Article Date: 10/1/2003

coding q & a
A Whole New World
Documentation rules and CPT codes for services to nursing home patients
By Suzanne Corcoran, C.O.E.

What do I need to know before going to see a patient in a nursing facility?

For an initial exam, consider who requested the visit. Before an M.D. or an O.D. can provide care to a nursing home patient, a documented order is required. It may come from a primary care physician, nursing staff, the patient's family or the patient, and is documented as part of the treatment plan in the patient's medical record.

How should we bill for these visits?

CPT code selection depends on several variables including the type of facility and whether Medicare covers the stay. Medicare Part A covers nursing facility stays under limited conditions; usually only after discharge from a hospital visit lasting at least three days. Check with the facility about the patient's Medicare status. The Medicare Part A coverage is limited to 100 days, then the benefit is exhausted and other coverage may take over.

For new or established patients who've been admitted to a nursing facility, use CPT codes 99311 to 99316. Use subsequent nursing facility care codes (99311 to 99313), depending on the level of service provided. (Only the admitting physician uses the comprehensive assessment codes [99301 to 99303].)

Sometimes a consultation is appropriate if you've met all of the usual consultation criteria, in which case you'd use the inpatient consult codes (9925x). You can also use the ophthalmology codes (920xx) to describe the encounter, although some payers may not recognize these codes in these locations.

There's a second family of codes for patients in domiciliary, rest home or custodial care facilities, which provide room, board and other personal assistance services, but don't include a medical component. Use CPT codes 99321 to 99333 to describe these visits.

What place of service codes do we use for these visits?

Some common examples:

31 (Skilled Nursing Facility [SNF]) if the patient's been admitted to a nursing facility and is covered under Medicare Part A

32 (Nursing Home/Nursing Facility) if the patient has been admitted to a nursing facility and doesn't have Part A SNF benefits

33 (Custodial Care Facility) for patients in custodial care facilities

What about diagnostic tests?

The reimbursement rules for services provided in nursing facilities changed about two years ago, although most Medicare carriers have recently implemented the changes. When the patient is in a Part A-covered nursing facility, the technical component of the diagnostic test is included in the facility's Medicare payment. This means that the SNF is responsible for providing technical services for its patients while they are receiving Medicare Part A benefits. This also applies to the tests you perform in your office for inpatient residents of these facilities.

Discuss payment with the SNF for the technical component of the tests you provide, since payment for this component of diagnostic tests is "by arrangement" with the facility and the Medicare Physicians Fee Schedule (MFS) doesn't apply. Medicare Part B will only pay you for the professional component under the MFS. If the patient isn't covered under Medicare Part A for the nursing facility stay (i.e., beneficiary not entitled to Part A, benefits exhausted, non-covered level of care), Part B payment may be possible for the full diagnostic test service.

Finally, be aware that carriers have received specific instructions from the Office of the Inspector General to review services provided in nursing facilities. Pay particular attention to the documentation requirements.

Suzanne Corcoran is vice president of Corcoran Consulting Group.  Reach her at (800) 399-6565 or at SCORCORAN@CORCORANCCG.COM.


Optometric Management, Issue: October 2003