Wiki Help with E/M Assisted Living Facilities 99324-99328

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ginacoder3185

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Hello,

Anyone know whether a nurse practitioner or a physician assistant can use this code set (99324-99328) at an assisted living facility for new patients or is this code set for MDs only? We also use codes 99304-99310 and NPs and PAs can only use established codes for new/established patients. I wonder if this is applicable to an assisted living facility as well? Thank you for your time!

Regina
 
I responded to your similar post in the general coding forum - the answer is the same here: yes, a nurse practitioner or physician assistant may use these codes if they saw a new patient. Not sure why you were told that NPs or PAs can only use established codes in certain circumstances, but that is not correct.
 
Hi thanks for your response regarding assisted living facility codes. For nursing homes, we were told codes 99304-99306 are for initial visits and only MDs can use these codes. NPs and PAs always use 99307-99310 for initial and established. Is this correct to your knowledge?
 

I was doing some research on this. Our POS is 31. According to this article, initial visits may only be provided by physician. But it sounds like an assisted living facility is different and any healthcare provider can use initial/established codes. Thank you!​


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SNF FACILITY RULES (PLACE OF SERVICE CODE 31)​


The initial comprehensive visit in a SNF must be provided by a physician and must occur no later than 30 days after a resident's admission into the SNF. The physician may not delegate the initial visit to another qualified health professional in a SNF stay. However, after the initial comprehensive visit in a SNF (99304-99306) the physician may delegate future subsequent care visits (99307-99310) to other qualified nonphysician practitioners (NPP), whether they are employed by the facility or not. With these follow-up visits, physician co-signature is not required. Note also, no visits at SNFs may be billed as split/shared services.
 
Yes, the rule you've cited here is a CMS regulation (not a coding rule) that requires an MD to perform the initial visit. So for a Medicare patient, that's correct - the MD must do that initial visit after the patient is admitted to the SNF. It does not mean that only an MD can use these codes, just that Medicare coverage rules require that the initial visit be done by the MD. So your NP or PA should not be seeing new patients at a SNF if they have Medicare coverage - it does not mean that the NP or PA can see the patient at the initial visit but then use a different code - that would be fraudulent billing.
 
As noted, the Medicare rules are different for SNF visits but as a point of clarification, it is not correct that the NP or PA cannot provide and report an E/M service that takes place before the physician's "initial visit." The CMS guidance is to report medically necessary E/M visits to a patient in a SNF stay using CPT codes 99307-99310 even if they are provided prior to the initial visit by the physician. "A qualified NPP may perform medically necessary E/M visits prior to and after the initial visit if all the requirements for collaboration, general physician supervision, licensure, and billing are met."

In the NF stay (eg, long-term care), CMS instructs "a qualified NPP (i.e., a nurse practitioner (NP), physician assistant (PA), or a clinical nurse specialist (CNS)), who is not employed by the facility, may perform the initial visit when the State law permits. The evaluation and management (E/M) visit shall be within the State scope of practice and licensure requirements where the E/M visit is performed and the requirements for physician collaboration and physician supervision shall be met."

An assisted living facility that is not providing nursing facility services is similar to a patient's home and not subject to the CMS guidelines for SNF or NF visits.
Hope that helps with the differentiation.
Cindy
 
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