Payment

Below, you'll find post-acute and long-term care (PA/LTC) coding information as well as how the Medicare Physician Fee Schedule will affect PA/LTC providers.

Coding in PA/LTC

AMDA Resources

New Transitional Care Management Codes

Prolonged Service Codes (99356-99357)
Threshold Times for Prolonged Service Codes

  • Ask the Expert: Do you have a question about post-acute and long-term care? Your question will be forwarded to an AMDA leader or staff person who has the expertise necessary to answer your question. A response to your question will be e-mailed directly to you. This feature is intended solely for use by AMDA members to confer with colleagues and AMDA staff; it is not intended to dispense medical advice to consumers. Consumers who have medical or health-related questions are urged to consult their physicians.
  • AMDA's Guide to Post-Acute and Long Term Care Coding, Reimbursement and Documentation
  • Centers for Medicare & Medicaid Services and Joint Commission Requirement for Physician Visits
  • Centers for Medicare & Medicaid Services (CMS) Resources
  • CMS’ Medicare Claims Processing Manual - CMS’ Medicare Claims Processing Manual Chapter 12 provides claims processing instructions for physician and non-physician practitioners. The manual includes nursing facility service codes (99304-99318), home and domiciliary care (99324-9935), and prolonged service codes (99354-99360).
  • CMS’ Evaluation & Management Services Guide (updated July 2008) - This guide provides a more detailed description of evaluation & management codes including details on the three key elements of service – history, examination, and medical decision making.
  • CMS Transmittal 808/Change Request 4246/Updated Processing Manual - This transmittal revises the Claims Processing Manual, Pub. 100-04, Chapter 12, §30.6.13 with the new code changes by the American Medical Association Current Procedural Terminology (CPT) 2006 for reporting evaluation and management visits in the skilled nursing facility (SNF) or nursing facility (NF) settings (codes 99304 - 99306 for the initial visit; codes 99307 - 99310 for subsequent nursing facility visits and code 99318 for an annual assessment visit) and who may use these codes. This transmittal identifies the federally mandated visits per the Long Term Care regulations and also clarifies the "initial visit" definition, medically necessary visits, "incident to" services, prolonged services, split/shared evaluation and management services, gang visits, and discharge day management in the SNF and NF settings.
  • Medicare & Medicaid Program Memos and Transmittals - Program transmittals are used to communicate new or changed policies, and/or procedures that are being incorporated into a specific (CMS) program manual.
  • CMS Local Coverage Determinations - click here to search for local coverage determinations made by your local contractors.
  • Frequently Asked Questions about billing for transitional care management (TCM) services. These FAQs are designed to address questions CMS received about billing of the TCM codes such as what date of service should be used on the claim and what place of service.
  • The TCM codes (99495 and 99496) became effective January 1, 2013 and can be used to report physician or qualifying nonphysician practitioners care management services for a patient following a discharge from a hospital, SNF, or CMHC stay, outpatient observations, or partial hospitalization.
  • CMS also previously issued a fact sheet to provide further education on the TCM services.
  • Additional Information

    Prolonged Service Codes (99356-99357)
    Threshold Times for Prolonged Service Codes

    Code Typical Time
    for Code
    Threshold Time
    to Bill Code 99356
    Threshold Time to Bill
    Codes 99356 & 99357
    99305 35 65 110
    99306 45 75 120
    99307 10 65 85
    99308 15 45 90
    99309 25 55 100
    99310 35 65 110
    99318 30 60 105
  • Change Request 5972 - This transmittal updates Chapter 12, §§30.6.15.1 and 30.6.15.2 and provides guidance on the proper use of prolonged service codes.
  • CMS’ MedLearn Matters MM5972 – This article provides additional clarifications and information on the proper use of prolonged service codes.CMS’ Medicare Learning Network - This provides additional clarification and information on the proper use of prolonged service codes.
  • NCCI Edits Issued

    The Centers for Medicare & Medicaid Services (CMS) updates annually its National Correct Coding Initiative (NCCI) Coding Policy Manual for Medicare Services (Coding Policy Manual). The Coding Policy Manual is available on CMS’ NCCI Website and should be utilized by carriers and fiscal intermediaries as a general reference tool that explains the rationale for NCCI edits. The purpose of the NCCI edits is to prevent improper payment when incorrect code combinations are reported. The NCCI contains two tables of edits. The Column One/Column Two Correct Coding Edits table and the Mutually Exclusive Edits table include code pairs that should not be reported together for a number of reasons explained in the Coding Policy Manual.

