Wiki Nursing Facility Discharge Services

[rsadkins]

Does anyone have any information about the level of exam needed to be performed by provider for CPT codes 99315 and 99316. CPT just says "final examination" and Medicare's MLN for Discharge Planning only says "a final summary of the resident's status at the time of discharge". Really no mention of an exam. I know this has to be face-to-face time, but how detailed does the exam need to be? Thanks.

 

[bethdeak]

If you review the guidelines for these codes you'll notice that they are time based. 99315 is 30 minutes or less, 99316 is more than 30 minutes.

In the guidelines it states that they include 'as appropriate' final examination of the patient, discussion of the stay, even if the time spent on that date is not continuous. Instructions should be given for continuing care to caregivers, discharge records should be completed, prescriptions and referrals issued (if needed).

The documentation should reflect the time spent. I've had providers document their exam of the patient along with their face to face time, and then the time spent coordinating services, scripts ect.

 

[vjww]

I assume you want to know if the exam has to documented based on BA or OS at the time of discharge? The code description does not specifically indicate the type of exam. So as long as some type final examination during a face-to-face evaluation was completed it should be okay to bill base on time.

 

[rsadkins]

Thanks!