Refer to the Novitas Local Coverage Determination (LCD) L35068, Evaluation and Management Services Provided in a Nursing Facility, for reasonable and necessary requirements.
The Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) code(s) may be subject to National Correct Coding Initiative (NCCI) edits. This information does not take precedence over NCCI edits. Please refer to NCCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.
Initial Nursing Facility Care, per day, (99304, 99305, and 99306) shall be used to report the initial visit. Only a physician may report these codes for an initial visit performed in a SNF (skilled nursing facility) or NF (nursing facility) (with the exception of the qualified NPP in the NF setting who is not employed by the facility and when State law permits, as explained above).
Refer to L35068 for reasonable and necessary requirements for subsequent nursing facility care. These codes are described as CPT codes 99307, 99308, 99309, and 99310.
Subsequent Nursing Facility Care, per day, (99307, 99308, 99309 and 99310) shall be used to report federally mandated physician E/M visits and medically necessary E/M visits. The CPT code 99318 describes the evaluation and management of a patient involving an annual nursing facility assessment. This code should be used to report an annual nursing facility assessment visit on the required schedule of visits on an annual basis. For Medicare Part B payment policy, an annual assessment visit code may substitute as meeting one of the federally mandated physician visits if the code requirements for CPT code 99318 are fully met and in lieu of reporting a Subsequent Nursing Facility Care, per day, service codes 99307, 99308, 99309, and 99310. It shall not be performed in addition to the required number of federally mandated physician visits. The CPT annual assessment code does not represent a new benefit service for Medicare Part B physician service.
Nursing Facility Services codes shall be used with place of service (POS) 31 (SNF) if the patient is in a Part A SNF stay. They shall be used with POS 32 (NF) if the patient does not have Part A SNF benefits or if the patient is in a NF or in a non-covered SNF stay (e.g., there was no preceding 3-day hospital stay). The Nursing Facility code definition also includes POS 54 (Intermediate Care Facility/Mentally Retarded) and POS 56 (Psychiatric Residential Treatment Center).
Medically Complex Care
Payment is made for E/M visits to patients in a SNF who are receiving services for medically complex care upon discharge from an acute care facility when the visits are reasonable and medically necessary and documented in the medical record. Physicians and qualified NPPs shall report E/M visits using the Subsequent Nursing Facility Care, per day (CPT codes 99307, 99308, 99309, and 99310) for these E/M visits even if the visits are provided prior to the initial visit by the physician.
SNF/NF Discharge Day Management Service (99315 and 99316)
Medicare Part B payment policy requires a face-to-face visit with the patient provided by the physician or the qualified NPP to meet the SNF/NF discharge day management service as defined by the CPT code. 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. The CPT code 99315 or 99316 shall be reported for this visit. The Discharge Day Management Service may be reported using CPT code 99315 or 99316, depending on the code requirement, for a patient who has expired, but only if the physician or qualified NPP personally performed the death pronouncement.
The CPT modifier -32 (Mandated Services) is not recognized as a payment modifier in Medicare. A second opinion evaluation service to satisfy a requirement for a third party payer is not a covered service in Medicare.