    CPT codes, descriptions, and material only are Copyright © 2016 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.

    CPT FAQs

    For a full page of CPT FAQs click here.

    ICD-10 Implementation

    On October 1, 2015, the health care industry transitioned from ICD-9 to ICD-10 codes for diagnoses and inpatient procedures. Below are links resources for more information about the transition.

    CMS Releases “Road to 10” Online Resource for Small Practices

    The Centers for Medicare & Medicaid Services (CMS) has released "Road to 10", an online resource built with the help of providers in small practices. This tool is intended to help small medical practices jumpstart their ICD-10 transition.

    “Road to 10” includes specialty references and gives providers the capability to build ICD-10 action plans tailored for their practice needs.

    Understanding the Basics

    These fact sheets will introduce you to ICD-10, explain why it’s necessary, and give you the information you’ll need to get started on your transition.

  • Intro Guide to ICD-10
  • The ICD-10 Transition: An Introduction
  • ICD-10 Basics for Medical Practices
  • Talking to Your Vendors About ICD-10: Tips for Medical Practices
  • ICD-10 Basics for Small and Rural Practices
  • You can now sign up to receive the latest CMS updates on ICD-10 transition here.

    Related Links to ICD-10 Resources

    AHIMA

  • http://www.ahima.org/education/onlineed/Programs/ICD10
  • https://www.ahimastore.org/ProductDetailELearning.aspx?ProductID=16002
  • http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_048119.hcsp?dDocName=bok1_048119
  • http://c.ymcdn.com/sites/www.leadingagemissouri.org/resource/resmgr/docs/icd_10_2014.pdf
  • American Medical Association

  • http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/hipaahealth-insurance-portability-accountability-act/transaction-code-set-standards/icd10-code-set.page
  • Centers for Medicare & Medicaid Services

  • https://www.cms.gov/Medicare/Coding/ICD10/ProviderResources.html
  • https://www.cms.gov/Medicare/Coding/ICD10/index.html?redirect=/ICD10/05a_ProviderResources.asp#TopOfPage
  • Updates in the News

  • ICD-10 Readiness in Long-Term Care
  • LTC Provider Preparation for ICD-10 Implementation
  • What is Your Organization’s ICD-10 IQ?
  • Medicare Part A - Skilled Nursing Facility PPS

    Medicare Part B - Therapy Caps

    Medicare Part D - Prescription Drug Program

    Resources for Physicians:

  • Medicare Part D From The Medical Director Perspective-Slide Presentation
  • CMS "Physician Part D Resource Fact Sheet" (scroll down to "Part D Tools"), includes information on CMS resources; also the physician's role in coverage determination, exceptions and appeals. Most of the resources for physicians have been consolidated at this web site, including access to direct phone numbers to drug plans' coverage determination staff, model forms, and clarification of coverage by Medicare Parts B v. D.
  • CMS Guidance on billing for drugs that may be covered under either Part B or Part D (scroll down to "Part D Tools")
  • Implementation Timetable
  • Drug Benefit Transition Resources from CMS (12-30-05) 
  • Preparing for the New Medicare Prescription Drug Benefit—The Role of the Medical Director and Long Term Care Physician — AMDA publication
  • AMDA summary of the final drug benefit regulation;
  • Slide presentation for physicians and family members on the Medicare drug benefit
  • AMDA analysis of the regulations;
  • Part I: MMA Medicare Drug Benefit Regulation is Final (Caring for the Ages, April 2005);
  • Part II: Medicare Part D Drug Benefit Regulations Place Administrative Burdens on Physicians (Caring for the Ages, May 2005);
  • AMDA analysis of CMS Guidance on Part D; and
  • AMDA Summary of exceptions and appeals processes under Part D.
  • frequently asked:

