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Savvy Coder: Coding & Reimbursement

Correct Coding in a Nursing Facility

By Sue Vicchrilli, COT, OCS, Academy Coding Executive

The Academy has received numerous questions with regard to the correct coding of office visits and special ophthalmic testing services for patients in skilled nursing facilities (SNFs) and nursing facilities (NFs). To understand the billing process, we must first identify the differences between the two types of facility.

An NF is a facility that provides 24-hour inpatient care to residents who need licensed supervision and supportive care but who do not require continuous nursing care. It is not certified as a SNF.

A SNF is certified by Medicare to have the staff and equipment necessary to give skilled nursing care and/or skilled rehabilitation services and other related health services.

Coding in a Nursing Facility
For a patient in an NF, examinations billed on the same day a procedure is performed must be supported with documentation of medical necessity (e.g., an additional illness or complications of an existing problem not related to the procedure). Modifier –25 significant, separately identifiable E&M service by the same physician on the same day of a procedure or other service, should be used.

If the primary purpose of the visit was to perform the procedure, the visit will not be allowed.

Medicare reimbursement can be made for one physician visit to the same patient in an NF in a calendar month. This is on the presumption that the visit is medically necessary for a person whose condition requires him to reside in such a home. Further visits are reimbursed only in situations where the physician has adequately substantiated the need for more frequent visits to the specific patient.

Claims submitted for more than one service in a calendar month should include documentation to support the following:

  • medical necessity of the service provided (e.g., acute illness)
  • level of service provided
  • medical necessity to support the frequency of the nursing home visits provided (e.g., change in treatment plan)

If you are coding for evaluation and management of a new or established patient involving an annual nursing facility assessment, use CPT codes 99301 to 99303.

For subsequent nursing facility care, per day, for the evaluation and management of a new or established patient, use CPT codes 99311 to 99313.

For a domiciliary or rest home visit for the evaluation and management of a new patient, use CPT codes 99321 to 99323.

For a domiciliary or rest home visit for the evaluation and management of an established patient, use CPT codes 99331 to 99333.

For the complete definition of each of the above codes, please see your copy of CPT 2004.

Coding for a SNF Patient
If the exam is performed in a SNF, use the CPT codes listed under NF. But coding for special ophthalmic testing services, including performance of an A-scan prior to cataract surgery, is a different matter. Which services must be billed by the physician? Which services have to be billed by the SNF? The ophthalmologist bills for the professional component of the test (using modifier –26) and the SNF bills for the technical component (using –TC). The SNF would then pay the physician for the technical component. This is true even when the equipment is owned and operated by the ophthalmic practice.

Place of Service
Medicare relies on the provider to accurately report the proper place of service on the claim form. For an office, NF or SNF, you would code –12, –13 or –31, respectively.

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