Source: https://paltc.org/cpt-faqs
Timestamp: 2019-06-24 20:10:28
Document Index: 462810781

Matched Legal Cases: ['§30', '§30', '§30', '§1861', '§1866', '§1861', '§1866', 'art 3']

CPT FAQs | AMDA
A computer-based training (CBT) course called “World of Medicare” is available from Centers for Medicare& Medicaid Services (CMS). It is an introduction to the Medicare program for providers. It covers the basics of Medicare's covered services, forms, etc. The course can be downloaded from the CMS website at the Medlearn Product Ordering Page under "Web-Based Training Courses” and completed at no charge.
What are the documentation requirements needed to satisfy an audit for seeing the same patient more than once a month? What can I do to protect myself?
In 2001, AMDA published the White Paper on Determination and Documentation of Medical Necessity in Long Term Care Facilities. This white paper was published to assist physicians with properly determining medical necessity. AMDA recommends that the physician be prepared to justify how the service or intervention is sound clinical practice and that it reflects reasonable and realistic goals, and expected outcomes.
For additional information, please see the Centers for Medicare & Medicaid Services’ (CMS) “1997 Documentation Guidelines for Evaluation and Management Services.” It can be downloaded from the CMS website at http://www.cms.gov/MLNProducts/Downloads/MASTER1.pdf.
As work on revising these Guidelines has been halted, the Centers for Medicare & Medicaid Services has been advising the use of either the 1995 or 1997 versions.
The NP may bill the 99307-99310 before the physician bills the 99304-99310, but not on the same day as the physician bills the 99304-99310.
The NP may bill the 99307-99310 before the physician bills the 99304-99310, but only under certain circumstances defined by Medicare Part B payment policy. CMS Transmittal 792/Change Request 4246/Updated Claims Processing Manual (Pub. 100-04, Chapter 12, §30.6.13) reiterates the policy:
The initial visit in a SNF and NF must be performed by the physician except as otherwise permitted (42 CFR 483.40 (c)(4)). The initial visit is defined in S&C-04-08 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. For Survey and Certification requirements, a visit must occur no later than 30 days after admission.
Under Medicare Part B payment policy, 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. (Please see previous question on determination of medical necessity above.) A qualified NPP may perform medically necessary E/M visits prior to and after the initial visit if all the requirements for collaboration, general physician supervision, licensure and billing are met.
The transmittal can be downloaded from the CMS website at http://www.cms.gov/transmittals/downloads/R808CP.pdf.
This is one of several questions and answers about CPT coding in the recently published revised edition of AMDA's Guide to Long Term Care Coding, Reimbursement and Documentation. The booklet is available for $25 for AMDA members and $35 for nonmembers.
For Medicare purposes, must a face-to-face visit between the physician and patient always occur to bill an evaluation and management service?
Yes. Although the Current Procedural Terminology (CPT) definitions for codes 99315 and 99316 are somewhat ambiguous in this respect, two Centers for Medicare & Medicaid Services (CMS) sources state that a face-to-face visit is required. According to a letter dated January 4, 2002, from to AMDA from CMS, "For Medicare purposes, a face-to-face visit between the physician and patient must always occur (with rare exceptions) in order to bill an evaluation and management (E/M) service. A face-to-face visit is required for a nursing facility discharge E/M service (code 99315 or 99316).” To view a complete copy of the CMS letter, click here.
CMS Transmittal 792/Change Request 4246/Updated Claims Processing Manual (Pub. 100-04, Chapter 12, §30.6.13 ) states under Requirement 4246.22, "Carriers shall instruct physicians and qualified NPPs to report CPT Code 99315-99316 (Nursing Facility Discharge Service) for an E/M visit (must be face-to-face) for discharge from the SNF/NF." The transmittal can be downloaded from the CMS website here.
When discharging a patient from a nursing facility, I am billing for services using 99315 and 99316 even if the services are not provided on the same day as the discharge day of the resident. Is this the correct way to bill for these services?
Yes. This is allowable under Change Request 4246 (Transmittal 808) from January 6, 2006. Requirement 4246.23 states, "Carriers shall instruct physicians and qualified NPPs that the SNF/NF discharge shall be reported for the actual date of the E/M visit even if the patient is discharged from the facility on a different date." Within the manual instructions, Section 30.6.13 - Nursing Facility Services (Codes 99304 - 99318), Subsection I has been changed to read, "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."
If I were not present when a resident died and did not perform the pronouncement of death, may I bill the 99315-99316 discharge codes and be reimbursed?
No. To bill under the 99315-99316 discharge series in a nursing facility, the physician must perform the final examination of the resident, counseling and prepare the discharge records. The Centers for Medicare & Medicaid Services’ (CMS) Transmittal 792/Change Request 4246/Updated Claims Processing Manual (Pub. 100-04, Chapter 12, §30.6.13 ) requirement 4246.24 states, "Carriers shall instruct physicians and qualified NPPs that CPT codes 99315-99316 (Nursing Facility Discharge Service) may be used to report a death pronouncement only if the physician or qualified NPP performed the pronouncement." The transmittal can be downloaded from the CMS website here.
If a patient is released from the facility to a hospital, and then returns to the facility, do I bill for a 99304-99306 for a new admission, or do I bill 99307-99310 for a subsequent visit?
The key is whether or not the patient has been formally admitted and discharged using the 99315-99316 discharge codes. If the patient has been formally discharged from the facility and is being readmitted, the physician can bill a 99304-99306. If the patient was out for observation and then returns to the facility without a formal discharge, the coding is for a subsequent visit using 99307-99310.
Which is the appropriate E/M code for an annual history and physical of a patient residing in a custodial care setting? What are the minimum visit requirements for these residents?
The requirements for an annual regulatory history and physical is applicable to patients receiving skilled care, nursing facility or intermediate care facility care, but it does not at this time encompass residents in assisted living settings or board and care facilities. Because the term "custodial" is occasionally used for patients at both the nursing facility and assisted living levels, it is incorrect to simply state that a history and physical may be performed in a "custodial care setting." The distinction lies in the medical component offered by the facility, not the status of the patient.
Excerpted from the State Operations Manual, Appendix PP, found here.
"Skilled nursing facility" is defined as an institution (or a distinct part of an institution) which is primarily engaged in providing skilled nursing care and related services for residents who require medical or nursing care, or rehabilitation services for the rehabilitation of injured, disabled, or sick persons, and is not primarily for the care and treatment of mental diseases; has in effect a transfer agreement (meeting the requirements of §1861(1)) with one or more hospitals having agreements in effect under §1866; and meets the requirements for a SNF described in subsections (b), (c), and (d) of this section.
"Nursing facility" is defined as an institution (or a distinct part of an institution) which is primarily engaged in providing skilled nursing care and related services for residents who require medical or nursing care, rehabilitation services for the rehabilitation of injured, disabled, or sick persons, or on a regular basis, health-related care and services to individuals who because of their mental or physical condition require care and services (above the level of room and board) which can be made available to them only through institutional facilities, and is not primarily for the care and treatment of mental diseases; has in effect a transfer agreement (meeting the requirements of §1861(1)) with one or more hospitals having agreements in effect under §1866; and meets the requirements for a NF described in subsections (b), (c), and (d) of this section.
Excerpted from the Medicare Carriers Manual, Part 3 - Claims Process, Section 15510 found
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