    Q. How is the time involved in revising drug regiments to comply with drug plan formularies reflected in coding for physician services? What about the time required to request and document exceptions and participate in the appeals process?
    A. CMS has not issued any guidance on how physicians should bill for work related to review of patient drug regimens and revision of drugs to comport with new Part D formularies because they envision it as part of regular MD visit. Simple medication changes involving a minimum of effort should not substantially add to a visit, similar to any encounter using straightforward decision-making. Changes in medication regiments that require significant cognitive work (such as consideration of drug interactions and risk/benefit to resident), increased counseling and coordination of care, and administrative work performed during the resident encounter would increase the level of service, as they would for any re-evaluation of medication regiment.

    There are also no instructions regarding billing for time involved in the exceptions process. CMS now estimates that physician work in requesting exceptions and documenting exceptions requests will take about 5 minutes, rather than the 45 minutes CMS had estimated in the Preamble to the Part D regulation. It should be noted that current changes in 2006 CPT codes do not have time elements yet assigned, so utilization to time should not be a prime determinant.

     

    Q. Are Part D plans required to accept the model Part D Coverage Determination Request Form and the model Part D Exceptions and Prior Authorization Request Form?
    A. Yes. Plans are required to accept any written instrument that is used by a prescribing physician to request a coverage determination or support an exceptions request. According to CMS, "While plans may have their own coverage determination request forms, they must also accept the model forms." A prescribing physician may use the model Exception and Prior Authorization Request Form to simultaneously file a written request for an exception and submit a supporting statement.

     

    Q. When does the adjudication timeframe begin for coverage determination requests that involve a prior authorization requirement or other utilization management requirement (e.g., quantity limit)?
    A. When prescribing physicians attempt to satisfy a PA requirement, the adjudication timeframe begins when the plan receives the request. For coverage determinations and prior authorizations, the Part D plan must notify the enrollee and physician of the decision no later than 24 hours from receiving an expedited request, or no later than 72 hours if the request is not expedited. If the request is received without information demonstrating an attempt to satisfy the PA requirement, the plan is to immediately contact the physician and inform the physician of the PA requirement.

     

    Q. When does the adjudication timeframe begin for exceptions requests?
    A. The timeframe begins when the plan receives the prescribing physician's supporting statement explaining the medical necessity for the drug (e.g., an explanation that the preferred or formulary drug would not be as effective for the enrollee as the requested drug, would have adverse effects for the enrollee, or both; an explanation why the utilization management requirement has been ineffective, is likely to be ineffective, or would have adverse effects for the enrollee.)

    For expedited requests, the plan must notify the enrollee and physician as expeditiously as the enrollee's health conditions required, but no later than 24 hours after receiving the physician's supporting statement. For standard requests, the timeframe is no later than 72 hours after receiving the physician's supporting statement. The model Exception and Prior Authorization Request Form includes check boxes and a free text field that can serve as the prescribing physician's supporting statement.

     

    Q. What can I do if the drug plan requires me to personally telephone the plan to obtain prior approvals?
    A. According to CMS, drug plans must accept the model forms or other written statements submitted by physicians and cannot require personal telephone contact. Drug plan requirements for telephone contact by physicians can be reported to .

     

    Physician Fee Schedule

    National Provider Identifier (NPI)

    CMS Issues Clarification on the Use of National Provider Identifier (NPI) for Secondary Providers

    The Centers for Medicare & Medicaid Services (CMS) issued Change Request (CR) 6093 and a companion MedLearn Matters article MM6093 that provides clarification for reporting NPIs for secondary providers. The change request states that all secondary providers must have an NPI and the billing provider is responsible for identifying the NPI if the secondary providers do not provide it at the time of service. If however, the billing provider is not able to identify the secondary provider NPI, the billing provider must use its own NPI for that secondary provider. To view the complete CR6093, click here. To view the companion MedLearn Matters Article MM6093, click here.

