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Auditing Physician Service


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Subsequent nursing home visits
Citations: CMS Medicare Claims Processing Manual,
Resources: Med Learn Matters, Nursing home services (pdf)  
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Subsequent nursing facility visits are reported with codes 99307--99310.  These codes are defined as per day codes, and do not have new and established patient divisions.  There are also initial nursing facility codes, which only a physician may use.  A physician or NPP may use the subsequent facility codes, either before or after the initial service (the admission) is performed.  It is often the case that an NPP sees the patient before the physician, in order to write initial orders and make sure the patient is stable on the first or second day of their stay in the nursing facility.  Then, the physician comes in at a later date to do the admission.

The subsequent nursing facility visits require 2 of 3 of the key components of history, exam and MDM. Because they are defined as per day codes, there is no additional payment if the clinician sees the patient more than once in the same calendar date.

There are no frequency rules about these codes.  A physician may see the patient as many times as is medically necessary.  There is no doubt that seeing the patient very frequently will result in carrier notice.  Also, CMS is wary of physicians who provide "gang" visits.  That is, as long as I'm here, I might as well see all my patients.  See patients outside of the mandated visits (mandated by the nursing home's condition of participation) only as often as is medically necessary.   If the nurse or family asks you to see a patient, document that and the reason why.

Be careful about billing a low level nursing facility visit with a procedure.  This is a trigger to your carrier and may result in an audit.  Bill for both only if they are both medically necessary, and documented and the E/M service is separate and distinct. 

For patients in skilled nursing facility, a visit is required every 30 days for the first 90 days, and every 60 days after that.

There are two place of service codes relevant: POS 31 for a skilled facility and POS 32 for nursing facility.

Use these codes for patients in swing beds, as well.

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