AN OVERVIEW OF BILLING MEDICARE FOR PHYSICIAN ASSISTANT EVALUATION AND MANAGEMENT SERVICES IN PENNSYLVANIA NURSING FACILITIES
William E. Dalton, MS Ed., PA-C, CPC

Visits to nursing facility patients are only one of the many primary care services provided by Pennsylvania physician assistants. Until recently, there was some confusion as to what evaluation and management (E/M) services a physician assistant (PA) could provide in these facilities and which services were eligible for Medicare reimbursement. This article will address many of these concerns and attempt to provide a better understanding of how to properly document and bill Medicare, for nursing facility patient E/M services.

Be assured that PA provided E/M services, which are legally authorized, are reimbursable by Medicare. According to HGSAdministrators (HGSA), the Medicare Part B insurance carrier for Pennsylvania, Contractor’s Policy Number V-44A, Evaluation and Management Services in a Nursing Facility, “Non-physician practitioners may bill for E/M services under their own Medicare number. If a non-physician practitioner’s service is billed under a group number, the non-physician practitioner must be identified as the rendering provider”. In other words, when a PA is providing primary care services in a nursing facility, the PA should bill for those services under his or her own Medicare provider identification number (PIN), and such services are reimbursable at 85% of the physician’s fee schedule amount.

E/M SERVICES NURSING FACILITY CODES
Before we look at PA provided E/M services in nursing facilities and how to meet the documentation requirements for billing them to Medicare, we need to have a basic understanding of what the services comprise and how they are reported to Medicare.

In 1998, the Nursing Facility E/M Services codes were revised and two new codes for discharge services were added. These codes are used for the reporting of E/M services provided for patients in Nursing Facilities, Intermediate Care Facilities (ICFs), Long Term Care Facilities (LTCFs), and Psychiatric Residential Treatment Centers.

PAs need to know that any nursing facility providing long-term care, rehabilitative, or convalescent services, must provide comprehensive functional capacity examinations utilizing a standardized Resident Assessment Instrument (RAI). The RAI is composed of three parts, the Minimum Data Set (MDS), the Resident Assessment Protocols (RAPs), and utilization guidelines. Such comprehensive assessments are done in conjunction with the development of a medical plan of care, and are required upon the patient’s admission to a nursing facility, as part of an annual (every 12 months) reassessment, or when there has been a major and permanent change in the patient’s status. The RAI is not meant to be an all inclusive plan of care, but is instead a dynamic instrument that helps to guide primary care providers and the facility staff, to maintain a level of care consistent with the optimization of the patient’s physical and psychosocial well being.

When providing E/M services, in nursing facilities, it is important to keep in mind that unlike office based care, there is no distinction as to whether the patient is a new or an established patient. Instead, E/M services are provided as either a Comprehensive Nursing Facility Assessment, reported using Current Procedural Terminology (CPT®) codes 99301, 99302, or 99303, or Subsequent Nursing Facility Care reported as a 99311, 99312, or 99313. For Nursing Facility Discharge Services, use 99315 or 99316.

Comprehensive nursing facility assessment codes are reported when a comprehensive assessment is performed. When a comprehensive nursing facility assessment code is reported on the day of admission to the facility, all other outpatient physician services (i.e. office or emergency department visits) are included in the nursing facility code and should not be billed separately. When a patient is discharged from the hospital or from observation status on the same day as the nursing facility admission or readmission, then the provider needs to report either the in-patient hospital discharge service code 99238 or 99239, or the observation discharge code 99217, in addition to the proper admission or readmission nursing facility code. When a patient is admitted and then discharged, on the same day, from an inpatient or observation status, then use hospital discharge codes 99234, 99235 or 99236, and a suitable nursing facility code.

In order to bill Medicare for E/M services, each level of care provided during the nursing facility assessment, whether comprehensive or subsequent, requires documentation of key E/M service components, and reporting the level of service provided by means of an appropriate CPT® code. The key components of care for all service levels are a history, examination, and an appropriate level of medical decision-making. (For a complete explanation of the key component requirements for each level of service please refer to the most recent edition of the Amercian Medical Association’s Current Procedural Terminology, Professional Edition. You may purchase a copy of this text by contacting the American Medical Association at 800-621-8335, or through various medical text suppliers). It is important to remember that for each level of care, the provider must meet or exceed the designated level of complexity for each key component of care.

EXAMPLES OF NURSING FACILITY ASSESSMENTS, E/M LEVELS OF CARE AND CPT® CODES
Now let’s take a look at the various E/M levels of care, the documentation requirements, and the appropriate CPT® code assignment for each.

All levels of comprehensive nursing facility assessments (99301-99303) require all three E/M key components to be performed, at a specific level of complexity, and documented accordingly. For example, the 99301 level of service, most often used for an annual nursing facility assessment, includes a detailed interval history, comprehensive examination, and straightforward or low medical decision-making. At this level the patient is usually stable or improving. A patient requiring this, 99301, level of care may be a 72-year-old, three year resident of a nursing facility, who since her last assessment 12 months ago has shown no changes in her overall physical or mental status, but does suffer from osteoporosis, osteoarthritis, chronic back pain, and moderate stable dementia.

An example of a 99302 level of service may be when the above patient develops a new problem or complication that results in a permanent change in status, such as worsening osteoporosis with multiple vertebral fractures, and an increase in the severity of her dementia. At this level, a detailed interval history, comprehensive examination, and a moderate to high level of medical decision-making are required.