    CMS Recommends Ways to Keep Your NPI Safe

    This message is for health care providers, particularly physicians and other practitioners, who have obtained NPIs and have records in the National Plan and Provider Enumeration System (NPPES). CMS recommends that each health care provider, including individual physicians and non-physician practitioners:

  • Know and maintain their NPPES User Ids and passwords;
  • Reset their NPPES passwords at least once a year. See the NPPES Application Help page regarding the ‘Reset Password’ rules. Those rules indicate the length, format, content and requirements of NPPES passwords; and
  • Review their NPPES records in order to ensure that the information reflects current and correct information.
  • Maintaining NPPES Account Information for Safety and Accessibility

    Health care providers, including physicians and non-physician practitioners, should maintain their own NPPES account information (i.e., User ID, Password, and Secret Question/Answer) for safety and accessibility purposes.

    Viewing NPPES Information

    Health care providers, including physicians and non-physician practitioners, can view their NPPES information in one of two ways:

    1. By accessing the NPPES record, and following the NPI hyperlink and selecting Login. The user will be prompted to enter the User ID and password that he/she previously created. * * If the health care provider has forgotten the password, enter the User ID and click the “Reset Forgotten Password” button to navigate to the Reset Password Page. If the health care provider enters an incorrect User ID and Password combination three times, the User ID will be disabled. Please contact the NPI Enumerator at 1-800-465-3203 if the account is disabled or if the health care provider has forgotten the User ID.
      OR
    2. By accessing the NPI Registry. The NPI Registry gives the health care provider an online view of Freedom of Information Act (FOIA)-disclosable NPPES data. The health care provider can search for its information using the name or NPI as the criterion.

    Updating NPPES Information

    Health care providers, including physicians and non-physician practitioners, can correct, add, or delete information in their NPPES records by accessing their NPPES records and following the NPI hyperlink and selecting Login. The user will be prompted to enter the User ID and password that he/she previously created.

    Please note: Required information cannot be deleted from an NPPES record; however, required information can be changed/updated to ensure that NPPES captures the correct information. Certain information is inaccessible via the web, thus requiring the change/update to be made via paper application. The paper NPI Application/Update Form can be downloaded and printed here.

    Need more information?

    Providers can apply for an NPI online or can call the NPI enumerator to request a paper application at 1-800-465-3203. Having trouble viewing any of the URLs in this message? If so, try to cut and paste any URL in this message into your web browser to view the intended information.

    Note: All current and past CMS NPI communications are available by clicking "CMS Communications" in the left column of the CMS webpage.

    Medicare Reminder--Accelerated/Advance Payments May Be Available for Financial Hardships Associated with NPI Implementation

    Some Medicare providers and suppliers might experience cash flow issues during their efforts to implement the NPI. The Medicare contractors and CMS will consider the availability of advance or accelerated payments where facts and circumstances fall within the scope of the CMS regulations and/or manual requirements for such payments

    In general, entities who bill without an NPI do not warrant consideration for an advance or accelerated payment since Medicare providers have been given ample time to secure an NPI.

    Medicare providers who may be experiencing cash flow problems related to NPI claims processing issues should contact their Medicare contractor to determine if they are eligible for an advance or accelerated payment. The Medicare contractor will review the request and provide a decision.

    Information and education on the NPI can be found here. Providers can apply for an NPI online here.

    Additional Resources

  • CMS has made available searchable data files of the NPI registry. To view and download the registry, click here.
  • There are a number of educational materials available on the CMS website.
  • NPI Frequently Asked Questions (FAQs)
  • Apply Now - National Plan and Provider Enumeration System (NPPES)
  • SNF Telehealth Services

    Frequently Asked Question on Telehealth

    Question: Will Medicare Part B pay for initial and subsequent nursing facility visits furnished by telehealth?

    Answer: Effective January 1, 2011, the Centers for Medicare & Medicaid Services approved the addition of subsequent nursing facility care services (99307–99310) to the list of Medicare telehealth services with the limitation of one telehealth subsequent nursing facility care service every 30 days. The initial visit and Federally-mandated periodic visits [as defined by 42 CFR §483.40(c)] should be conducted in-person. It may not be furnished through telehealth. Medicare beneficiaries are eligible for telehealth services only if they are in an originating site (skilled nursing facilities are an authorized originating site) located in a rural health professional shortage area or in a county outside of a Metropolitan Statistical Area. As a condition of payment, an interactive audio and video telecommunications system must be used that permits real-time communication between a physician or practitioner at the distant site and the beneficiary at the originating site.

