Billing Coding Part 3 Nursing Home Home Visit

Billing & Coding Part 3 Nursing Home & Home Visit Coding North. Shore Family Medicine Practice Management Curriculum 5 -22 -13

Objectives • Review how to bill and code Nursing Home and Home visits. • Review the key components required to bill these encounters. • Discuss similarities in billing these encounters compared with the ambulatory and inpatient encounters we previously discussed.

Billing & coding roadmap Where are we • • Session 1: Session 2: Session 3: Session 4: The Ambulatory Encounter Inpatient Billing Nursing Home and Home Visits Modifiers and Procedure Billing

A Quick Review: Components of Billing (same as inpatient & outpatient billing) • CPT (Procedure) Codes – defines what you are doing • ICD -9 (Diagnosis) Codes – defines why you are doing the above activity • HCPC coding – defines supplies and medications given • Modifier Codes – provide additional information for the insurance company detailing what you are doing.

Selecting the Proper Code Step 1 Where was the service provided? • Office • Hospital • Nursing facility • Rest home or assisted living facility • Home

Selecting the Proper Code Step 2 • What type of service was provided? – New or established patient? – Initial or subsequent care in a hospital or nursing facility? – Managing or consulting care? • What is the key or controlling factor that defines the level of service? – Complexity of the history, examination, and medical decision making? – Time spent in counseling and coordinating care?

CPT Codes for Physician E/M Services • • • Outpatient/Office (99201 -99215) Inpatient hospital (99221 -99236) Nursing Facility (99304 -99318) Domiciliary/ Rest Home or ALF (99307 -99337) Home (99341 -99350)

Determining E/M Level Key / Controlling Elements (required) • History • Physical examination • Medical decision making Contributory Factors (optional) • Counseling • Coordination of care • Nature of the presenting problem • Time spent.

History HPI ROS PFSH Type of Visit Brief N/A Problem Focused (P) Brief Problem-Pertinent N/A Expanded Problem Focused (E) Extended Pertinent Detailed (D) Extended Complete Comprehensive (C)

Physical Exam • • Problem-focused examination (P) – Limited examination of the affected body area or organ system • • Expanded problem-focused examination (E) – Limited examination of the affected body area or organ system and other symptomatic or related organ system(s) • • Detailed examination (D) – Extended examination of the affected body area(s) and other symptomatic or related organ system(s) • • Comprehensive examination (C) – General multisystem examination (more than eight organ systems); only organ systems apply for the comprehensive exam

Complexity Diagnosis /Management Data Review Complication / Risk Complexity Minimal or none Minimal Straightforward (S) Limited Low (L) Multiple Moderate (M) Extensive High (H)

Key • • P = problem-focused E = extended problem-focused D = detailed C = comprehensive S = straightforward decision-making L = low complexity M = moderate complexity H = high complexity

Initial Nursing Facility Care Level History Exam Complexity Time 99304 D D S/L N/A 99305 C C M N/A 99306 C C H N/A Requires 3/3 key Components Key: P = problem-focused E = extended problem-focused D = detailed C = comprehensive S = straightforward decision-making L = low complexity M = moderate complexity H = high complexity

Subsequent Nursing Facility Care Level History Exam Complexity Time 99307 P P S N/A 99308 E E L N/A 99309 D D M N/A 99310 C C H N/A Requires 2/3 Key Components Key: P = problem-focused E = extended problem-focused D = detailed C = comprehensive S = straightforward decision-making L = low complexity M = moderate complexity H = high complexity

Nursing Facility Discharge Level History Exam Complexity Time 99315 N/A N/A <30 minutes 99316 N/A N/A >30 minutes

Home Visit : New Service Level History Exam Complexity Time 99341 P P S 20 99342 E E L 30 99343 D D M 45 99344 C C M 60 99345 C C H 75 Requires 3/3 Key Components Key: P = problem-focused E = extended problem-focused D = detailed C = comprehensive S = straightforward decision-making L = low complexity M = moderate complexity H = high complexity

Home Visits: Established Level History Exam Complexity Time 99347 P P S 15 99348 E E L 25 99349 D D M 40 99350 C C M/H 60 Requires 2/3 Key Components Key: P = problem-focused E = extended problem-focused D = detailed C = comprehensive S = straightforward decision-making L = low complexity M = moderate complexity H = high complexity

Documenting Time as the Key or Controlling Element • If the physician visit consists predominantly (more than 50%) of counseling or coordination of care with the patient and/or family, time may be considered the key or controlling factor for choosing the correct E/M code.

What is Face-To-Face Time • Face-to-face time is only that time that the physician spends face-to-face with the patient and/or family. This includes time spent obtaining a history, doing an examination, and counseling the patient/family. This is the time used to define an office visit, office consultation, or other outpatient service, including home and assisted living facility services. • Non-face-to-face time is physician time spent working before or after an outpatient encounter or working off the inpatient unit/floor. This time is not included in the calculation of intraservice time.

Extended Service Billing • Prolonged service, with direct face-to-face patient contact – Office or other outpatient setting (99354 -99355) – Inpatient setting (99356 -99357) • Prolonged service, without face-to-face patient contact – At this time, there is no valuation or reimbursement for these services

Summary • Nursing home visits and Home visits require the similar key elements to bill an encounter as the ambulatory and inpatient encounters. • Specific requirements differ based on each situation.

Quesitons