coding & reimbursement
Coding Nursing Home Exams
Treating patients outside your office can be rewarding, but getting reimbursed can be tricky.

To get Medicare reimbursement for services you provide in nursing homes, you must satisfy requirements, provide the right documentation and use the correct CPT codes. This is especially important because carriers have been instructed by the Office of the Inspector General (OIG) to review these claims carefully.

Q: What do I need to know when seeing a nursing home patient for the first time? The most important considerations are who requested your services, and why. To warrant Medicare coverage you must have a documented order before providing the service.

This order is usually part of the attending physician's treatment plan in the patient's medical record, but the request for your services may also come from the patient's family or the patient. If the request didn't come from the physician, the notations at the beginning of your medical record must indicate who initiated the visit and the nature of the problem that justified the services (e.g., illness, injury, symptoms). Ultimately, it may be best to route such requests through the attending physician for the sake of continuity of care.

Remember that routine eye exams are not reimbursed, but the glaucoma screening benefit Medi-care inaugurated in 2002 may apply to some nursing home patients.

If the visit is a follow-up to re-evaluate a pre-existing condition -- as indicated in your previous chart note for this patient -- then the required order is your own.

Q: How should we bill for these visits? Several variables determine which CPT code is correct:

• If the visit qualifies as a consultation for a nursing home patient, use inpatient consultation codes (9925x).
• If the visit doesn't qualify as a consultation, use subsequent nursing facility care codes (99311 to 99313) or the ophthalmology codes (920xx). Remember: Some payers may not recognize ophthalmology codes in nursing home situations.
• Only the admitting physician can use comprehensive assessment codes (99301 to 99303).
• Domiciliary, rest home, or custodial care facilities -- unlike nursing homes -- provide room, board and other personal assistance services but don't include a medical component. These visits should be described using a different family of CPT codes: 99321 to 99333.

Q: What "place of service" codes should we use for these visits? Medicare Part A covers nursing facility stays under very limited conditions -- usually only after discharge from a hospital visit lasting at least 3 days. Otherwise, Part B covers the services of eyecare professionals. (Check with the facility about the patient's Medicare status.)

Here are a number of different place of service codes:

• 31 -- skilled nursing facility (SNF), patient covered under Medicare Part A
• 32 -- nursing home or nursing facility, patient not covered by Part A SNF benefits
• 33 -- domiciliary, rest home, or custodial care facility
• 54 -- intermediate care facility/mentally retarded
• 55 -- residential substance abuse facility
• 56 -- psychiatric residential treatment center.

Q: What about supplemental diagnostic tests? When the patient is in a Part A-covered nursing facility, the technical component of diagnostic testing, as well as tests you perform in your office for in-patient residents of these facilities, is included in the Medicare payment made to the facility. Your payment for the technical component comes through the facility. However, Medicare Part B will pay you directly for the professional component (i.e., modifier 26).

If the patient isn't covered under Medicare Part A for the nursing facility stay (i.e., beneficiary not entitled to Part A, benefits exhausted, non-covered level of care), Part B payment for the diagnostic test can include both the technical and professional components.

Suzanne Corcoran is vice president of Corcoran Consulting Group. You can reach her at (800) 399-6565 or at scorcoran@corcoranccg.com.