(Medicare Claims Processing Manual)

Payment is made under the physician fee schedule by Medicare Part B for federally mandated visits. Following the initial federally mandated visit by the physician or qualified NPP where permitted, payment shall be made for federally mandated visits that mo nitor and evaluate residents at least once every 30 days for the first 90 days after admission and at least once every 60 days thereafter.   Effective January 1, 2006, the Subsequent Nursing Facility Care, per day, codes 99311-  99313 are deleted.   Beginning January 1, 2006, the new CPT codes, Subsequent Nursing Facility Care, per day, (99307 -  99310) shall be used to report federally mandated physician E/M visits and medically necessary E/M visits.   A/B MACs (B) 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.  The Nursing Facility Services codes represent a per day service.   The federally mandated E/M visit may serve also as a medically necessary E/M visit if the situation arises (i.e., the patient has health problems that need attention on the day the scheduled mandated physician E/M visit occurs).  The physician/qualified NP P shall bill only one E/M visit.   Beginning January 1, 2023, the CPT code, Other Nursing Facility Service (99318), has been deleted and is no longer used to report an annual nursing facility assessment visit on the required schedule of visits on an annual basis.  Effective for dates of ser vice on and after 1- 1-2023, for Medicare Part B payment policy, the regular code set for Nursing Facility Services shall be used.   Qualified NPPs, whether employed or not by the SNF, may perform alternating federally mandated physician visits, at the option of the physician, after the initial federally mandated visit by the physician in a SNF.   Qualified NPPs in the NF setting, who are not employed by the NF and who are working in collaboration with a physician, may perform federally mandated physician visits, at the option of the State.   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.  E/M visits, prior to and after the initia l federally mandated 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.   C. Visits by Qualified Nonphysician 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.  G eneral 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.   Medically Necessary Visits   Qualified NPPs may perform medically necessary E/M visits prior to and after the physicians 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 malf ormed body member are payable under the physician fee schedule under Medicare Part B.  A physician or NPP may bill the most appropriate initial nursing facility care code (CPT codes 99304 -99306) or subsequent nursing facility care code (CPT codes 99307- 99310), even if the E/M service is provided prior to the initial federally mandated visit.   SNF Setting --Place of Service Code 31   Following the initial federally mandated 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.   NF Setting --Place of Service Code 32   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, perfor m the initial federally mandated 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.   Questions pertaining to writing orders or certification and recertification issues in the SNF and NF settings shall be addressed to the appropriate State Survey and Certification Agency departments for clarification.   D. 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.  Physicians an d qualified NPPs shall report initial nursing facility care codes for their first visit with the patient.  The principal physician of record must append the modifier  -AI (Principal Physician of Record), to the initial nursing facility care code when billed to identify the physician who oversees the patients care from other physicians who may be furnishing specialty care.  Follow -up visits shall be billed as subsequent nursing facility care visits.   E. Incident to Services   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 unde r 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 the SNF/NF setting and shall not be reported using the CPT codes for office or other outpatient visits or use place of service code 11.   F. Prolonged NF Services   Beginning January 1, 2023, prolonged NF services are reported using Medicare-specific coding (HCPCS code G0317). Prolonged Services can be reported when time is used to select visit level, and the total time for the highest-level visit is exceeded by 15 or more minutes for services that are reasonable and medically necessary. See Prolonged Services section below for detailed reporting instructions on prolonged NF visits. Prolonged services are not reportable in conjunction with codes for NF discharge day ma nagement.   G. Multiple Visits   The complexity level of an E/M visit and the CPT code billed must be a covered and medically necessary visit for each patient (refer to 1862 (a)(1)(A) of the Act).  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 as defined by the CPT code.  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.   H.  Split (or Shared) SNF/NF E/M Visit   SNF E/M visits may be billed as split (or shared) visits if they meet the rules for split (or shared) visit billing, discussed in our other manual sections, except for SNF E/M visits that are required to be performed in their entirety by a physician.  