    Background

    Section 149 of Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) added hospital-based or critical access hospital-based renal dialysis centers, skilled nursing facilities, and community mental health centers to the list of entities that may act as originating sites for payment of telehealth services, effective January 1, 2009. The Centers for Medicare & Medicaid Services noted in its Physician Fee Schedule Final Rule that since MIPPA does not change the existing eligibility criteria for payment and billing requirements related to telehealth services, it is adopting policies similar to existing policies with respect to provision of and payment for telehealth services in these additional originating sites. CMS is doing so on an interim final basis and will respond to any comments and finalize policies in subsequent rulemaking. CMS also announced that the CY 2009 originating site facility fee is $23.72.

    More specifically, services provided by distant site physicians or practitioners are only paid for via telehealth if such services are not included in a bundled payment to the facility that serves as an originating site. The telehealth originating site facility fee is a separately billable Part B payment that is payable outside any other payment methodology. Renal dialysis centers, the community mental health centers and SNFs are all paid based upon different payment systems. Therefore, for example, when a SNF is the originating site for Medicare telehealth services, it can receive separate payment for a telehealth originating site facility fee in addition to a bundled per diem payment under the SNF PPS for a resident’s covered Part A stay. Also, not only would the originating site facility fee be separately billable outside of the SNF PPS, but so would those professional services (furnished at the distant site) that meet criteria specified in section 1834(m)(2)(A) of the Act for payment as telehealth services.

    However, payment for the services of clinical social workers, registered dieticians, and nutritional specialists may not be paid for under the telehealth benefit as these services are bundled in the SNF/PPS. There are similar restrictions for professional services furnished via telehealth if the services are included in the composite rate or the monthly capitation rate for physician services payable to ESRD facilities.

    Eligibility Requirements

    According to Medicare Claims Processing Manual Chapter 12 Section 190.2, Medicare beneficiaries are eligible for telehealth services only if they are presented from an originating site located in either a rural health professional shortage area (HPSA) as defined by §332(a)(1) (A) of the Public Health Services Act or in a county outside of an MSA as defined by §1886(d)(2)(D) of the Act.

    Entities participating in a Federal telemedicine demonstration project that were approved by or were receiving funding from the Secretary of Health and Human Services as of December 31, 2000, qualify as originating sites regardless of geographic location. Such entities are not required to be in a rural HPSA or non-MSA.

    Eligible Telehealth Services

    According to Medicare Claims Processing Manual Chapter 12 Section 190.3, eligible services include:

  • Consultations (CPT codes 99241 - 99255) - Effective January 1, 2006;
  • Office or other outpatient visits (CPT codes 99201 - 99215);
  • Individual psychotherapy (CPT codes 90804 - 90809);
  • Pharmacologic management (CPT code 90862);
  • Psychiatric diagnostic interview examination (CPT code 90801) – Effective March 1, 2003;
  • End Stage Renal Disease (ESRD) related services (HCPCS codes G0308, G0309, G0311, G0312, G0314, G0315, G0317, and G0318) – Effective January 1, 2005;
  • Individual Medical Nutrition Therapy (HCPCS codes G0270, 97802, and 97803) - Effective January 1, 2006;
  • Neurobehavioral status exam (CPT code 96116) - Effective January 1, 2008; and
  • Follow-up inpatient telehealth consultations (HCPCS codes G0406, G0407, and G0408) - Effective January 1, 2009.
  • The use of a telecommunications system may substitute for a face-to-face, “hands on” encounter for these services. Additional services will be added through the rulemaking process. See the CMS website link below for more information.
  • Important Links

  • CMS Web site
  • Medicare Claims Processing Manual Chapter 12 Sections 190-190.7
  • Medicare Claims Processing Manual Chapter 15 Sections 270-270.5.1
  • Change Request 6215