American Academy of Ophthalmology Web Site: www.aao.org
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
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:
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
Place of Service