- I am an attending physician for a dually eligible (Medicare and Medicaid) long-term care patient, do I bill Medicare or Medicaid?
Medicare is the primary payer for dual eligible. Medicaid is the secondary payer. Depending on the state, Medicare may cover 80% of the cost of the service and the 20% co-insurance or deductible is paid by Medicaid, either entirely or in part. The physician who participates in the Medicare program often may coordinate with the state to have the Medicaid co-insurance or deductible billing done automatically. It should be noted however, that since the repeal of the Boren Amendment, the state can waive its responsibility to pay the deductible by determining that the 80% of the charge to Medicare is equivalent to 100% of the state’s value for that visit and thus the state owes the physician no additional funds.
A computer-based training (CBT) course called “World of Medicare” is available from Centers for Medicare& Medicaid Services (CMS). It is an introduction to the Medicare program for providers. It covers the basics of Medicare's covered services, forms, etc. The course can be downloaded from the CMS website at the Medlearn Product Ordering Page under "Web-Based Training Courses” and completed at no charge.
- What are the documentation requirements needed to satisfy an audit for seeing the same patient more than once a month? What can I do to protect myself?
In 2001, AMDA published the White Paper on Determination and Documentation of Medical Necessity in Long Term Care Facilities. This white paper was published to assist physicians with properly determining medical necessity. AMDA recommends that the physician be prepared to justify how the service or intervention is sound clinical practice and that it reflects reasonable and realistic goals, and expected outcomes.
For additional information, please see the Centers for Medicare & Medicaid Services’ (CMS) “1997 Documentation Guidelines for Evaluation and Management Services.” It can be downloaded from the CMS website at http://www.cms.gov/MLNProducts/Downloads/MASTER1.pdf.
As work on revising these Guidelines has been halted, the Centers for Medicare & Medicaid Services has been advising the use of either the 1995 or 1997 versions.
- I work with nurse practitioners (NP) who are in the facility when the patient arrives. We understand that the NP cannot bill the 99304-99306 series. May the NP bill the 99307-99310 before or on the same day as the physician bills the 99304-99310?
The NP may bill the 99307-99310 before the physician bills the 99304-99310, but not on the same day as the physician bills the 99304-99310.
The NP may bill the 99307-99310 before the physician bills the 99304-99310, but only under certain circumstances defined by Medicare Part B payment policy. CMS Transmittal 792/Change Request 4246/Updated Claims Processing Manual (Pub. 100-04, Chapter 12, §30.6.13) reiterates the policy:
The initial visit in a SNF and NF must be performed by the physician except as otherwise permitted (42 CFR 483.40 (c)(4)). The initial visit is defined in S&C-04-08 as the initial comprehensive assessment visit during which the physician completes a thorough assessment, develops a plan of care and writes or verifies admitting orders for the nursing facility resident. For Survey and Certification requirements, a visit must occur no later than 30 days after admission.
Further, per the Long Term Care regulations at 42 CFR 483.40 (c)(4) and (e) (2), the physician may not delegate a task that the physician must personally perform. Therefore, as stated in S&C-04-08 the physician may not delegate the initial visit in a SNF. This also applies to the NF with one exception.
The only exception, as to who performs the initial visit, relates to the NF setting. In the NF setting, a qualified NPP (i.e., a nurse practitioner (NP), physician assistant (PA), or a clinical nurse specialist (CNS)), who is not employed by the facility, may perform the initial visit when the state law permits this. The evaluation and management (E/M) visit shall be within the state scope of practice and licensure requirements where the E/M visit is performed and the requirements for physician collaboration and physician supervision shall be met.
Under Medicare Part B payment policy, other medically necessary E/M visits may be performed and reported prior to and after the initial visit, if the medical needs of the patient require an E/M visit. (Please see previous question on determination of medical necessity above.) A qualified NPP may perform medically necessary E/M visits prior to and after the initial visit if all the requirements for collaboration, general physician supervision, licensure and billing are met.
The transmittal can be downloaded from the CMS website at http://www.cms.gov/transmittals/downloads/R808CP.pdf.
- I am a medical director of a subacute care program in a rehab facility and am responsible for daily guidance and assistance to nurses and therapists. We have weekly team conferences that include the nursing staff, pharmacists, and therapists to discuss all patients and set new goals and establish outcomes. We also have weekly family conferences with the patients, family members, and members of the care team where we discuss the patient's progress and our discharge recommendations. Are there CPT codes that I can use for these conferences?
Unfortunately, there are no discrete CPT codes for interdisciplinary team or family conferences. However, if you are the attending physician for the patient being discussed in either type of conference, when you choose the subsequent care code for the next actual visit to this patient, you should document and consider the additional medical decision-making time and activity generated by the conference, much as you do for the telephone calls between visits related to that patient's care.
If these conferences are related only to your responsibilities as medical director of the subacute care program in the facility, this time and responsibility should be part of the job description, contractual agreement, and administrative fee you establish with the facility administration for your services as medical director.
This is one of several questions and answers about CPT coding in the recently published revised edition of AMDA's Guide to Long Term Care Coding, Reimbursement and Documentation. The booklet is available for $25 for AMDA members and $35 for nonmembers.
- For Medicare purposes, must a face-to-face visit between the physician and patient always occur to bill an evaluation and management service?
