billing for nursing home visits

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Coding Physician Visits in Skilled Nursing Facilities/Nursing Facilities

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As of April 22, due to the COVID-19 public health emergency , CMS is waiving the requirement in 42 CFR 483.30 for physicians and non-physician practitioners to perform in-person visits for nursing home residents and allow visits to be conducted, as appropriate, via telehealth options. Prior to this, telehealth was only available for established patient visits.

Coding for Skilled Nursing Facility

• To be reported when the MD, DO, OD visits the patient in the Skilled Nursing Facility.
• Place of Service is 13.
• Initial Visit whether patient is new or established 99304, 99305, 99306
• Subsequent Skilled Nursing Facility visits performed in person or via telehealth: 99307, 99308, 99309, 99310

Coding for Nursing Home Visits

• To be reported when the MD, DO, OD visits the patient in a Nursing Home.
• Place of service is 13
• New Patient: 99324, 99325, 99326, 99327, 99328
• Established Patient: 99334, 99335, 99336, 99337
• Modifier -25

Note: When billing an intravitreal injection (or any minor surgery) the same day as an encounter, consider the definition of modifier -25 and although medically necessary, if the established patient exam is performed solely to confirm the need for the injection, the exam is not separately billable.

Coding for Home Visits

• To be reported when the MD, DO, OD visits the patient at their home.
• Place of service is 12
• New Patient: 99341, 99342, 99343, 99344, 99345
• Established Patient: 99347, 99348, 99349, 99350

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Understanding Nursing Home Billing – Codes and Workflow

What Is Nursing Home Billing and How Does It Work?

• Billing frequency specified in the contract
• Inclusion of basic charges and ancillary servicess Rates influenced by care complexity, service level, room type, and amenities

Components of Nursing Home Billing Codes and Procedures

• Assessment of Care Level
• Insurance Plans Coverage
• Billing Period Overview
• Coding Framework
• Specific CPT Codes in Use
• Modifiers Enhancing Specificity

Assessment of Care Level in Nursing Home Billing

Primary care:.

• Serving as the foundation of healthcare, primary care involves general practitioners, such as physicians, nurse practitioners, and physician assistants.
• These healthcare professionals provide a broad range of medical services, acting as the initial point of contact for patients and playing a crucial role in the healthcare system.

Secondary Care:

• As the next stage in the healthcare continuum, secondary care entails primary care providers referring patients to specialists like pathologists and oncologists.
• Specialists in secondary care offer in-depth treatment and management of specific conditions, contributing expertise to the diagnosis and treatment of complex medical issues.

Tertiary Care:

• Representing the highest level of specialty care, tertiary care employs advanced technologies and procedures to address complex and severe cases.
• Specialized facilities, such as dialysis and neurosurgery centers, provide highly specific care, significantly impacting patient outcomes and enhancing overall quality of life.

Quaternary Care:

• At the forefront of healthcare, quaternary care offers the most advanced and experimental treatments.
• Limited to select institutions, these treatments often involve a multidisciplinary approach, pushing the boundaries of what is achievable in healthcare and contributing to the advancement of medical knowledge.

Insurance Coverage in Nursing Home Billing

Billing period overview in nursing home billing.

• The billing cycle, typically calculated on a monthly basis, defines the timeframe for each billing occurrence.
• In cases where a resident’s stay doesn’t initiate on the first day of the billing cycle, the nursing home employs a proration approach.
• The prorated amount is calculated by multiplying the per-day charge for room and board by the number of days spent in the facility during the admission month.
• To provide residents with foresight into upcoming costs, some care facilities issue a pre-bill for the forthcoming month.

Coding Framework in Nursing Home Billing

ICD-10 codes: Dedicated to conveying patient diagnoses, ICD-10 codes are pivotal in the billing landscape, ensuring the inclusion of medical procedures and services in nursing home bills.

HCPCS codes : Designed to highlight specific services or supplies offered to patients, HCPCS codes find application in billing procedures, particularly for Medicare and Medicaid transactions.

