Transcript Case Studies in Billing and Coding in the Carolinas

Case Studies in
Nursing Home
Billing and Coding
Charles Crecelius
MD PhD FACP MD
Exercise 28

88 yo cognitively intact NH resident with
ALS has no advance directives and wants
to discuss her prognosis and advance care
plans with her family, who have variable
feeling of what to do. 40 minutes are
spent discussing her condition, her
wishes, and formulating an advance care
plan that expresses her desires.
Advance Care Planning Codes


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

CPT 99497; 99498 starting January 2016
Used to report F2F time with patient, family
or surrogate in explaining, counseling and
discussing advance directives, with or without
completing ACP forms
No active management of the problem(s)
during time period, but is billed with E/M visit
Details pending (documentation / frequency)
First 30 minutes: 99497 $86
Each additional 30 minutes: 99498 $86
More to follow…….
Exercise 27

Mr. Johnson’s family after the first month
home requires frequent attention. Staff
and physician make multiple calls a month
regarding community resources, DM and
CHF management, coordinating care with
other providers, and revising a written
care plan which is shared with the family
Chronic Care Management
Services 99490





Only CPT code for chronic non-face to face
disease management covered
Must have 2 or more chronic conditions
which will last 12 months or until death,
with significant risk of death, acute
exacerbation-decompensation or functional
decline
Home, AL and residential based … for now
Includes non-face to face physician & staff
work
Not billed with care plan or TCM codes
What’s Necessary to Bill 99490
Care plan documented and shared with patient –
caregiver, based on physical, social, functional &
environmental assessment, comprehensive for all
health problems
 Includes interacting with all to establish / revise
care plan, coordinating care and education
 24/7 access to provider, continuity care, timely
access to provider, certified EHR
 Written acceptance of patient, can revoke
 Excludes work done on another E/M service day

Reimbursement for 99490





Report once a month, and only one
practitioner per patient
Includes face to face and non-face to face
services of clinical staff
Physician or qualified provider must
oversee / direct activities
Minimum 20 minutes a month – no
maximum
Currently pays $42.91 a month
What if Mr. Johnson goes into the
Nursing Home? Can we still bill
chronic care management?
CPT descriptor specifically states no, but
CMS does not have to do what the CPT says
Currently their tentative interpretation
indicates it cannot be billed in SNF but may
be able to be paid for in NF if criteria are
met
More to follow re: CCCM and others…
EXERCISE 26

You cared for Mary Smith in the nursing home, a
patient recuperating from a hip fracture repair
complicated by newly diagnosed diabetic
neuropathy and early dementia, who was able to
be discharged to home last week under the care
of her relatively healthy attentive husband. You
receive a Form CMS-485, “Home Health
Certification and Plan of Care” which you are
asked to read, amend as needed, sign and return.
Mrs. Smith has not yet seen her usual PCP and will
not follow-up with him/her for 3 more weeks.
Home Health Certifications
Rationale:
 The discharging nursing home physician is in the best
position to know the patient’s home care needs.
While technically the PCP could sign the form as they
will see the patient in the allotted time frame (90
days before or 30 days after start of services), they
would not have a clear understanding of the needs of
the patient at that time. This is a separate billable
service that is distinct from the discharge process of
ordering needed services. Only certification and not
supervision is being requested on the 485 form. Of
note, the POS would be -31 / SNF.

Home Health Certifications



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
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
G0180 Home Health Care Certification
Physician certification of home health services
under a home health plan of care (patient not
present), including
contacts with home health agency
review of reports of patient status to affirm the
initial implementation of the plan of care
per certification period
Frequency 2014: 1,453,378
LTC 1.4%
~ $53 Reimbursement
Home Health Certifications
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G0181 Home Health Care Supervision
Physician supervision Medicare-covered services by a
participating home health agency (patient not present)
requiring complex and multidisciplinary care modalities
regular physician development +/- revision of care plans
review subsequent patient status reports, laboratory and
other studies
communication (including telephone calls) with other
health care professionals involved in patient care,
integration of new information into the medical treatment
plan +/- medical therapy adjustment
within a calendar month, 30 minutes or more
2009 Frequency: 423,535
LTC 0.8%
~ $105 Reimbursement
EXERCISE 26

