Results 1 to 2 of 2

Initial Skilled Nursing Facility Visits

  1. #1
    Default Initial Skilled Nursing Facility Visits
    Exam Training Packages
    The doctor I am coding for sees a patient in a skilled nursing facilty for the first time and dictates his note. He has a problem focused HPI, detatiled exam, and low complextity MDM. The initial visits require 3 of 3 components to code the lowest level and the hpi and exam must be detailed or comprehensive.

    So, the MD doesn't meet the requirements to code the lowest initial SNF code. I was told by auditors we can use subsequent codes in an inpatient setting if the MD can't meet the documentation requirements. Does this apply to SNF initial visits too?

  2. #2
    Location
    Tacoma, WA
    Posts
    1,087
    Default
    Quote Originally Posted by jennyifer View Post
    The doctor I am coding for sees a patient in a skilled nursing facilty for the first time and dictates his note. He has a problem focused HPI, detatiled exam, and low complextity MDM. The initial visits require 3 of 3 components to code the lowest level and the hpi and exam must be detailed or comprehensive.

    So, the MD doesn't meet the requirements to code the lowest initial SNF code. I was told by auditors we can use subsequent codes in an inpatient setting if the MD can't meet the documentation requirements. Does this apply to SNF initial visits too?
    So what is missing from the history that would potentially make it a detailed history? Are there details that were perhaps discussed and left out of the providers dictation? I would definitely review the documentation with the provider...an addendum could be added if details were missed. If there are not more details, then educating the provider about what is needed on the Initial SNF visit would be good. And in that case you would just code a subsequent visit that meets the documentation provided.
    Arlene J. Smith, CPC, CPMA, CEMC, COBGC

Similar Threads

  1. Skilled Nursing Facility
    By kellit21 in forum Orthopaedics
    Replies: 0
    Last Post: 11-20-2013, 03:12 PM
  2. Skilled nursing facility
    By kumeena in forum Billing/Reimbursement
    Replies: 1
    Last Post: 02-22-2012, 07:59 AM
  3. Initial Skilled Nursing Facility Visits
    By jennyifer in forum Internal Medicine
    Replies: 0
    Last Post: 12-15-2011, 10:36 AM
  4. Skilled nursing home initial visit
    By janetrose in forum Medical Coding General Discussion
    Replies: 1
    Last Post: 11-14-2010, 08:22 PM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
  •  
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?

Login

Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.