CPT codes: Offering granularity, CPT codes play a vital role in pinpointing the exact procedures or services administered to patients. In nursing home billing, these codes are fundamental for accurately billing private insurance.

Revenue codes: Functioning as identifiers for the type of service provided, revenue codes are instrumental in the billing processes associated with Medicare and Medicaid in nursing home facilities.

This coding framework not only establishes a standardized approach but also ensures the meticulous representation of the diverse services within nursing homes. It underpins the integrity of billing procedures, aligning with regulatory guidelines and fostering transparency in financial transactions.

Specific CPT Codes in Nursing Home Billing

99304-99306: Initial Nursing Facility Care

These codes specifically designate the billing for the initial care provided to residents entering a nursing facility. They encompass a range of services during the initial evaluation and consultation phase.

99307-99310: Subsequent Nursing Facility Care

Covering subsequent care visits within the nursing facility, these codes capture the ongoing medical services and consultations provided to residents after the initial phase.

99315-99316: Nursing Facility Discharge Services

These codes are utilized for billing services related to the discharge of residents from the nursing facility. They encompass the management and coordination involved in the discharge process.

This utilization of specific CPT codes in nursing home billing ensures a detailed and accurate depiction of the diverse medical services provided at different stages of a resident’s stay. It facilitates a systematic approach to billing, aiding in transparent financial transactions and adherence to regulatory standards.

Modifiers in Nursing Home Billing - Refining Specificity

Modifiers, integral in nursing home billing, enhance the precision of services and procedures documented with Current Procedural Terminology (CPT) codes. Employed alongside these codes, modifiers clarify modifications made to healthcare interventions, contributing to detailed billing information.

Modifier 25: Indicates a separately identifiable Evaluation and Management (E/M) service on the same day as a procedure, highlighting comprehensive care.

Modifier 59: Designates a distinct or independent procedure or service, ensuring clear differentiation between healthcare interventions.

Modifier 51: Signifies multiple procedures during a single session, offering insight into the complexity of medical services.

Modifier -52: Indicates partial reduction or elimination of a procedure, providing transparency on adjustments made during care.

Modifier -53: Denotes discontinuation of a procedure due to extenuating circumstances, explaining instances where healthcare interventions may not be completed as planned.

Modifier -74: Highlights procedures performed in a teaching setting by a resident under direct supervision, emphasizing educational context.

Use of modifiers may vary by payer, necessitating collaboration with the billing department and insurers. Facilities may impose restrictions, requiring consultation with the billing department for accurate guidance.

Optimizing Financial Transparency in Nursing Home Billing

Financial transparency is paramount in nursing home billing to build trust and ensure clarity for residents and their families. Here, we explore strategies to optimize financial transparency in the billing process: Transparent Fee Structures: Clearly outline charges for core services and additional amenities in the fee structure.

Detailed Billing Statements: Provide residents with comprehensive monthly billing statements, detailing costs and associated services.

Accessible Payment Policies: Communicate easily understandable payment policies, including deadlines, accepted methods, and penalties for late payments.

Implementing these measures promotes financial transparency, contributing to a positive experience for residents and their families in navigating nursing home billing processes.

Final Thoughts

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Nursing Home Billing Guidelines & Codes - A Roadmap to Reimbursement

Maximize your nursing home reimbursement with ease: Expert guidance on the latest billing guidelines & codes.

Are you a healthcare provider experiencing difficulties in navigating the complex world of nursing home billing and coding? Nursing Homes have an immense role to play, whether for long-term or short-term care. Nursing homes can be categorized into ALF( Assisted Living Facilities), SNF (Skilled Nursing Facilities SNF), and ALC (Assisted Living Centers).

This comprehensive guide will break down the latest nursing home billing guidelines and decipher billing code codes, giving you an understanding of constantly changing CMS guidelines to ensure your facility receives the proper reimbursement for the vital care provided to your residents.

Nursing Home Billing Guidelines

Nursing homes, also known as skilled nursing facilities, provide around-the-clock medical care and assistance with daily living activities for older adults and those with chronic health conditions.

