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Tuesday Feb 16, 2016

Medicare: Physicians are mixing up E/M codes for skilled nursing facilities

It seems there’s room for improvement in how many physicians code for evaluation and management (E/M) services provided to patients in skilled nursing facilities (SNFs).

The Centers for Medicare & Medicaid Services (CMS) recently said(www.cms.gov) its auditors found that physicians and non-physician practitioners (NPPs) are reporting incorrect codes for E/M services provided to SNF Medicare patients.

Specifically, physicians and NPPs are using CPT codes 99221-99223 (initial hospital care), 99231-99233 (subsequent hospital care), and 99238-99239 (hospital discharge day management) to bill for E/M services supplied to SNF patients. However, those codes are for E/M services supplied to hospital patients.

As described in the Medicare Claims Processing Manual(www.cms.gov) Section 30.6.13, E/M services provided to patients residing in an SNF must be reported using the appropriate CPT level of service code within the range identified for initial nursing facility care (99304-99306) and subsequent nursing facility care (99307-99310). The annual nursing facility assessment is billed using CPT code 99318, and SNF discharge services are billed using CPT codes 99315-99316. Using an inpatient hospital E/M CPT code represents inappropriate billing when you render E/M services in an SNF.

Part of the confusion may stem from the fact that the patients in question are in hospital “swing beds,” which can represent either inpatient hospital or nursing facility care, depending on how the hospital is billing Medicare for its services. Section 30.6.9.D of the Medicare Claims Processing Manual advises that if the hospital is billing Medicare for the patient’s inpatient care as inpatient hospital care, the hospital care CPT codes apply for purposes of reporting physician services to the patient. If the hospital is billing Medicare for the patient’s inpatient care as nursing facility care, then the nursing facility CPT codes apply for physician services. So, if in doubt about the status of a Medicare patient in a “swing bed,” check with the hospital regarding how it is billing Medicare for the patient’s inpatient care and adjust your coding accordingly.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Posted at 11:49AM Feb 16, 2016 by David Twiddy

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