This First Coast Billing and Coding Article for Local Coverage Determination (LCD) L36230 Evaluation and Management Services in a Nursing Facility provides billing and coding guidance for frequency limitations as well as diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in the LCD, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.
Refer to the LCD for reasonable and necessary requirements and limitations.
The redetermination process may be utilized for consideration of services performed outside of the reasonable and necessary requirements in the LCD.
Coding Guidelines
The CPT 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 CPT Nursing Facility code definition also includes POS 54 (Intermediate Care Facility/Mentally Retarded) and POS 56 (Psychiatric Residential Treatment Center).
Initial Nursing Facility Care, per day, (99304, 99305, and 99306) shall be used to report the initial visit.
A readmission to a SNF or NF shall have the same payment policy requirements as an initial admission in both the SNF and NF settings.
A physician who is employed by the SNF/NF may perform the E/M visits and bill independently to Medicare Part B for payment. An NPP who is employed by the SNF or NF may perform and bill Medicare Part B directly for those services where it is permitted as discussed above. The employer of the PA shall always report the visits performed by the PA. A physician, NP, or CNS has the option to bill Medicare directly or to reassign payment for his/her professional service to the facility. As with all E/M visits for Medicare Part B payment policy, the E/M documentation guidelines apply.
The principal physician of record must append the modifier “-AI” (Principal Physician of Record) to the initial nursing facility care code. This modifier will identify the physician who oversees the patient’s care from other physicians who may be furnishing specialty care. All other physicians or qualified NPPs who perform an initial evaluation in the NF or SNF may bill the initial nursing facility care code.
Payment is made under the physician fee schedule by Medicare Part B for federally mandated visits.
Subsequent Nursing Facility Care, per day (CPT codes 99307, 99308, 99309, and 99310) shall be used to report federally mandated physician E/M visits and medically necessary E/M visits.
Contractors shall not pay for more than one E/M visit performed by the physician or qualified NPP for the same patient on the same date of service. The Nursing Facility Services codes represent a "per day" service.
The federally mandated E/M visit may serve also as a medically necessary E/M visit if the situation arises (i.e., the patient has health problems that need attention on the day the scheduled mandated physician E/M visit occurs). The physician/qualified NPP shall bill only one E/M visit.
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 nursing facility 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 code (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 a Medicare Part B physician service.
A physician or NPP may bill the most appropriate initial nursing facility care code (99304, 99305, 99306) or subsequent nursing facility care code (99307, 99308, 99309, and 99310), even if the E/M service is provided prior to the initial federally mandated visit.
A split/shared E/M visit cannot be reported in the SNF/NF setting. The split/shared E/M visit applies only to selected E/M visits and settings (i.e., hospital inpatient, hospital outpatient, hospital observation, emergency department, hospital discharge, office and non-facility clinic visits, and prolonged visits associated with these E/M visit codes).
Effective January 1, 2010, consultation codes are no longer recognized for Medicare Part B payment. Physicians shall code patient evaluation and management visits with E/M codes that represent where the visit occurs and that identify the complexity of the visit performed. In the nursing facility setting, all physicians (and qualified nonphysician practitioners where permitted) may bill the most appropriate initial nursing facility care code (99304, 99305, and 99306) or subsequent nursing facility care code (99307, 99308, 99309, 99310) that reflects the services the physician or practitioner furnished.
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. 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.
Notice: It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.
Documentation Requirements
- All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
- Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
- The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.
- It would not be appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported. The service should be documented during or as soon as practicable after it is provided in order to maintain an accurate medical record.
- Documentation must detail the specific elements of the E/M service for the patient on the day of service. It must be clear from the documentation why the service was necessary that day. Services supported by repetitive entries lacking encounter specific information will be denied.
- The documentation of each patient encounter must include the following:
- reason for the encounter and relevant history;
- physical examination findings and prior diagnostic test results, if applicable;
- assessment, clinical impression, or diagnosis; and
- medical plan of care
- Documentation for billed visits must meet the required components of the E/M service code. Qualified E/M services health care professionals may use either the 1995 or 1997 documentation guidelines to document a patient encounter.
Utilization Guidelines
In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.
Compliance with the provisions in LCD L36230, Evaluation and Management Services in a Nursing Facility may be monitored and addressed through post payment data analysis and subsequent medical review audits.
