The frequency of visits to an SNF resident may also be a focus of medical review.
    Carriers are not supposed to impose limits on the frequency of visits to nursing-home residents. "The visits should be based on how stable the resident is and should be documented carefully," Bauman says.

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