Yes. Although the Current Procedural Terminology (CPT) definitions for codes 99315 and 99316 are somewhat ambiguous in this respect, two Centers for Medicare & Medicaid Services (CMS) sources state that a face-to-face visit is required. According to a letter dated January 4, 2002, from to AMDA from CMS, "For Medicare purposes, a face-to-face visit between the physician and patient must always occur (with rare exceptions) in order to bill an evaluation and management (E/M) service. A face-to-face visit is required for a nursing facility discharge E/M service (code 99315 or 99316).” To view a complete copy of the CMS letter, click here.
CMS Transmittal 792/Change Request 4246/Updated Claims Processing Manual (Pub. 100-04, Chapter 12, §30.6.13 ) states under Requirement 4246.22, "Carriers shall instruct physicians and qualified NPPs to report CPT Code 99315-99316 (Nursing Facility Discharge Service) for an E/M visit (must be face-to-face) for discharge from the SNF/NF." The transmittal can be downloaded from the CMS website here.
- When discharging a patient from a nursing facility, I am billing for services using 99315 and 99316 even if the services are not provided on the same day as the discharge day of the resident. Is this the correct way to bill for these services?
Yes. This is allowable under Change Request 4246 (Transmittal 808) from January 6, 2006. Requirement 4246.23 states, "Carriers shall instruct physicians and qualified NPPs that the SNF/NF discharge shall be reported for the actual date of the E/M visit even if the patient is discharged from the facility on a different date." Within the manual instructions, Section 30.6.13 - Nursing Facility Services (Codes 99304 - 99318), Subsection I has been changed to read, "The E/M discharge day management visit shall be reported for the date of the actual visit by the physician or qualified NPP even if the patient is discharged from the facility on a different calendar date."
Some facilities bill for the services performed by a physician that were completed around the time of discharge for pre-work (work completed prior to discharge day) and post-work (completed after discharge day). This practice results in one billing for the accumulated time it has taken to complete discharge services.
- If I were not present when a resident died and did not perform the pronouncement of death, may I bill the 99315-99316 discharge codes and be reimbursed?
No. To bill under the 99315-99316 discharge series in a nursing facility, the physician must perform the final examination of the resident, counseling and prepare the discharge records. The Centers for Medicare & Medicaid Services’ (CMS) Transmittal 792/Change Request 4246/Updated Claims Processing Manual (Pub. 100-04, Chapter 12, §30.6.13 ) requirement 4246.24 states, "Carriers shall instruct physicians and qualified NPPs that CPT codes 99315-99316 (Nursing Facility Discharge Service) may be used to report a death pronouncement only if the physician or qualified NPP performed the pronouncement." The transmittal can be downloaded from the CMS website here.
- If a patient is released from the facility to a hospital, and then returns to the facility, do I bill for a 99304-99306 for a new admission, or do I bill 99307-99310 for a subsequent visit?
The key is whether or not the patient has been formally admitted and discharged using the 99315-99316 discharge codes. If the patient has been formally discharged from the facility and is being readmitted, the physician can bill a 99304-99306. If the patient was out for observation and then returns to the facility without a formal discharge, the coding is for a subsequent visit using 99307-99310.
- Which is the appropriate E/M code for an annual history and physical of a patient residing in a custodial care setting? What are the minimum visit requirements for these residents?
The requirements for an annual regulatory history and physical is applicable to patients receiving skilled care, nursing facility or intermediate care facility care, but it does not at this time encompass residents in assisted living settings or board and care facilities. Because the term "custodial" is occasionally used for patients at both the nursing facility and assisted living levels, it is incorrect to simply state that a history and physical may be performed in a "custodial care setting." The distinction lies in the medical component offered by the facility, not the status of the patient.
Below are excerpts from the State Operations Manual, which provides specific guidelines on nursing facility/skilled nursing facility care. There is also excerpted information on the appropriateness of using domiciliary codes when billing for physician services.
Excerpted from the State Operations Manual, Appendix PP, found here.
The following are the statutory definitions at §§1819(a) and 1919(a) of the Social Security Act (the Act) for a skilled nursing facility and a nursing facility:
"Skilled nursing facility" is defined as an institution (or a distinct part of an institution) which is primarily engaged in providing skilled nursing care and related services for residents who require medical or nursing care, or rehabilitation services for the rehabilitation of injured, disabled, or sick persons, and is not primarily for the care and treatment of mental diseases; has in effect a transfer agreement (meeting the requirements of §1861(1)) with one or more hospitals having agreements in effect under §1866; and meets the requirements for a SNF described in subsections (b), (c), and (d) of this section.
"Nursing facility" is defined as an institution (or a distinct part of an institution) which is primarily engaged in providing skilled nursing care and related services for residents who require medical or nursing care, rehabilitation services for the rehabilitation of injured, disabled, or sick persons, or on a regular basis, health-related care and services to individuals who because of their mental or physical condition require care and services (above the level of room and board) which can be made available to them only through institutional facilities, and is not primarily for the care and treatment of mental diseases; has in effect a transfer agreement (meeting the requirements of §1861(1)) with one or more hospitals having agreements in effect under §1866; and meets the requirements for a NF described in subsections (b), (c), and (d) of this section.
If a provider does not meet one of these definitions, it cannot be certified for participation in the Medicare and/or Medicaid programs.
Excerpted from the Medicare Carriers Manual, Part 3 - Claims Process, Section 15510 found
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