You cared for Mr. Johnson, released 8 days ago
after a SNF stay post-hospitalization for an
exacerbation of COPD and CHF, complicated at the
SNF by delirium / worsening dementia, C.Diff
colitis, hypoglycemia – poor DM control and F/E
issues. He is now at your clinic / office setting and
needs a reevaluation of all medical issues, referral
to community resources, review and instruction of
medications, including diabetic management with
family done by your staff. Staff did call him 2 days
after discharge to make sure medications
prescribed were correct.
Transitional Care Management
Services Code 99495
 99495
- Moderate complexity patients
◦ Requires physician / staff to make direct
contact, by phone or electronically, with the
patient or caregiver within 2 business days of
discharge.
◦ A face-to-face visit with the patient is required
within 14 calendar days of discharge.
◦ Global period – bill on day 29
◦ If seen again, can bill usual office codes
Transitional Care Management
Services Code 99496
 99496
- High-complexity patients
◦ Requires direct contact with the patient or
caregiver within 2 business day
◦ Face-to-face visit within 7 calendar days
Both codes billable by only one party (PCP
or specialist) in the outpatient setting
 Requires medication reconciliation and any
needed coordination of care

Transitional Care Management
Services Codes (99495 and -6)

Non- face-to-face services that may be
performed by the physician or other qualified
health care professional and/or licensed clinical
staff under his/her direction:
◦ Staff services: medication adherence,
education of patients / caregivers e.g. selfmanagement, HHA communication, facilitating
access to care.
◦ Physician services: discharge information
review, diagnostic test follow up, community
resources referrals, educating patients /
families, interaction with other health
professionals
EXERCISE 24

A skilled nursing home patient with
dementia has a previously noted and
evaluated stage III pressure ulcer on
her buttocks which you are asked to
see due to poor healing / worsening.
Evaluation quickly determines that the
wound needs to be debrided at the
bedside with scalpel and forceps.
Several grams of necrotic material are
removed from the 2x4 cm wound
without complications. Orders are left
for further care of the wound only. No
other medical issues are addressed at
this visit.
Active Wound Care Management

Rationale:

CPT: Only the procedure should be billed.
No separate E/M service was provided.
Active wound care management was
provided at the bedside; Debridement
codes require surgical settings
Types of Debridement Codes

Two types ulcer procedure codes
◦ Both sets CPT redefined / revalued 2011
◦ Active wound care
 Removal of devitalized tissue, any
method, with minimal or local/topical
anesthesia
 Any stage, any provider, any service
site
◦ Debridement codes
 More extensive usually not billable in
LTC – considered a surgical procedure
Active Wound Care Codes


Active wound care procedures are performed
to remove devitalized and/or necrotic tissue
and promote healing. Provider is required to
have one on one patient contact.
Two levels of care depending only on total
surface area (not depth or stage)
◦ 97597 First total surface area < 20 cm2
◦ 97598 Each additional 20 cm2


Involves ongoing care, but not a global code
Typically billed in outpatient settings
Active Wound Care 97597
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Any method (eg, high pressure water jet,
suction, sharp selective debridement with
scissors, scalpel and forceps)
Any open wound (eg, fibrin, devitalized
epidermis and/or dermis, exudate, debris,
biofilm)
Includes topical application(s), wound
assessment, use of a whirlpool, instruction(s)
for ongoing care
Per session, total wound(s) surface area
- first 20 square centimeters or less
Active Wound Care 97598
Describes wound care beyond 20 cm2
 List separately in addition to 97597
 Each additional 20 square centimeters, or
part thereof
 Sum all wounds done on that day

Debridement Codes 1104x Series

Debridement codes redefined for 2011
◦ 11040-1, skin partial-full thickness deleted
 Use active wound care management codes
◦ 11042-7 Subcut to bone depth & size based
Considered a surgical procedure
 Billed in outpt or inpt surgical centers
 Billing in LTC may result in denial

EXERCISE 23

A chronic nursing home patient with
well compensated Alzheimer’s disease
and hypertension who has had no new
issues since the last visit is seen for a
regulatory visit, and whose history,
exam and medical decision making is
straightforward excepting a question
of diminished hearing. Cerumen
impactions are found in both ears and
are removed by the physician using a
wire loop without complications.