These facilities are essential to the healthcare system, as they allow individuals to receive the care they need in a safe and comfortable environment. However, with the care and services provided come billing and reimbursement responsibilities for the nursing home administrators.

To ensure proper reimbursement and compliance with regulations, nursing home administrators must understand and follow the various nursing home billing guidelines set forth by Medicare and Medicaid and private insurance companies.

The level of care provided by a nursing home facility is the primary determinant of how much reimbursement you can expect from insurance providers.

Knowing what type of care your residents need and ensuring that your facility meets these requirements can help ensure proper payment for services rendered. There are four types of care involved:

• Primary care is the cornerstone of healthcare, where general practitioners such as physicians, nurse practitioners, and physician assistants provide a wide range of medical services to individuals dealing with common illnesses and injuries. These providers act as the first point of contact for patients and play a vital role in the healthcare system.
• Secondary care is the next step in the healthcare journey. Primary care providers refer patients to specialists such as pathologists and oncologists for more in-depth treatment and management of specific conditions. These specialists provide expert care and play a critical role in diagnosing and treating complex conditions.
• Tertiary care is the highest level of specialty care, where advanced technologies and procedures are employed to tackle complex and severe cases. These specialized facilities, such as dialysis and neurosurgery centers, provide the most specialized care and play a vital role in saving lives and improving the quality of life for patients.
• Quaternary care is the cutting-edge of healthcare, where the most advanced and experimental treatments are offered to patients. These treatments are typically only available at select institutions and often involve a multidisciplinary approach to care. Quaternary care is critical in pushing the boundaries of what is possible in healthcare and advancing medical knowledge.

Insurance Plans Coverage Criteria

Medicare Part A and Part B plans have distinct acceptance criteria for nursing home services. Under Part A, a patient in a nursing facility is covered for 20 days. Beyond the 21st day, Medicare will provide partial coverage for services, and co-insurance will apply.

It is important to note that coverage criteria are limited to the extent of available benefits. Once the patient's benefits have been exhausted, the nursing facility staff will submit claims to the resident for additional coverage.

Medicare part B coverage kicks in for long-term care facilities once the patient has been disqualified for part A Coverage. Some of the most often reimbursed services in long-term care are physical, occupational, and speech therapy services.

Billing Period for Nursing Home

Claims for Nursing home billing are sent monthly. Nursing homes usually bill patients by using CMS-1450 (which is also called UB-04 ). Claims can also be sent if the patient is:

• Dropped from skill care
• Benefits are exhausted

For providers to bill accurately, they should remember that proper documentation is made.

Billing Cycle

The billing cycle for nursing home services requires a series of steps that ensure accurate and timely billing to patients or their insurance providers.

• First, the MAC (Medicare Administrative Contractor) will return a continuing stay bill if the prior bill has not yet been processed. In this case, it is important to hold onto the returned bill until the Remittance Advice (RA) for the prior bill has been received.
• Next, it is important to note that certain days, such as the day of discharge or death or the day when a patient begins a Leave of Absence (LOA), are not counted as utilization days for billing purposes. Additionally, if a patient discharges and returns before the following midnight, it is not considered a discharge for billing purposes.
• Another important aspect of the billing cycle is the HIPPS rate code that appears on the claim. This code must match the assessment transmitted and accepted by the state where the facility operates.
• Once all the information is collected and verified, the bill is submitted to the patient or insurance provider. The payment is then processed, and the facility receives a Remittance Advice (RA) indicating the payment amount and any adjustments made to the bill.
• Finally, the billing cycle is completed when the facility receives payment for the services provided, and the billing records are updated accordingly. It is important to note that the billing cycle may vary depending on the facility's policies, procedures, and the type of services provided.

Following the proper nursing home billing guidelines, a path can be set for proper reimbursement from the insurance side. This should also be kept in mind that guides are constantly changing, so it’s better to follow up with CMS to remain updated.

What are the codes used in Nursing Home Billing

In nursing home billing, several codes are used to describe the services provided to patients accurately.

ICD-10 codes: These codes are used to indicate the diagnosis of the patient and are used for billing medical procedures and services.