NF visits do not meet the definition of split (or shared) services, and therefore, are not billable as such.  See section 30.6.18 for additional information.   I.  SNF/NF Discharge Day Management Service   Medicare Part B payment policy requires a face- to-face visit with the patient provided by the physician or the qualified NPP to meet the SNF/NF discharge day management service as defined by the CPT code.  The E/M discharge day management visit shall be reported for the date of the actual visit by the physician or qualified NPP even if the patient is discharged from the facility on a different calendar date.  The CPT codes 99315 - 99316 shall be repor ted for this visit.  The Discharge Day Management Service 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. 30.6.14 - Home or Residence Services (Codes 99341 - 99350)                         (Rev. 11732, Issued: 12 -08-22, Effective: 01-01-23, Implementation: 01-03-23)  Physician Visits to Patients Residing in Various Places of Service   Prior to January 1, 2023, the American Medical Associations Current Procedural Terminology (CPT) used new patient codes 99324 - 99328 and established patient codes 99334 - 99337 for Domiciliary, Rest Home (e.g., Boarding Home), or Custodial Care Services, to report evaluation and management (E/M) services to residents residing in a facility which provides room, board, and other personal assistance services, generally on a long- term basis.  These CPT codes were used to report E/M services in facilities assigned places  of service (POS) codes 13 (Assisted Living Facility), 14 (Group Home), 33 (Custodial Care Facility) and 55 (Residential Substance Abuse Treatment Facility).  Assisted living facilities may also be known as adult living facilities.  The CPT codes 99324 -  99337 for Domiciliary, Rest Home (e.g., Boarding Home), or Custodial Care Services are deleted beginning January 1, 2023.   Beginning January 1, 2023, the CPT is merging the two E/M visit families currently titled Domiciliary, Rest Home (e.g., Boarding Home), or Custodial Care Services  and Home Services. The new family will be titled Home or Residence Services.  The codes in this family (CPT codes 99341  99350) will be used to report E/M services furnished to a patient residing in their home, in an assisted living facility, in a group home (that is not licensed as an intermediate care facility for individuals with intellec tual disabilities), in a custodial care facility, or in a residential substance abuse treatment facility.  There are no changes to the included care settings from each respective family, rather the current care settings for each of the current families are being included within the new, merged family.  For services in an intermediate care facility for individuals with intellectual disabilities and services provided in a psychiatric residential treatment center, see Nursing Facility Services in Section 30.6.13.  Physicians and qualified nonphysician practitioners (NPPs) furnishing E/M services to residents in a living arrangement described by one of the POS listed above must use the level of service code in the CPT code range 99341 -  99350 to report the service they provide.   Beginning in 2006, reasonable and medically necessary prolonged services may be reported with the appropriate companion E/M codes when a physician or qualified NPP, provides a prolonged service that is beyond the usual E/M visit service for a Home or Residence Service.  All the requirements for prolonged services at 30.6.15 must be met.  Beginning in 2006, E/M services provided to patients residing in a Skilled Nursing Facility (SNF) or a Nursing Facility (NF) must be reported using the appropriate CPT level of service code within the range identified for Initial Nursing Facility Care (CPT  codes 99304 -  99306) and Subsequent Nursing Facility Care (CPT codes 99307 -  99310).  Use CPT codes 99315 -  99316 for SNF/NF discharge services.  The Home or Residence Services codes should not be used for these places of service.   The CPT SNF/NF code definition includes intermediate care facilities (ICFs) and long term care facilities (LTCFs).  These codes are limited to the specific 2 -digit POS 31 (SNF), 32 (Nursing Facility), 54 (Intermediate Care Facility/Individuals with Intelle ctual Disabilities) and 56 (Psychiatric Residential Treatment Center).   The CPT nursing facility codes should be used with POS 31 (SNF) if the patient is in a Part A SNF stay and POS 32 (nursing facility) if the patient does not have Part A SNF benefits.  There is no longer a different payment amount for a Part A or Part B benefit period in these POS settings.   30.6.14.1 - Home or Residence Services (Codes 99341 - 99350) When Performed in Place of Service 12 (Home)   (Rev. 11732, Issued: 12 -08-22, Effective: 01- 01-23, Implementation: 01- 03-23)  A. Requirement for Physician Presence in Place of Service 12 (Home)  A home visit using codes 99341- 99350 with POS 12 cannot be billed by a physician unless the physician was actually present in the beneficiarys home.  Section 10.1.1 in Chapter 1 of this manual provides additional information on billing with POS 12.