Rationale:

CPT 99308 History and Exam –
expanded problem focused; decision
making low complexity

CPT 69210 Cerumen removal was
provided; can only bill once regardless
of one or two ears done

-25 Modifier - Significant, separately
identifiable evaluation and management
service by the same physician on the
same day of the procedure or other
service
EXERCISE 22


Regulatory 60 day nursing facility visit
after the first 90 days of admission with
patient no longer on Medicare Part A,
with your patient who has mild senile
dementia, Alzheimer's type, with no
change in status, stable hypertension
controlled by diet, and who is
ambulating with a walker one year post
stroke.
Visit performed a facility nurse
practitioner, who has an employment
agreement with the facility and has a
collaborative agreement with the
medical director.
30.6.13 C Visits by Qualified
Nonphysician Practitioners
◦
Per the regulations at 42 CFR 483.40 (f),
a qualified NPP, who meets the
collaboration and physician supervision
requirements, the State scope of practice
and licensure requirements, and who is
not employed by the NF, may at the
option of the State, perform the initial
visit in a NF, and may perform any other
federally mandated physician visit in a NF
in addition to performing other medically
necessary E/M visits.
NPP Authority to Make Visits / Write Orders
Initial
Comprehens.
Visits /
Orders##
Other
Required
Visits
Other
Medically
Necessary
Visits/
Orders
No
Alternate
Visits
Yes
No
No
Alternate
Visits
Yes
Subject to
State
No
No
Yes
N/A
Certification /
Recertification
SNF
NP , CNS & PA
Facility-employed
NP, CNS & PA not a
facility employee
NF
NP, CNS & PA
Facility-employed
NP, CNS & PA not a
facility employee**
Yes
Yes
Yes
N/A
##Medically necessary visits may be performed prior to the initial comprehensive visit.
**At
the option of the State
EXERCISE 9

Nursing facility visit by a physician as
the patient’s attending physician, who
is also the Hospice Medical Director, to
assess to assess new symptoms
related to the hospice diagnosis in an
80-year-old woman, on Hospice for
chronic debility, with Parkinson's
disease, Dementia, chronic
hypertension, constipation, cataracts,
COPD, and degenerative arthritis. Visit
reveals Stage II decubitus.
40.1.2 - Patient Care Services
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
Payment (to Hospices) for physicians or nurse
practitioner serving as the attending physician,
who provide direct patient care services and
who are hospice employees or under
arrangement with the hospice, is made in the
following manner:
Hospices establish a charge and bills the FI
(MAC) for these services.
Physicians must get payment from hospice
 40.1.3 - Attending Physician
Services

Can not bill Medicare as an “attending
physician:”
◦ When services related to a hospice patient’s
terminal condition are furnished under a
payment arrangement with the hospice by the
designated attending physician, the physician
must look to the hospice for payment.
◦ In this situation the physicians’ services are
hospice services and are billed by the hospice
to its FI (MAC).
EXERCISE 10

Nursing facility visit by a physician
as the patient’s attending
physician, to assess new symptoms
related to the hospice diagnosis in
an 80-year-old woman, on Hospice
for chronic debility, with
Parkinson's disease, Dementia,
chronic hypertension, constipation,
cataracts, COPD, and degenerative
arthritis. Visit reveals Stage II
decubitus.
 40.1.3 - Attending Physician
Services

In order to bill Medicare as an “attending
physician:”
1. Not employed nor receives compensation by
Hospice
2. Professional services only (not technical)
3. Can be in addition to the services of hospiceemployed physicians
4. The professional services of a non-hospice
affiliated attending physician for the
treatment and management of a hospice
patient’s terminal illness are not considered
“hospice services.”
 40.1.3 - Attending Physician
Services

In order to bill Medicare as an “attending
physician:”
5. Services are reasonable and necessary for the
treatment and management of a hospice
patient’s terminal illness
6. Services not furnished under a payment
arrangement with the hospice
7. Must be coordinated with any direct care
services provided by hospice physicians.
8. These services are coded with the GV
modifier: “Attending physician not employed
or paid under agreement by the patient’s
hospice provider”
EXERCISE 11