The following example of a 99303 level of service requires documentation of a comprehensive history and examination, and a moderate to high level of medical decision-making. In this example, the patient may be a 62-year-old male with recent hospitalization for an acute cerebral vascular accident (CVA) with subsequent left sided hemiplegia, now being discharged from the hospital to the nursing facility for ongoing care and rehabilitation.

When providing subsequent nursing facility care E/M services, reported with CPT® codes 99311, 99312, or 99313, the patients do not require a comprehensive assessment, and have not had any permanent change in status. The provider must document at least two of three key components as designated by the level of service provided. An example of a 99311 may be a 75-year-old female patient with stable moderate dementia, stable moderate hypertension, chronic constipation, and no status change, being seen for a scheduled 60-day follow-up visit. For this level of service, the provider must document two of the three following components: problem focused interval history, problem focused examination, and/or medical decision-making of straightforward or low complexity.

Using the same patient described above, a 99312 level of service, might be complaints of mild low back pain that necessitated a lower back history and examination during her follow-up visit. This scenario would meet the requirements for a 99312 level of care with an expanded problem focused interval history, expanded problem focused examination, and/or medical decision making of moderate complexity.

To demonstrate a 99313 level of care, let’s use this same patient again, but at this visit she is noted to have a worsening of her hypertension, and a more in-depth evaluation of this problem is carried out. Her hypertension evaluation includes a detailed history, and a target organ assessment and examination that includes various appropriate laboratory studies. Thus, in this instance the requirements for a detailed interval history, detailed examination, and/or medical decision-making of a moderate to high level have been met.

The difference between the two code sets, for comprehensive assessment or subsequent nursing facility care, is primarily in the level of service. Basically, the subsequent care codes are meant to be used on a more day-to-day basis, such as for regularly scheduled interval follow-up visits, whereas the comprehensive service levels are used at the time of an initial nursing facility admission, readmission, or when there has been a major permanent change in the patient’s status.

DISCHARGE SERVICES CODES
Until 1998, there were no CPT® codes available to adequately describe nursing facility discharge services. Up until then, providers used the existing subsequent nursing facility care codes, even though they did not fully describe the services provided. However, as of 1998, there are two CPT® codes, 99315 and 99316, to be used in describing nursing facility discharge day management services.

The discharge day management codes are unique in that they are time based, and are used to report the total time of the service(s) provided, even when the total time is not a continuous process. These codes are reported by time increments, and are assigned either a 99315 for a discharge day management time of 30 minutes or less, or 99316 for greater than 30 minutes. Both codes apply to the provision of the medical service(s) and administrative tasks required for the patient’s discharge from the nursing facility. Such services may include a final examination of the patient, creation of a continuing plan of care, writing prescriptions, making arrangements for on-going specialist care after discharge, and the myriad administrative duties required for discharging the patient from the nursing facility.

FREQUENCY OF NURSING HOME VISITS
Since most nursing facility patients have chronic medical problems or illnesses that are essentially stable, there is usually not a need for frequent visits by their primary care provider. Furthermore, with the exception of admissions, readmissions, or significant changes in status, the patient does not usually require comprehensive re-evaluations or significant changes in their medical plan of care.

Accordingly, Medicare has published guidelines for what they feel are an acceptable number of provider visits to nursing facility patients and reasonable charges for the services provided during those visits. The guidelines are published in Medicare Carriers Manual, Part 3 (HCFA-Pub. 14-3) Section 5210. Reimbursement For Physicians’ Visits To Nursing Home Patients, and state, in part, “Effective for services rendered on or after April 1, 1990, for residents of a nursing home who receive visits from a member of a physician/physician assistant/nurse practitioner team, 1.5 visits per month per resident are permitted on a routine basis. Because it is impossible to apply this standard on a month-by-month basis, you need to use a longer period. Consider using either a 4- or 6-month period to monitor the 1.5 visit requirement. As with physician nursing home visits, additional team visits are payable when the team member adequately substantiates the need for more frequent visits to the specific patient. Of the team visits made during the monitoring period, at least one must be made by a nonphysician member of the team”.

SUMMARY
In summary, Medicare recognizes PAs as a part of the primary care team for nursing facility patients, and will reimburse for the E/M services they provide. However, in order to receive appropriate reimbursement for these services, Medicare documentation and reporting standards must be met, and appropriate CPT® codes used to report them. At times, these requirements and guidelines may seem a little confusing, especially for new PA providers, but they are meant to ensure appropriate CPT® coding and reporting of E/M services, as well as, payment for those services. Hopefully, this article has helped to clarify these Medicare guidelines and payment policies, as they apply to providing E/M services for nursing facility patients, and how PAs may comply with them.

GLOSSARY
Current Procedural Terminology (CPT®) – a list of identifying codes and terms for reporting physician provided medical services and procedures. CPT codes, descriptions, modifiers, instructions, guidelines, and other data are Copyright 2001 AMA
HGSA – HGSAdministrators, the Centers for Medicare and Medicaid Services (CMS) designated contracted Medicare Part B insurance carrier for Pennsylvania
Physician fee schedule amount – the amount that Medicare is willing to pay for a specific service
PIN – Provider Identification Number (Medicare)

CPT® is a registered trademark of the American Medical Association

William E. Dalton, MS Ed., PA-C, CPC, is with Compliance Concepts, Inc., a healthcare Medicare and Medicaid compliance consulting group, and he is a member of the PSPA reimbursement committee.

Published in Spring 2004 PSPA News