Covered Indications
1. Initial Nursing Facility Care
Initial nursing facility care includes all evaluation and management services (E/M) performed by the same physician or group done in conjunction with that admission when performed on the same date as the admission or readmission. The nursing facility care level of service reported by the admitting physician should include the services related to the admission he/she provided in the other sites of service, as well as, in the nursing facility setting.
The initial visit in a skilled nursing facility (SNF) and nursing facility (NF) must be performed by the physician except as otherwise permitted (42 CFR 483.30 (c) (4)). The initial visit is defined 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 (S&C) requirements, the visit must occur no later than 30 days after admission.
Further, per the Long-Term Care regulations at 42 CFR 483.30 (c) (4) and (e) in a SNF, the physician may not delegate a task that the physician must personally perform. Therefore, the physician may not delegate the initial comprehensive visit in a SNF. The only exception, as to who performs the initial visit, relates to the NF setting (42 CFR 483.30 (f)). In the NF setting, a qualified non physician practitioner (NPP) such as 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 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. 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.
2. Subsequent Nursing Facility Care
Coverage for subsequent nursing facility care for evaluation of specific medical conditions will be considered reasonable and necessary if they would require the skill of a physician or non-physician practitioner (where permitted by state licensure) to evaluate the patient in a face-to-face contact.
In the nursing home environment, patients are in a controlled environment in which they are under close supervision and have immediate access to care from trained medical professionals. Under these circumstances, it is customary for physicians to direct nursing home personnel to perform, in the absence of the physician, many of those services that may be necessary but of a relatively minor nature. Frequent visits by the physician under these circumstances would then be unnecessary, particularly if the patient is medically stable. However, it would not be unreasonable for the attending physician to make several visits at the time of a new episode of illness or an acute exacerbation of a chronic illness. The medical record must clearly reflect the particular circumstances requiring the increased frequency of services by documenting the following:
- patient instability or change in condition that the physician documents is significant enough to require a timely medical or mental status evaluation and/or physical examination to establish the appropriate treatment intervention and/or change in care plan;
- therapeutic issues that the physician documents require a timely follow-up evaluation to assess effectiveness of therapy or treatment; for example, recent surgical or invasive diagnostic procedures, pressure ulcer evaluation, psychotropic medication regimens, or (for the terminally ill) comfort measures;
- medical conditions including delirium, dementia, or changes in mental status manifested with behavioral symptoms that require timely evaluation; and
- nursing staff, rehabilitation staff, patient, or family requests to address a documented medical issue of concern that requires a physical (or mental status) examination.
The following clinical situations are examples of conditions where more frequent visits may be considered reasonable and necessary:
- stage III or IV pressure sore healing
- management of acute exacerbation of unstable COPD
- management of acute exacerbation of unstable angina
- management of acute exacerbation of unstable diabetes
- acute infection
- acute behavioral cognitive and/or functional changes
- acute fall or injury
The medical record must clearly reflect the medical necessity of the service, as well as, the key components necessary to report the particular level of care reported.
3. Visits to Comply with Federal Regulations in the SNF and NF
The distinction made between the delegation of physician visits and tasks in a skilled nursing facility (SNF) and in a nursing facility (NF) is based on the Medicare Statute. Section 1819 (b) (6) (A) of the Social Security Act (the Act) governs SNF’s while section 1919 (b) (6) (A) of the Act governs NF’s. The federally mandated visits in a SNF and NF must be performed by the physician except as otherwise permitted (42 CFR 483.30 (c) (4) and (f)). Please refer to 42 CFR 483.30 (c) (1) for frequency of physician visits.
4. Visits by Qualified Non-Physician Practitioners
All E/M visits shall be within the State scope of practice and licensure requirements where the visit is performed, and all the requirements for physician collaboration and physician supervision shall be met when performed and reported by qualified NPPs. General physician supervision and employer billing requirements shall be met for PA services in addition to the PA meeting the State scope of practice and licensure requirements where the E/M visit is performed.
5. Medically Necessary Visits
Qualified NPPs may perform medically necessary E/M visits prior to and after the physician's initial visit in both the SNF and NF. Medically necessary E/M visits for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member are payable under the physician fee schedule under Medicare Part B.
6. 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.
7. Multiple Visits
The complexity level of an E/M visit billed must be a covered and medically necessary visit for each patient.
Limitations
- Indications that are not listed in the "Covered Indications" section of this LCD.
- The service was not directly provided by the physician or non-physician practitioner.
- The service was provided without face-to-face interaction with the patient.
- The medical record documentation does not clearly satisfy the Medicare criteria for "Reasonable and Necessary."
- The service is covered under a contract with the nursing home.
- The service is a bundled part of facility services furnished to Medicare beneficiaries in the participating facility.
- Follow-up subspecialty and/or specialized care is/are not clearly documented in the medical record to reflect the medical necessity of the service(s) rendered.
- Consecutive daily or courtesy visits are not reasonable and necessary for follow-up.
- The service is for non-covered screening purposes.
- The medical record does not verify that the service described by the CPT/HCPCS code was provided.
- Medicare Part B payment policy does not pay for additional visits that may be required by State law for a facility admission or for other additional visits to satisfy facility or other administrative purposes. E/M visits, prior to and after the initial physician visit, that are reasonable and medically necessary to meet the medical needs of the individual patient (unrelated to any State requirement or administrative purpose) are payable under Medicare Part B.
- Where a physician establishes an office in a SNF/NF, the "incident to" services and requirements are confined to this discrete part of the facility designated as his/her office. "Incident to" E/M visits, provided in a facility setting, are not payable under the Physician Fee Schedule for Medicare Part B. Thus, visits performed outside the designated "office" area in the SNF/NF would be subject to the coverage and payment rules applicable to SNF/NF setting.
- Claims for an unreasonable number of daily E/M visits by the same physician to multiple patients at a facility within a 24-hour period may result in medical review to determine medical necessity for the visits. The E/M visit (Nursing Facility Services) represents a "per day" service per patient. The medical record must be personally documented by the physician or qualified NPP who performed the E/M visit, and the documentation shall support the specific level of E/M visit to each individual patient.
- Many elderly patients have chronic conditions such as hypertension, diabetes, orthopedic conditions, and abnormalities of the toenails. The mere presence of inactive or chronic conditions does not constitute medical necessity for any setting. There must be a chief complaint or a specific reasonable and medically necessary need for each visit.
- Medical necessity must exist for each individual visit and must not be a visit of convenience (unless the medical record clearly documents the necessity for the visit). The initial visit and the reason for subsequent visits must not be driven by group visits to one facility without other factors as mentioned above (e.g., the clear support of medical necessity for each individual visit). The service must not be solicited.
As published in the CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 13, Section 13.5.4, an item or service may be covered by a contractor LCD if it is reasonable and necessary under the Social Security Act Section 1862 (a)(1)(A). Contractors shall determine and describe the circumstances under which the item or service is considered reasonable and necessary.