Nursing facility visit by a physician
as the patient’s attending
physician, to assess new symptoms
of leg pain and fever unrelated to
the hospice diagnosis in an 80year-old woman, on Hospice for
chronic debility, with Parkinson's
disease, Dementia, chronic
hypertension, constipation,
cataracts, COPD, and degenerative
arthritis. Visit reveals cellulitis.
 40.1.50
- Billing and Payment
for Services Unrelated to
Terminal Illness
◦ Any covered Medicare services not related to
the treatment of the terminal condition for
which hospice care was elected, and which are
furnished during a hospice election period,
may be billed by the rendering provider to the
carrier for non-hospice Medicare payment.
◦ These services are coded with the GW
modifier: “service not related to the hospice
patient’s terminal condition”
Hospice -Summary
• Care not related to terminal illness
• Bill Medicare – modifier GW
• Care related to terminal illness
• MD not associated with hospice
• Bill Medicare – modifier GV
• MD associated/employed with hospice
• Bill Hospice / Contract
EXERCISE 19
92 year old woman with history of
dementia, ASCVD, and DM who was
seen at the nursing home in the
morning requiring admission to
hospital in the afternoon.
 Same Physician performs NH visit
and hospital admission on the same
day

MULTI-SITE SAME DAY
Nursing Facility Visit w/
Hospital Visit or Admission
Same MD, Same date
• 30.6.9.1 - Payment for Initial Hospital
Care Services
• Medicare does not pay for the NH visit
• Medicare will pay only Initial Hospital Care
code
EXERCISE 12

You are asked by staff to sit in on a
care plan meeting about a 82 year
old patient who is not present with
a recent CVA who is not
progressing well in physical
rehabilitation.
Medical Team Conferences
Medicare does not pay for MTC
Bundled into NH visits
• 99366: MTC w/ face to face
• 99367: MTC w/o face to face w/MD
• 99368: MTC w/o face to face w/ NPP
•
Suggestion : document meeting, add into next progress
note, OR visit patient same day and evaluate issues and
discuss findings (Carrier manual does not address)
EXERCISE 13

Nursing facility visit and
assessment to take over the
primary care of a 75-year-old
diabetic, previously stable, who
was on oral hypoglycemic agents,
but who now requires initiation of
insulin therapy and a new medical
plan of care.
There may be options….



Definition of “Initial Visit” In NH per
CPT:
” Initial nursing facility care, per day, for the
evaluation and management of a patient, which
requires these 3 key components: A … history; A
… examination; and Medical decision making that
is ... Counseling and/or coordination of care with
other providers or agencies are provided
consistent with the nature of the problem(s) and
the patient's and/or family's needs”
Does initial refer to the physician or facility?
CMS Definition of Initial Visit

The initial visit in both skilled nursing
facilities (SNFs) and NFs is defined (per the
Survey and Certification memorandum (S&C04-08, dated November 13, 2003) 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

Do we do this in assuming the care from
another provider?
EXERCISE 14

Nursing facility visit on a Monday to
78 year old male with fractured hip,
sent to NH for rehabilitation,
developed new onset diabetes
mellitus requiring insulin during
the stay now stable, being
discharged to an adult living facility
which will happen on Thursday.
30.6.13 I SNF/NF Discharge Day Management
◦ Requires a face-to-face visit
◦ Reported for date of actual visit by NPP
or physician even if patient is
discharged on a different date.
◦ 99315 (< 30 min)
99316 (>30 min)
◦ Final exam, instructions, discharge
records, prescription, referrals
EXERCISE 15

92 year old woman with history of
dementia, ASCVD, and DM who was
a DNR and was found by the
nursing staff without pulse or
respirations at the time you were in
the nursing home.
30.6.13 I SNF/NF Discharge Day
Management
◦ Death “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.”
EXERCISE 16

A patient who was seen on Monday
for a discharge on Thursday,
develops pneumonia on
Wednesday, you call in treatment
and have the discharge cancelled.
Codes can be resubmitted….
Must rescind the discharge code if bill
submitted and resubmit as a subsequent
code
 Best option is not to submit discharge code
until patient is actually discharged
 If there is a brief delay and patient leaves
with no further visit then the bill remains
the same

EXERCISE 1

Scheduled nursing facility visit for an
84-year-old male with DM, chronic
renal insufficiency, HTN, S/P CVA,
MID, Depression, CHF, pressure ulcer
hx, PVD, GERD, OA; on digitalis, ACE
inhibitor, diuretics, oral anti-diabetic
agent, PPI, SSRI, COX-2, plavix and
insulin, requiring minor adjustments
of medications; labs: BMP, CXR, BGs
weekly; consults: wound team
SUBSEQUENT CARE
New or Established

