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B. Use of Emergency Department Codes in Office Emergency department coding is not appropriate if the site of service is an office or outpatient setting or any sight of service other than an emergency department. The emergency department codes should only be used if the patient is seen in the emergency department and the services described by the HCPCS code definition are provided. The emergency department is defined as an organized hospital-based facility for the provision of unscheduled or episodic services to patients who present for immediate medical attention. C. Use of Emergency Department Codes to Bill Nonemergency Services Services in the emergency department may not be emergencies. However, the codes (99281-99288) are payable if the described services are provided. However, if the physician asks the patient to meet him or her in the emergency department as an alternative to the physician’s office and the patient is not registered as a patient in the emergency department, the physician should bill the appropriate office/outpatient visit codes. Normally a lower level of emergency department code would be reported for a nonemergency condition. D. Emergency Department or Office/Outpatient Visits on Same Day as Nursing Facility Admission Emergency department visit provided on the same day as a comprehensive nursing facility assessment are not paid. Payment for evaluation and management services on the same date provided in sites other than the nursing facility are included in the payment for initial nursing facility care when performed on the same date as the nursing facility admission. E. Physician Billing for Emergency Department Services Provided to Patient by Both Patient’s Personal Physician and Emergency Department Physician If a physician advises his/her own patient to go to an emergency department (ED) of a hospital for care and the physician subsequently is asked by the ED physician to come to the hospital to evaluate the patient and to advise the ED physician as to whether the patient should be admitted to the hospital or be sent home, the physicians should bill as follows: • If the patient is admitted to the hospital by the patient’s personal physician, then the patient’s regular physician should bill only the appropriate level of the initial hospital care (codes 99221- 99223) because all evaluation and management services provided by that physician in conjunction with that admission are considered part of the initial hospital care when performed on the same date as the admission. The ED physician who saw the patient in the emergency department should bill the appropriate level of the ED codes. • If the ED physician, based on the advice of the patient’s personal physician who came to the emergency department to see the patient, sends the patient home, then the ED physician should bill the appropriate level of emergency department service. The patient’s personal physician should also bill the level of emergency department code that describes the service he or she provided in the emergency department. The patient’s personal physician would not bill a consultation because he or she is not providing information to the emergency department physician for his or her use in treating the patient. If the patient’s personal physician does not come to the hospital to see the patient, but only advises the emergency department physician by telephone, then the patient’s personal physician may not bill. NURSING FACILITY VISITS – CPT CODES 99304-99316 Initial Nursing Facility Care Codes 99304-99306 are selected based on the type of history, exam, and medical decision making based which will be based on the patient’s problem(s) requiring admission to the facility. Typical times have not been established. CPT provides guidance for selecting the appropriate level of admission by giving the 5-38 *All CPT Codes, Descriptions, and Two-Digit Modifiers Only Are Copyright 2006 American Medical Association. GEN 2007 REV 07-01 Copyright 2007 Newby Consulting, Inc.
typical severity of the problem(s) requiring admission. These codes should be reported by the admitting physician responsible for the care of the patient during the inpatient stay. Annual Nursing Facility Services Code 99318 is used to describe the annual nursing facility assessment. This code must include a detailed interval history, a comprehensive examination, and medical decision making that is of low to moderate complexity. These patients are usually stable, recovering, or improving. Physicians should not report 99318 on the same day as subsequent nursing facility codes 99307-99310. Subsequent Nursing Facility Care Codes 99307-99310 are selected based on the type of history, exam, and medical decision making which will be based on the patient’s presenting problem(s). Typical times have not been established. CPT provides guidance for selecting the appropriate level of admission by the patient’s status, e.g., stable, inadequate response to therapy, new problem, etc. Nursing Facility Discharge Discharge day management services are coded 99315 or 99316. The codes are selected based on the amount of time spent for the final discharge from the nursing facility. Medicare Guidelines for Nursing Facility Coding Medicare Claims Processing Manual Chapter 12 §30.6.13 (Rev. 1, 10-01-03) B3-15509-15509.1 (Rev. 808 Implementation No later than 01-23-06) A. Visits to Perform the Initial Comprehensive Assessment and Annual Assessments The distinction made between the delegation of physician visits and tasks in a skilled nursing facility (SNF) and in a nursing facility (NF) is based on the Medicare Statute. §1819 (b) (6) (A) of the Social Security Act (the Act) governs SNFs while §1919(b)(6)(A) of the Act governs NFs. For further information, refer to Medlearn Matters article number SE0418 at www.cms.hhs.gov/medlearn/matters The initial visit in a SNF and NF must be performed by the physician except as otherwise permitted (42CFR483.40(c)(4)). The initial visit is defined in as the initial comprehensive assessment visit during which the physician [Emphasis Added] completes a thorough assessment, develops a plan of care and writes or verifies admitting orders for the nursing facility resident. For Survey and Certification requirements, a visit must occur no later than 30 days after admission. Further, per the Long Term Care regulations at 42CFR483.40(c)(4) and (e)(2), the physician may not delegate [Emphasis Added] a task that the physician must personally perform. Therefore, the physician may not delegate the initial visit in a SNF. This also applies to the NF with one exception. The only exception, as to who performs the initial visit, relates to the NF setting [Emphasis Added]. In the NF setting, a qualified NPP [Emphasis Added] (i.e., a nurse practitioner (NP), physician assistant (PA), or a clinical nurse specialist (CNS), who is not employed by the facility, may perform the initial visit [Emphasis Added] when the State law permits. The evaluation and management (E/M) visit shall be within the State scope of practice and licensure requirements where the E/M visit is performed and the requirements for physician collaboration and physician supervision shall be met. Under Medicare Part B payment policy, other medically necessary E/M visits may be performed and reported prior to and after the initial visit, if the medical needs of the patient require an E/M visit. A qualified NPP may perform medically necessary E/M visits prior to and after the initial visit if all the requirements for collaboration, general physician supervision, licensure and billing are met. 5-39 *All CPT Codes, Descriptions, and Two-Digit Modifiers Only Are Copyright 2006 American Medical Association. GEN 2007 REV 07-01 Copyright 2007 Newby Consulting, Inc.
Page 1 and 2: PQRI MEASURE CODING AND REPORTING P
Page 3 and 4: ! The line item charge should be $0
Page 5 and 6: ICD-9: 250.00-250.93, 648.00-648.04
Page 7 and 8: _____ _____ _____ _____ _____ Beta-
Page 9 and 10: Definition: Pharmacologic Therapy:
Page 11 and 12: Definition: Characterization includ
Page 13 and 14: eport the proper CPT II Category II
Page 15 and 16: • Physicians and qualified nonphy
Page 17 and 18: preoperative medical evaluation (if
Page 19 and 20: The excision of malignant lesion co
Page 21 and 22: complex repairs (CPT codes 13100-13
Page 23 and 24: HEMORRHOIDECTOMY BY SIMPLE LIGATURE
Page 25 and 26: Medicare “Incident to Clarificati
Page 27 and 28: service or other face-to-face servi
Page 29 and 30: HOSPITAL OBSERVATION SERVICES - CPT
Page 31 and 32: If the physicians are each responsi
Page 33 and 34: documented. If the time is not docu
Page 35 and 36: Follow-Up Consultation Service Effe
Page 37: A physician (primary care or specia
Page 41 and 42: Medicare Part B payment policy does
Page 43 and 44: HOME SERVICES - CPT CODES 99341-993
Page 45 and 46: the medical records must clearly do

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