Revenue Cycle Insider

Question: Our primary care physician (PCP) sees an established 79-year-old patient in the office for hypertension, type 2 diabetes, and chronic kidney disease. After a hospitalization for pneumonia and deconditioning, the patient is discharged to a skilled nursing facility (SNF) for Medicare Part A-covered rehabilitation services. Two days after the transfer, the PCP visits the patient at the SNF for the first time. The physician reviews the hospital discharge summary and medication list, performs a comprehensive evaluation, reconciles medications, and addresses pneumonia recovery, diabetes management, and a recent rise in creatinine. The physician documents moderate medical decision making (MDM) and assumes responsibility as the principal physician overseeing the patient’s care at the facility. Because the patient is established to the practice, should we report an established office/outpatient evaluation and management (E/M) code or a subsequent nursing facility care code?

Washington, D.C. Subscriber

Answer: In this situation, you’ll want to focus on an E/M code that acknowledges the encounter took place at an SNF: Look to 99305 (Initial nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 35 minutes must be met or exceeded.). Even though the patient has an “established” status with the provider, according to the CPT^® Evaluation and Management (E/M) Services Guidelines, nursing facility code selection is based on the nursing facility E/M code family and whether the encounter represents an initial or subsequent nursing facility service during the stay.

For Medicare, append modifier AI (Principal physician of record) to 99305 because the PCP is identified as the principal physician overseeing the patient’s care. Other physicians or qualified healthcare professionals who provide an initial nursing facility service during the same stay may also use the appropriate respective code for the initial stay, but they should not append modifier AI. Report place of service (POS) 31 (Skilled nursing facility) when the patient is receiving Part A-covered skilled care in the SNF.

Rachel Dorrell, MA, MS, CPC-A, CPPM, Production Editor, AAPC