Answer These Professional SNF and NF Billing Questions

Providers of long-term care services must comply with several different regulating criteria, and it is the coder’s responsibility to understand applicable rules when coding these unique services. In recent years, there have been extensive changes in the Nursing Facility Services section of the CPT^® manual. Although this article cannot include all you need to know to bill for skilled nursing facility (SNF) or nursing facility (NF) services, it will answer some basic questions and give you a good place to start.

What is the Difference Between a SNF and a NF?

For starters: They have different place of service (POS) codes. Use POS code 31 for a Medicare Part A SNF stay, and POS code 32 for a patient who doesn’t have Part A benefits. Always make sure you use the correct POS.
Per CPT^®, POS code 31 describes a facility that primarily provides inpatient skilled nursing care and related services to patients who require medical, nursing, or rehabilitation services but does not provide the treatment level available in a hospital. POS code 32 is somewhat similar and describes a facility that provides nursing care and related services for the rehabilitation of injured, disabled, or sick people above the level of custodial care to those other than the mentally disabled.
Secondly: The care rendered is different. Care provided in a SNF requires skilled nursing and/or rehabilitative staff involvement on a daily basis, which might include registered nurses, licensed practical and vocational nurses, physical and occupational therapists, speech-language pathologists, and audiologists.
Care given by non-professional staff isn’t considered skilled care, but rather custodial or personal care, and includes assistance with activities of daily living, such as: bathing, dressing, eating, grooming, getting in and out of bed, or toileting.

How are Professional Services Billed for SNF and NF?

Although there is a difference in the setting and the care provided, the codes used to report the professional services in either facility are found in the same nursing facility evaluation and management (E/M) category. CPT^® doesn’t have subcategories to differentiate a SNF from an NF.
In 2006, we saw an overhaul to the Nursing Facility Services codes to reflect better current medical practice and to provide a consistent format throughout CPT^®. Three codes were introduced to report nursing facility admissions (Initial Nursing Facility Care: 99304-99306), along with four codes to report follow-up nursing facility care (Subsequent Nursing Facility Care: 99307-99310), and a new a new code to report yearly assessments (Other Nursing Facility Services: 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). In 2008, we saw typical/average times re-established for these codes, and language added to the code descriptions.
The Initial Nursing Facility Care codes are per day, and include all work in all sites performed on the same service date. They require all three key components of history, exam, and medical decision making to be satisfied to report a particular level.
Consider the following example documentation for an initial service:
CC: hip fx
HPI: 84 yo female here after left hip fx for rehab. Had hip surg on 2-18-10. Had post-op anemia and was transfused in the hosp. Moderate pain with ambulation and taking Vicodin for pain.
PMH: CAD s/p CABG 1987, angioplasty 2001, HTN, hypothyroid, hyperlipidemia
PSH: CABG, vag hyst/bladder repair, cataracts, appy
Meds: ASA, Lovenox, Zetia, Fe, HCTZ, glucosamine, synthroid, Toprol XL, Accupril, Zocor, Vit. E, Tyl PRN, Prilosec, Vicodin PRN
Soc hx: married, tob/alcohol abuse
FH: negative for bleeding/clotting disorders
ROS: some trouble with sleeping here, naps during day, CP, SOB, abd c/o, using depends, legs pain, walking with walker, some memory problems
Allergy: NKDA
PE: Alert and oriented, NAD, HEENT: PERRL, pharynx clear; Neck: supple, adenopathy, COR: RRR w/o murmur; Lungs: CTA; ABD: soft, NT; Extremities:  edema, left hip non-tender, incision site clean and dry without s/s infection
IMP:
s/p hip fx here for rehab
CAD stable on meds
Hypothyroidism on replacement
HTN, will monitor
# chol – cont meds
GERD prophylac Prilosec
DVT prophylaxis w/Lovenox
Based on the above documentation, the service may be reported using level I Initial Nursing Facility Care code 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.
For Medicare payers, remember also to add modifier AI Principal physician of record to indicate the services were provided by the principal physician of record, who is overseeing the patient’s care (as opposed, for instance, to a provider reporting a consultative service in the nursing facility for a Medicare patient).
The Subsequent Nursing Facility Care codes also are per day, and include diagnostic studies chart and results review, and any changes in the patient’s status since the last assessment. These codes only require two of the three key components to be satisfied to report any particular level.
For example, subsequent service documentation for the patient above might state:
CC: F/U Left hip fx, Doing well with rehab and pt is expecting to go home soon. Ambulating better. Pain minimal.
HTN, Hypothyroid, hyperlipidemia are stable.
ROS: doing better getting sleep at night. CP, SOB.
PE: VSS, COR RRR w/o murmur, Lungs CTA, Left hip incision healing nicely.
IMP: Responding to rehab nicely, Awaiting PT clearance, Hypothyroidism on replacement; HTN good control; # chol – cont meds, DVT prophylaxis w/ Lovenox.
Continue current meds.
In this case, the detailed history, expanded exam, and moderate medical decision making would warrant a level III subsequent nursing facility care service, 99309 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: a detailed interval history; a detailed examination; medical decision making of moderate complexity.