HCPCS codes: These codes are used to indicate the specific services or supplies provided to the patient and are used for billing Medicare and Medicaid.

CPT codes: These codes are used to indicate the specific procedures or services provided to the patient and are used for billing private insurance.

Revenue codes: These codes indicate the type of service provided and are used for billing Medicare and Medicaid.

CPT Codes used in Nursing Home Billing

In nursing home billing, Current Procedural Terminology (CPT) codes are used to indicate the specific procedures or services provided to patients. These codes are used for billing private insurance and are developed and maintained by the American Medical Association (AMA).

Examples of CPT codes that are primarily used in nursing home billing include:

• Evaluation and management codes (99304-99306) - to bill for physician visits, including initial evaluations and consultations.
• Nursing Home Discharge Management codes ( 99315 & 99316 ) – to be billed when for nursing facility discharge day management
• Follow-Up Codes(99307-99310) – Used to be billed for subsequent nursing facility care visits
• Procedure codes (10040-69990) - are used to bill for procedures such as wound care, injections, and diagnostic tests.
• Physical therapy codes (97001-97755 ) - These codes are used to bill for physical therapy services provided by a therapist or assistant.
• Occupational therapy codes (97001-97755) - used to bill for occupational therapy services provided by a therapist or assistant.
• Speech-language pathology codes (92526-92625) - used to bill for speech-language pathology services provided by a therapist or assistant.

It's important to note that the codes used will depend on the specific services provided, so it's essential to refer to the AMA's CPT codes for the most up-to-date information. Additionally, it's important to check with the facility's billing department and the private insurance company to ensure that the codes used are valid for reimbursement.

Modifiers Used Along CPT Codes

Modifiers are used in conjunction with CPT codes to indicate that a service or procedure has been modified in some way.

Here are some examples of modifiers that how modifiers are used in nursing home billing:

Modifier 25: This modifier indicates that a significant, separately identifiable Evaluation and Management (E/M) service was provided on the same day as a procedure or service.

Modifier 59: This modifier indicates that a procedure or service was distinct or independent from other services performed on the same day.

Modifier 51: This modifier indicates that multiple procedures were performed during a single session.

Modifier -52: This modifier is used to indicate that a procedure or service was partially reduced or eliminated at the physician's discretion.

Modifier -53: This modifier is used to indicate that a procedure or service was discontinued due to extenuating circumstances.

Modifier -74: This modifier is used to indicate that a procedure or service was performed in a teaching setting by a resident under the direct supervision of an attending physician.

It is important to note that the use of modifiers may vary depending on the payer, so it's essential to check with the facility's billing department and the private insurance company to ensure that the codes and modifiers used are valid for reimbursement. Additionally, the facility may have some restrictions on certain modifiers, so it's essential to check with the facility's billing department for guidance.

Words by Author

Navigating the constantly evolving landscape of nursing home billing can be challenging for healthcare providers. However, providers can maximize reimbursement for their services by adhering to the CMS nursing home billing guidelines and utilizing the appropriate coding schema.

Outsourcing nursing home billing services to a reputable and affordable company, such as HMS USA LLC in NY, can alleviate the burden and complexity of this task, allowing providers to focus on providing quality care to their patients.

ABOUT AUTHOR

Tammy Carol

As a blog writer with years of experience in the healthcare industry, I have got what it takes to write well researched content that adds value for the audience. I am a curious individual by nature, driven by passion and I translate that into my writings. I aspire to be among the leading content writers in the world.

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7 tips to maximize revenue for nursing home services

Physicians should consider these seven tips to make nursing home services more lucrative.

It’s probably difficult for most internists to imagine: Seeing patients when it’s convenient for the physician, largely avoiding high-deductible health plans, and ensuring a steady income with few interruptions. For Connecticut-based internist Jeffrey Kagan, MD, this dream is a reality thanks to the fact that he spends 20 percent of his time seeing patients in nursing homes. 

“There’s a myth out there that you don’t get paid much to see patients in the nursing home, and that’s just not true,” says Kagan. “With nursing homes, it’s actually a nice constant flow of revenue.” 

