Internal Medicine Coding Alert

Published on Wed Oct 05, 2005 PDF

Question: An internist discharges a patient without performing a face-to-face encounter. May I still report 99315-99316? The code description reads in part, "as appropriate, final examination."


Florida Subscriber


Answer: You should check with the insurer or your local carrier for specific nursing facility (NF) discharge code information. Because CPT's directions make the face-to-face distinction unclear, no Medicare National Coverage Determination (NCD) exists on 99315-99316 (Nursing facility discharge day management ...).

Many carriers, however, such as AdminaStar Federal (Indiana), make a face-to-face encounter mandatory. A CMS official's written response to the American Medical Directors Association's inquiry promulgated this interpretation.

The letter states, "For Medicare purposes, a face-to-face visit between the physician and patient must always occur (with rare exceptions) in order to bill an evaluation and management service. A face-to-face visit is required for a nursing facility discharge E/M service (code 99315 or 99316). The Current Procedural Terminology (CPT) definitions for codes 99315 and 99316 are somewhat ambiguous in this respect, and in the absence of further national policy interpretation in the Medicare Carriers Manual, we have deferred to local Medicare carriers for local policy interpretation."

Out: If your internist does not see the patient face-to-face on the discharge day, you should report the discharge code on the last day the physician saw the patient. Example: During nursing home rounds, an internist sees a patient on Oct. 5. After checking with staff, he discharges the patient by phone on Oct. 7. You should report 99315-99316 and date the claim Oct. 5, instead of assigning 99311-99313 (Subsequent nursing facility care, per day, for the evaluation and management of a new or established patient ...) for the E/M rounds and 99315-99316 for the indirect discharge.
 
Even though 99315-99316 may require a face-to-face encounter, the codes still apply to dead-patient discharge services, as long as the internist "sees" the patient that day. You may also use 99315-99316 "for death pronouncement, and the physician must likewise be present in order to report the service for payment," according to the CMS letter.

Resources: To view a complete copy of the CMS letter, go to http://www.amda.com/federalaffairs/cms_em_svcs.pdf.