Who Can Bill the Initial Professional Service in the SNF and NF?

This answer depends on whom you ask.
Some states allow non-physician practitioners (NPPs), as well as physicians, to perform the initial visit. But if you ask Medicare, there is a difference between a SNF and an NF, and who can perform the initial visit.
According to Medicare (PHYS-079), use Initial Nursing Facility Care codes to report an initial visit in a SNF, and this service must be performed by the physician and cannot be delegated. In the NF setting, a qualified NPP (such as a nurse practitioner (NP), physician assistant (PA), etc.), who is not employed by the facility, may perform the initial visit when within the scope of their practice and state law.
One exception to this rule is if the patient’s condition warranted a medically necessary visit due to illness or injury prior to the physician’s initial visit in either the SNF or NF setting. Qualified NPPs may bill a Subsequent Nursing Facility Care code, even if their service is provided before the physician’s initial visit. The documentation and diagnoses codes associated with the service need to support the medical necessity of such a service.
An example of a medically necessary, subsequent note (in the SOAP format) prior to the initial visit might be:
S: Acute visit; asked to see pt for a blister on her right upper abdomen, it opened and is described as dry, scabbed with mild redness at the site.
O: It measures 0.9 x 0.8 cm without swelling or increased warmth. She does c/o pain with mild palpation. Today the scab is off. There is yellow-green slough in the wound bed with mild redness around the site. T. 98.2, BP. 130/80, P. 72, R. 20
A: Stage II open area RUQ abdomen—Questionable etiology.
P: Moist to dry dressing.
Based on the above documentation, it would be appropriate to report level II Subsequent Nursing Facility Care code 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 for this service.
The initial visit, according to Medicare (PHYS-079 and Internet Only Manual, Pub. 100-04, chapter 12, section 30.6.13), is “defined 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.” This visit must occur no later than 30 days after admission.
Although the verbiage in the Medicare description states “comprehensive” assessment, the required documentation to report the lowest level Initial Nursing Facility Care code is only a detailed history and examination with straightforward/low medical decision-making. Do not misconstrue the word “comprehensive” in Medicare’s description to have the same meaning as “comprehensive” in the documentation guidelines as it pertains to history and exam.

Where, When Can the Initial NF Visit Take Place?

An initial nursing facility service can occur in the physician’s office, the hospital, or the SNF/NF—and it can occur on a different date than the admission date to the SNF/NF. Medicare will reimburse for these services only when billed with POS codes 31 or 32. The documentation should show the location and date that the face-to-face service occurred.

Who Can Bill Subsequent Professional Services in the SNF and NF?

Again, depending on whom you ask, the answer may be different.
According to Medicare, either the NPP or the physician can perform the mandated follow-up visits in the SNF or the NF. But in the NF, qualified NPPs cannot be employed by the facility.
Use the Subsequent Nursing Facility Care codes to report federally mandated and any medically necessary visits that might arise. Qualified NPPs may perform alternating federally mandated physician visits. Medicare doesn’t offer guidance regarding the frequency of physician-continued involvement in the patient’s care throughout their SNF stay. Some states don’t allow NPPs to perform all the mandated visits, but they can perform some of them. Check your state laws and create an internal policy outlining the frequency of physician visits to demonstrate their continued involvement.
Bill the annual nursing facility visit using CPT^® code 99318, which can be used in lieu of a Subsequent Nursing Facility Care code.

Can SNF or NF Services Be Billed Split/Shared?

No.

How Is SNF or NF Discharge Billed?

Similar to Hospital Discharge Services, Nursing Facility Discharge Services, too, are time-based codes.
CPT^® 99315 Nursing facility discharge day management; 30 minutes or less is used to report a discharge service of less than 30 minutes, while 99316 Nursing facility discharge day management; more than 30 minutes is appropriate for a discharge service of greater than 30 minutes.
Discharge visits include the final examination of the patient, discussion of the nursing facility stay, patient care instructions, and completion of medical records/forms. Report the date the service was actually performed, even if that date differs from the calendar date the patient was discharged from the facility.
Kerin Draak, MS, WHNP-BC, CPC, CEMC, COBGC, has been involved in the health care field for over 18 years, specializing in women’s care. She is the coding educator for a 220+ provider multispecialty clinic and was instrumental in the development of its internal chart audit program. Kerin has developed educational tools, guides, and policies for the clinic. She is an AAPC National Advisory Board (NAB) member and serves as president of her local AAPC chapter.