Kagan especially likes that he rarely sees denials unless a patient with Medicare switches to a Medicare Advantage plan (or vice versa) and doesn’t notify his office. “We try to get accurate information from the very beginning,” he adds. “If the patient’s insurance doesn’t change, then it works, and billing goes smoothly.”

Other physicians say nursing home services can be lucrative but not without challenges. Vishal Aggarwal, MD, a geriatrician at Elite Medical Clinic in Tulsa, Okla., previously spent 50 percent of his time seeing patients in nursing homes but decided to stop last year because of the difficulty in getting paid. One challenge was that Oklahoma Medicaid only paid for two nursing home visits per month. This meant that when Aggarwal saw Medicaid patients more than that, his work was unpaid-even when it was medically necessary. 

Connecticut Medicaid doesn’t limit the number of medically necessary visits per month, says Kagan. “For example, it would be medically necessary to see someone for an acute problem like pneumonia or vomiting but not necessary to adjust the dose of warfarin or insulin,” he says.

Another challenge for Aggarwal was that he often felt pressured by the nursing home to see patients even when he wasn’t a participating provider in their Medicare Advantage network. When this happened, patients were often responsible for the bill, and it was nearly impossible to collect from them, he says. “It was easier to not see the patient, but you can’t say that to the nursing home. It put me in a very difficult situation,” he adds. 

Kagan doesn’t have this problem because he participates with each of the local Medicare Advantage plans. 

Finally, when patients didn’t have a primary care physician or didn’t see any other physician during an Accountable Care Organization (ACO) performance year, the ACO to which Aggarwal belonged attributed nursing home patients to him. This meant he was responsible for providing a year’s worth of preventive care for patients he only saw once or twice. When he didn’t provide these services, the data falsely indicated that he wasn’t managing patients effectively, and his clinic’s reputation started to suffer.

Kagan says some ACOs can eliminate nursing home patients from a physician’s attributed list so they aren’t responsible for all of a patient’s care. Kagan’s ACO is revamping its process for nursing home patient attribution so he isn’t penalized when there are gaps in preventive care.  

Although physicians can’t control some of these payment barriers, there are certainly steps they can take to make nursing home services more lucrative, says Vanessa Moldovan, CPC, CPMA, senior billing specialist at Medic Management Group LLC, a healthcare consulting company in Akron, Ohio. Here are seven tips to consider. 

Do your homework  before seeing patients in the nursing home. 

To avoid denials, physicians-and any non-physician providers they employ to treat patients in the nursing home-must be credentialed with every nursing facility in which they render services, says Michele Rodgers, certified medical manager at Healthstone Primary Care Partners, an internal medicine practice in Hollywood, Fla. 

The practice’s administrative staff should also contact the nursing home to obtain each patient’s demographic and insurance information to determine whether the physician is contracted with the patient’s insurance provider, says Rodgers. To minimize denials, this determination should take place as soon as possible. For patients with Medicare, it should take place before the first mandated visit, which Medicare states must occur within 48 hours of admission to the nursing facility, she adds. 

If the physician isn’t contracted with the patient’s payer, the services will likely be subject to the patient’s out-of-network benefits-and the patient could owe a significant co-insurance, says Rodgers. When patients have this information in advance, they may be more likely to follow through with payment or go to another nursing home that has an arrangement with a physician who’s in the patient’s network, she adds.

Know what codes to report.

Report a CPT code from the 99304-99306 code range for the initial nursing home visit, depending on the severity of the patient’s diagnosis and services rendered, says Moldovan. For all other medically necessary visits, report a CPT code from the 99307-99310 code range, she adds. This includes the federally-mandated visits for Medicare patients that occur every 30 days for the first 90 days after admission to the facility and at least once every 60 days thereafter.

It can get tricky when a patient with Medicare or a commercial plan leaves the nursing facility and returns a short time later. Kagan provides this example: A patient is discharged to rehab following a hip repair. On the third day of rehab, the patient develops respiratory distress and is re-hospitalized for acute hypoxic respiratory failure due to pneumonia. 

