Procedure code and Description
CPT/HCPCS Codes
G9685 Evaluation and management of a beneficiary’s acute change in condition in a nursing facility
99304 Initial nursing facility care, per day, for the evaluation and management of a patient, which requires these 3 key components: a detailed or comprehensive history; a detailed or comprehensive examination; and medical decision making that is straightforward or of low complexity. Usually, the problem(s) requiring admission are of low severity. Typically, 25 minutes are spent at the bedside and on the patient’s facility floor or unit.
99305 Initial nursing facility care, per day, for the evaluation and management of a patient, which requires these 3 key components: a comprehensive history; a comprehensive examination; and medical decision making of moderate complexity. Usually, the problem(s) requiring admission are of moderate severity. Typically, 35 minutes are spent at the bedside and on the patient’s facility floor or unit.
99306 Initial nursing facility care, per day, for the evaluation and management of a patient, which requires these 3 key components: a comprehensive history; a comprehensive examination; and medical decision making of high complexity. Usually, the problem(s) requiring admission are of high severity. Typically, 45 minutes are spent at the bedside and on the patient’s facility floor or unit.
99307 Subsequent nursing facility c are, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: a problem focused interval history; a problem focused examination; straightforward medical decision making. Usually, the patient is stable, recovering, or improving. Typically, 10 minutes are spent at the bedside and on the patient’s facility floor or unit.
99308 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: an expanded problem focused interval history; an expanded problem focused examination; medical decision making of low complexity. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Typically, 15 minutes are spent at the bedside and on the patient’s facility floor or unit.
99309 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: a detailed interval history; a detailed examination; medical decision making of moderate complexity. Usually, the patient has developed a significant complication or a significant new problem. Typically, 25 minutes are spent at the bedside and on the patient’s facility floor or unit.
99310 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: a comprehensive interval history; a comprehensive examination; medical decision making of high complexity. The patient may be unstable or may have developed a significant new problem requiring immediate physician attention. Typically, 35 minutes are spent at the bedside and on the patient’s facility floor or unit.
99315 Nursing facility discharge day management; 30 minutes or less.
99316 Nursing facility discharge day management; more than 30 minutes.
99318 Evaluation and management of a patient involving an annual nursing facility assessment, which requires these 3 key components: a detailed interval history; a comprehensive examination; and medical decision making that is of low to moderate complexity. Usually, the patient is stable, recovering, or improving. Typically, 30 minutes are spent at the bedside and on the patient’s facility floor or unit.
Visits to Perform the Initial Comprehensive Assessment and Annual Assessments
The distinction made between the delegation of physician visits and tasks in a skilled nursing facility (SNF) and in a nursing facility (NF) is based on the Medicare Statute.
The federally mandated visits in a SNF and NF must be performed by the physician except as otherwise permitted The principal physician of record must append the modifier “-AI”, (Principal Physician of Record), to the initial nursing facility care code. This modifier will identify the physician who oversees the patient’s care from other physicians who may be furnishing specialty care. All other physicians or qualified NPPs who perform an initial evaluation in the NF or SNF may bill the initial nursing facility care code. The initial federally mandated visit is defined in S&C-04-08 (see www.cms.hhs.gov/medlearn/matters) as the initial comprehensive 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.
Further, in a SNF the physician may not delegate a task that the physician must personally perform. Therefore, as stated in S&C-04-08 the physician may not delegate the initial federally mandated comprehensive visit in a SNF.
The only exception, as to who performs the initial visit, relates to the NF setting. In the NF setting, a qualified NPP (i.e., a nurse practitioner (NP), physician assistant (PA), or a clinical nurse specialist (CNS)), who is not employed by the facility, may perform the initial visit when the State law permits. The evaluation and management (E/M) visit shall be within the State scope of practice and licensure requirements where the E/M visit is performed and the requirements for physician collaboration and physician supervision shall be met.
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. 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 CPT Nursing Facility Services codes shall be used with place of service (POS) 31 (SNF) if the patient is in a Part A SNF stay. They shall be used with POS 32 (nursing facility) if the patient does not have Part A SNF benefits or if the patient is in a NF or in a non-covered SNF stay (e.g., there was no preceding 3-day hospital stay). The CPT Nursing Facility code definition also includes POS 54 (Intermediate Care Facility/Mentally Retarded) and POS 56 (Psychiatric Residential Treatment Center).
