Wiki Frequency of Nursing Home E/M billing

[SienTC1720]

I bill for the MD in a nursing home, and we are a bit worried about billing to Medicare, mostly because he received a "warning letter" in February regarding the frequency he billed the code 99310, which we have greatly reduced since then.

I am now a bit worried about how often he sees/bills E/M visits for the patients. I know it relies on the severity of what they are being treated for, but some still seem a bit excessive.

For example, patient admitted mid October, with permanent atrial fibrillation, we have 22 service dates for her. Nov 1st through November 16th there are visits everyday.

I have looked at the LCDs and other coding information CMS has. I just want more clarity, and some opinion about these visits.

Thanks in Advance.

 

[thomas7331]

I'm not aware of any frequency limits by Medicare for any E&M codes, but I think you have a legitimate concern here. It's routine for a provider to follow a patient on a daily basis during an inpatient stay in a hospital, but if the patient is stable enough for discharge to a nursing home, you don't usually see daily visits by a physician.

That said, as a coder or biller, you're doing your job correctly if you've accurately coded what is in the documentation, and it's not up to you to tell the provider they're seeing a patient too often - that's the physician's decision alone. Assuming that the coding of these visits is supported by the record, if Medicare decides to challenge this, it would be on the basis of the medical necessity of those visits, and it would be up to the physician to defend this. Remember that medical necessity is defined (in part) by CMS as that which is "in accordance with the generally accepted standards of medical practice" and "clinically appropriate, in terms of type, frequency, extent, site, and duration, and considered effective for the patient's illness, injury, or disease". Determining whether or not these visits meet these definitions is something that is outside the scope of coder training and would require a peer review.

If you have a good relationship with your physician, you may want to discuss your concerns with him and remind him that if a payer looks at these frequent visits, the documentation of the patients' conditions needs to make it clear that the frequency is in accordance with standards of practice and that any other physician reviewing the records would agree that this level of care is reasonable and necessity for any similar patient. Since you already know that Medicare is scrutinizing your billing patterns, it also may be helpful to have another MD take a look at the records and see if they agree with his frequency and perhaps recommend any improvements to the documentation that might help to bolster a case for the medical necessity of the care.