Medicare Compliance & Reimbursement

SNF's and standard NFs have new reimbursement and billing options.

Qualified non-physician practitioners working in both skilled nursing and standard nursing facilities can now obtain reimbursement for patient evaluation and management visits. The new policy covers nurse practitioners, physician assistants, clinical nurse specialists and other NPPs for medically necessary E/M visits before or after a physician's initial comprehensive assessment visit.

In SNF settings, a physician must always perform the initial visit, according to a recent Centers for Medicare & Medicaid Services Medlearn Matters article. After the initial visit, physicians may delegate alternating, federally mandated follow-up visits to NPPs, regardless of whether they are the SNF's employees.

In standard NF settings, however, state-approved NPPs can perform initial visits in NFs that don't employ them. During these initial visits, the NPP performs a thorough patient assessment, develops a care plan and writes or verifies admitting orders for the NF resident. When a physician delegates an initial visit to a qualified NPP, the visit must occur within 30 days of the bene's admission.

Qualified NPPs may also provide federally mandated visits subsequent to an initial visit as states' long-term care regulations permit. As with initial visits, state-approved NPPs who are not employees of the NF may perform these federally mandated follow-up visits.

In both SNF and NF settings, qualified NPPs may perform medically necessary E/M visits before and after the initial visit if the facility meets collaboration, physician-supervision, licensure and billing requirements.

Code changes accompany the new rule--new codes replace the Current Procedural Terminology codes for reporting initial NF care and subsequent NF care, effective Jan. 1, 2006. CPT codes 99304--99306 (Initial Nursing Facility Care) replace CPT codes 99301--99303 (Comprehensive Nursing Facility Assessments), and codes 99307--99310 (Subsequent Nursing Care) replace codes 99311--99313 (Subsequent Nursing Facility Care).

In addition, Medicare has added two new code sets. Billers must use codes 99315--99316 (Discharge Day Management Service) "to report the physician or NPP's face-to-face visit with the patient to meet the SNF/NF discharge day-management service requirement." CMS says. To report an annual NF assessment, billers must report code 99318 (Other Nursing Facility Services).

For further details about these changes, read the Medlearn Matters article at www.cms.hhs.gov/MedlearnMattersArticles/downloads/MM4246.pdf.