Local Coverage Article Billing and Coding

Billing and Coding: Evaluation and Management Services Provided in a Nursing Facility

A56712

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Contractor Information

Article Information

General Information

Article ID
A56712
Article Title
Billing and Coding: Evaluation and Management Services Provided in a Nursing Facility
Article Type
Billing and Coding
Original Effective Date
07/25/2019
Revision Effective Date
11/21/2019
Revision Ending Date
N/A
Retirement Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

CPT codes, descriptions and other data only are copyright 2021 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

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CMS National Coverage Policy

N/A

Article Guidance

Article Text

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.

Coding Information

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.

Coding Information

CPT/HCPCS Codes

Group 1

(10 Codes)
Group 1 Paragraph

Note: Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book.

Group 1 Codes
CodeDescription
99304 Nursing facility care init
99305 Nursing facility care init
99306 Nursing facility care init
99307 Nursing fac care subseq
99308 Nursing fac care subseq
99309 Nursing fac care subseq
99310 Nursing fac care subseq
99315 Nursing fac discharge day
99316 Nursing fac discharge day
99318 Annual nursing fac assessmnt

CPT/HCPCS Modifiers

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

(1 Code)
Group 1 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

NOTE: No diagnosis to procedure code limitations are being applied at this time.

Group 1 Codes
CodeDescription
XX000 Not Applicable

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

(1 Code)
Group 1 Paragraph

N/A

Group 1 Codes
CodeDescription
XX000 Not Applicable

Additional ICD-10 Information

N/A

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

CodeDescription
999x Not Applicable

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

CodeDescription
99999 Not Applicable

Other Coding Information

N/A

Revision History Information

Revision History DateRevision History NumberRevision History Explanation
11/21/2019 R1

Article revised and published on 11/21/2019. Consistent with CMS Change Request 10901, all coding information from the related LCD has been placed into this article. Due to system changes, the order of the Coding Section has been revised and new sections for CPT/HCPCS Modifiers and Other Coding Information have been added.

Associated Documents

Related National Coverage Documents
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Statutory Requirements URLs
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Rules and Regulations URLs
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CMS Manual Explanations URLs
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Other URLs
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Public Versions
Updated On Effective Dates Status
11/15/2019 11/21/2019 - N/A Currently in Effect You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

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