99309 (TWO OF THREE)
◦ DETAILED HX
◦ DETAILED EXAM
◦ MEDICAL DECISION MAKING:
 MODERATE
◦ 25 minutes

USED FOR
◦ PATIENT DEVELOPED SIGNIFICANT
COMPLICATION OR SIGNIFICANT NEW
PROBLEM
◦ “ROUTINE / REGULATORY” VISIT
EXERCISE 2

Telephone call by nursing to assess
patient with chronic atrial
fibrillation with an abnormal
Prothrombin time of INR 3.8, no
bleeding noted, no other symptoms
noted
Telephone Calls
E/M codes / $$ established, not paid for
by CMS
 Physician to patient, parent or guardian
 E/M service not related to previous E/M
service within 7 days or planned E/M
service next 24 hours or soonest available
appointment

◦
◦
◦
◦
CPT
CPT
CPT
CPT
99441
99442
99443
99444
5-10 min $13.71 – 12.27
11-20 min $26.70 – 25.22
21-30 min $38.97 – 37.89
internet service, no time / $$
Telephone Calls
• Can consider in care & coordination next visit
- carefully
• “Bundled” into NH visits
• Suggestion : document calls, add into next
progress note
•Not delineated in Manual
•
Preservice (24hrs)/postservice (7 days)
EXERCISE 3

Nursing facility assessment and
creation of medical plan of care upon
readmission to the nursing facility of
an 82-year-old male who was
previously discharged. The patient has
just been discharged from the hospital
where he had been treated for an
acute gastric ulcer bleed associated
with transient delirium. The patient
returns to the nursing facility
debilitated, protein depleted, and with
a stage III coccygeal pressure ulcer.
INTIAL NURSING FACILITY CARE
New or Established

99306 (THREE OF THREE)
◦ COMPREHENSIVE HX
◦ COMPREHENSIVE EXAM
◦ MEDICAL DECISION MAKING:
 HIGH
◦ 45 minutes

USED FOR:
◦ INITIAL ADMISSION / READMISSION
◦ Usually, the problem(s) requiring
admission are of high severity.
COMPLEXITY OF MEDICAL DECISION
MAKING –INITIAL (3 OF THREE)
# DIAG AMT DATA
RISK
TYPE
CODE
Minimal
Minimal
Minimal
STRAIGHT.
99304
Limited
Limited
Low
LOW
99304
Multiple
Moderate
Moderate
MODERATE
99305
Extensive
Extensive
High
HIGH
99306
EXERCISE 4

Visit in skilled nursing facility by
your nurse practitioner, who has a
collaborative agreement with you,
to an existing 70-year old patient of
yours following a 10-day treatment
of a cellulitis of the foot who
continues to have swelling and
redness of the foot.
30.6.13 C Visits by Qualified
Nonphysician Practitioners

State Regulations, State Scope of
Practice
◦
“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.”
30.6.13 E Incident To Services in
the Nursing Home
◦ “Incident to” E/M visits, provided in a
facility setting, are not payable under
the Physician Fee Schedule for
Medicare Part B.
COMPLEXITY OF MEDICAL DECISION
MAKING SUBSEQUENT (2 OF THREE)
# DIAG
AMT DATA
RISK
TYPE
CODE
Minimal
Minimal
Minimal
STRAIGHT.
99307
Limited
Limited
Low
LOW
99308
Multiple
Moderate
Moderate
MODERATE
99309
Extensive
Extensive
High
HIGH
99310
EXERCISE 5

Visit on day one of stay to gather
information, perform a preliminary
assessment and verify orders in skilled
nursing facility by your nurse practitioner,
who has a collaborative agreement with
you, to a previously independently living
90-year-old male who suffered a recent
cerebral vascular accident (CVA) and is
transferred to the hospital subacute
rehabilitation unit for further
rehabilitation supportive services.
30.6.13 A Visits to Perform the
Initial Comprehensive Assessment
and Annual Assessments

Definition of “Initial Visit”:
◦

“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.”
Prior to/ after “Initial Visit”:
◦
“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.”
“Qualified NPP may perform.”