Physicians must determine whether the return to the nursing facility is considered an initial visit or subsequent, says Kagan. He provides this guidance: Unless the patient or their family pays to hold the bed in the patient’s absence-typically $300 to $400 per day-physicians can report an initial services code upon that patient’s return. If the patient or their family pays to hold the bed, then the original nursing home stay continues, and physicians must report a subsequent visit code when the patient returns. 

However, physicians should keep in mind that Medicare and many commercial payers track all admission and discharge dates, says Moldovan. If a physician tries to bill an initial visit before the nursing home discharges the patient, the payer will likely deny payment for the visit, she adds. 

Something else to keep in mind: Medicaid requirements may differ from state to state. For example, Connecticut Medicaid requires nursing homes to hold the bed for 14 days, says Kagan. If a patient with Medicaid is readmitted to the nursing home during that time, the physician must report a subsequent services code. If it’s after 14 days, the physician can report an initial services code, he adds.

If there’s any question as to whether the service is initial or subsequent, Kagan suggests contacting the director of admissions or biller at the nursing facility. Physicians shouldn’t assume that every patient is a readmission because they could be missing out on approximately $48 or more per visit (the difference between the initial and subsequent visits for a patient of similar clinical complexity), he says. 

Report CPT codes 99315 or 99316 for nursing facility discharge services, depending on the time spent performing these services. Discharge services include final examination of the patient, providing continuing care instructions to relevant caregivers, preparing the discharge records, completing referrals, and ordering prescriptions. Report CPT code 99318 for the annual nursing facility assessment. 

Double-check the place of service (POS) code. 

Many physicians incorrectly use POS code 11 (office) rather than POS code 31 (skilled nursing facility) or 32 (nursing facility), says Moldovan. Physicians must report the correct POS code in two places on the claim form-next to the name and address of the facility where services are rendered and next to the CPT code itself, she says. Some EHRs pre-populate the facility name and/or the POS code, and physicians may need to override one or both manually, she adds.

Append modifiers, when necessary. 

To be paid appropriately for providing nursing home services to Medicare patients receiving hospice care, physicians must append one of the following modifiers: -GV (when a provider performs a service related to the problem for which a patient was admitted into hospice) or modifier -GW (when the service is not related to the hospice patient’s terminal condition), says Rodgers. “If providers don’t usually treat patients on hospice, they may not be aware of these modifiers,” she explains.

Ensure documentation supports each CPT code. 

“Providers using these codes must familiarize themselves with what they need to document to substantiate the bill,” says Rodgers. 

Each code requires a chief complaint, history, exam, and medical decision-making, says Jane Miller, practice manager and auditor at a two-physician primary care practice in southern Ohio. “These codes require just as much documentation as regular office visit codes, she says. 

As with office visit E/M codes, higher-level nursing facility codes can raise questions with payers if documentation is sparse, says Miller. She provides the example of CPT code 99310 -the highest-level code for a subsequent nursing facility service. “You have to be really careful with this code, and you need to make sure that documentation reflects severity,” she adds.

Distinguish between nursing and assisted living facilities. 

The CPT manual describes assisted living facilities as those that provide room, board, and other personal assistance services, generally on a long-term basis. These facilities do not include a medical component. When physicians render services in an assisted living facility, they should report a CPT code from the 99324-99328 code range for new patients and the 99334-99337 code range for established patients, says Moldovan. Report POS code 13 with these CPT codes, she adds.

Don’t forget prolonged services. 

Kagan says he bills CPT codes 99358-99359 (prolonged services without direct patient contact) for time spent on the phone with nurses, family, or other physicians. Note that these codes must be reported in addition to an E/M code, and they require at least an additional 60 minutes of services beyond what’s typically associated with the E/M code. Physicians can also report CPT codes 99354-99355 for prolonged services with direct patient contact.

“Seeing patients in a nursing home can be rewarding in several ways,” says Kagan. “The schedule is flexible, and the patients and staff are very appreciative. Also, a dedicated nursing home practice requires minimal overhead and can be quite ­profitable.” 

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