Effective January 1, 2006, the Initial Nursing Facility Care codes 99301– 99303 are deleted.
Beginning January 1, 2006, the new CPT codes, Initial Nursing Facility Care, per day, (99304 – 99306) shall be used to report the initial federally mandated visit. Only a physician may report these codes for an initial federally mandated visit performed in a SNF or NF (with the exception of the qualified NPP in the NF setting who is not employed by the facility and when State law permits, as explained above).
A readmission to a SNF or NF shall have the same payment policy requirements as an initial admission in both the SNF and NF settings.
A physician who is employed by the SNF/NF may perform the E/M visits and bill independently to Medicare Part B for payment. An NPP who is employed by the SNF or NF may perform and bill Medicare Part B directly for those services where it is permitted as discussed above. The employer of the PA shall always report the visits performed by the PA. A physician, NP or CNS has the option to bill Medicare directly or to reassign payment for his/her professional service to the facility.
As with all E/M visits for Medicare Part B payment policy, the E/M documentation guidelines apply.
Medically Necessary Visits
Qualified NPPs may perform medically necessary E/M visits prior to and after the physician’s initial federally mandated 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 malformed 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.
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, perform 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.
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 and qualified NPPs shall report the 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 patient’s care from other physicians who may be furnishing specialty care. Follow-up visits shall be billed as Subsequent Nursing Facility Care, per day (codes 99307, 99308, 99309, and 99310) codes.
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 under 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 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.
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.
Consultation Services
Effective January 1, 2010, consultation codes are no longer recognized for Medicare Part B payment. Physicians shall code patient evaluation and management visits with E/M codes that represent where the visit occurs and that identify the complexity of the visit performed. In the nursing facility setting, all physicians (and qualified nonphysician practitioners where permitted) may bill the most appropriate initial nursing facility care code (99304, 99305, and 99306) or subsequent nursing facility care code (99307, 99308, 99309, 99310) that reflects the services the physician or practitioner furnished.
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. CPT code 99315 or 99316 shall be reported 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.
Limitations
• Indications that are not listed in the “Indications and Limitations of Coverage” section of this policy.
• The service was not directly provided by the physician or non-physician practitioner.
• The service was provided without face-to-face interaction with the patient.
• The medical record documentation does not clearly satisfy the Medicare criteria for “Reasonable and Necessary.”
• The service is covered under a contract with the nursing home.
• The service is a bundled part of facility services furnished to Medicare beneficiaries in the participating facility.
• Follow-up subspecialty and/or specialized care is/are not clearly documented in the medical record to reflect the medical necessity of the service(s) rendered.
• Consecutive daily or courtesy visits are not reasonable and necessary for follow-up.
• The service is for non-covered screening purposes.
• The medical record does not verify that the service described by the CPT/HCPCS code was provided.
. Telemedicine Services The following existing HCPCS codes will be activated for coverage effective January 1, 2011: 99231 99233 99308 99310 G0108 G0420 99232 99307 99309 G0109 G0421 Note: The GT modifier must be included when reporting Telemedicine services.
Comprehensive History for CPT 93306
• Reason for admission
• Extended history of present illness (HPI)-Extended consists of four or more elements of the HPI
• Review of systems directly related to the problem(s) identified in the HPI
• Medically necessary review of ALL body systems’ history
• Medically necessary complete past, family, and social history
HPI – History of Present Illness
A chronological description of the development of the patient’s present illness from the first sign and/or symptom or from the previous encounter to the present. Descriptions of present illness may include:
• Location• Quality• Duration• Severity• Timing• Context• Modifying factors• Associated signs/symptoms significantly related to the presenting problem
Chief Complaint
The Chief Complaint is a concise statement from the patient describing:
• The symptom• Problem• Condition• Diagnosis• Physician recommended return, or other factor that is reason for the encounter
Review of Systems
An inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms which the patient may be experiencing or has experienced.
For purpose of Review of Systems the following systems are recognized:
• Constitutional (i.e., fever, weight loss)• Eyes• Ears, Nose, Mouth Throat• Cardiovascular • Respiratory • Gastrointestinal• Genitourinary• Musculoskeletal• Integumentary (skin and/or breast) • Psychiatric • Endocrine • Hematologic/Lymphatic• Allergic/Immunologic