30.6.13 Medically Necessary
Visits
“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”
EXERCISE 6

Visit on day two of stay to evaluate a
fever in skilled nursing facility by your
nurse practitioner, who has a
collaborative agreement with you, to
79-year-old male, who has not yet
been seen for an initial physician
assessment, who suffered a recent
fractured hip and is transferred to the
facility for further rehabilitation
services.
EXERCISE 7

Urgent nursing facility visit to
develop a new plan of care for an
amputee with atherosclerosis
obliterans who has refused to eat
for three days, has fever and
decreased urinary output for one
day, and is SOB upon your arrival.
 30.6.1
- Selection of Level of
Evaluation and Management Service

D. Use of Highest Levels of Evaluation
and Management Codes
◦ “Carriers must advise physicians that to bill
the highest levels of visit and consultation
codes, the services furnished must meet the
definition of the code (e.g., to bill a Level 5
new patient visit, the history must meet
CPT’s definition of a comprehensive history).”
SUBSEQUENT CARE
New or Established

99310 (TWO OF THREE)
◦ COMPREHENSIVE HX
◦ COMPREHENSIVE EXAM
◦ MEDICAL DECISION MAKING:
 HIGH
◦ 35 minutes

USED FOR
◦ The patient may be unstable or may have
developed a significant new problem
requiring immediate physician attention.
EXERCISE 8

On rounds, you are asked to be
seen by one of your nursing facility
patients sitting in the hallway, who
was not scheduled to be seen, and
who is complaining of new acute
onset right lower extremity pain
and swelling with shortness of
breath over the past 2 hours.
SUBSEQUENT CARE
New or Established

99309 (TWO OF THREE)
◦ DETAILED HX
◦ DETAILED EXAM
◦ MEDICAL DECISION MAKING:
 MODERATE
◦ 25 minutes

USED FOR
◦ PATIENT DEVELOPED SIGNIFICANT
COMPLICATION / NEW PROBLEM
◦ “ROUTINE / REGULATORY” VISIT OF
COMPLEX PATIENT
EXERCISE 17


Regulatory 30 day skilled nursing home
visit in the first 90 days of admission,
with a patient who has mild senile
dementia, Alzheimer's type, with no
change in status, stable hypertension
controlled by diet, and who is
ambulating with a walker one year post
stroke.
Patient seen by your nurse practitioner,
who has a collaborative agreement with
you, who saw the patient last month for
a regulatory visit, but seen last week by
the physician for an acute visit.
30.6.13 C Visits by Qualified Nonphysician
Practitioners

Federally Mandated Visits
◦ SNF (31)
◦
“Following the initial visit by the physician,
the physician may delegate alternate
federally mandated physician visits to a
qualified NPP who meets collaboration and
physician supervision requirements and is
licensed as such by the State and
performing within the scope of practice in
that State.”
EXERCISE 18
Seen by Physician for a scheduled
follow-up to a resident with controlled
hypertension, s/p CVA, DM on insulin
and dementia at 9:00 AM. During
visit, patient seems to exhibit flu
symptoms.
 Seen by your nurse practitioner, who
has a collaborative agreement with
you, at 3:00 PM on the same day, for
follow-up of the flu like illness


30.6.13 B. Visits to Comply
With Federal Regulations (42
CFR 483.40)
“Carriers 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.”
“Medicare Part B payment policy does not pay
for additional E/M visits that may be
required by State law for a facility admission
or for other additional visits to satisfy
facility or other administrative purposes.”
EXERCISE 20
92 year old woman with history of
dementia, ASCVD, and DM who was
seen at by you at the Emergency
Department in the morning
requiring admission to the nursing
home in the afternoon.
 Same Physician performs ED visit
and NH admission on same day

MULTI-SITE SAME DAY
Office/Outpatient/ED Visit w/
Nursing Facility Admission
Same MD, Same date
• 30.6.7 - Payment for Office or Other Outpatient
Evaluation and Management (E/M) Visits
• Medicare does not pay for the office or ED visit
• Medicare will pay only Initial Nursing Facility Care
code
• Bundle E/M visits on the same date provided in
sites other than the nursing facility into the initial
nursing facility care code
EXERCISE 21


92 year old woman with history of
dementia, ASCVD, and DM who was seen
and discharged from the hospital in the
morning to be admitted to the skilled
nursing facility in the afternoon.
Same Physician performs hospital
discharge and NH admission on same day
MULTI-SITE SAME DAY
Hospital Discharge Management w/
Nursing Facility Admission
Same MD, Same date
• 30.6.9.2 - Subsequent Hospital Visit and Hospital
Discharge Management
•
Medicare does pay for the Hospital Discharge visit
(99238, 99239)
•
Medicare will also pay Initial Nursing Facility Care code