Payment for care plan oversight


Fam Pract Manag. 2002 Nov-Dec;9(10):22.

To the Editor:

I appreciated “Billing for nursing home work” [Coding & Documentation, July/August 2002, page 22]. I think it is crucially important for physicians providing care for nursing home patients to be adequately reimbursed for their services, or soon they will be out of business. You are right that one cannot bill Medicare for care plan oversight for nursing home patients. However, I think these services can be recapped in the subsequent monthly progress note, demonstrating a greater level of recorded history and medical decision making. For example, describing in the note that since the last visit the patient developed fever and dysuria, a urinalysis and culture were ordered and treatment was instituted could legitimately raise the visit from a 99311 to a 99312.

Author's response:

I agree that it is important for physicians providing care for nursing facility patients to be adequately reimbursed for their services and that developments between visits with these patients may affect the level of service rendered during subsequent encounters. Using your example, a patient who develops fever and dysuria may necessitate a more extensive history and exam to ascertain their status and impact on the patient. The patient may also require a more complex medical decision making process that accounts for an increased number of diagnoses and management options, more data (e.g., from the urinalysis and culture) to be reviewed and greater risk to the patient. Any or all of these may result in a higher level of service than would have been the case otherwise.

That said, I would caution against automatically upcoding nursing facility visits to account for work done between visits, especially if that work is not documented in connection with the visit in question. That type of automatic upcoding could invite an audit that may ultimately prove very costly.


"Don't worry, Mrs. Fitzbee. As soon as I find the correct Medicare guidelines, that splinter is out of here!"


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Copyright © 2002 by the American Academy of Family Physicians.
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