Billing & Coding Part 3 Nursing Home & Home Visit Coding NorthShore Family Medicine Practice Management Curriculum

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: The Ambulatory Encounter Session 2: Inpatient Billing Session 3: Nursing Home and Home Visits Session 4: 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 ( ) Inpatient hospital ( ) Nursing Facility ( ) Domiciliary/ Rest Home or ALF ( ) Home ( )

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 HPIROSPFSHType of Visit BriefN/A Problem Focused (P) BriefProblem-PertinentN/AExpanded Problem Focused (E) Extended PertinentDetailed (D) ExtendedComplete 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 ReviewComplication / RiskComplexity MinimalMinimal or noneMinimalStraightforward (S) Limited LowLow (L) MultipleModerate Moderate (M) Extensive HighHigh (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 LevelHistoryExamComplexityTime 99304DDS/LN/A 99305CCMN/A 99306CCHN/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 LevelHistoryExamComplexityTime 99307PPSN/A 99308EELN/A 99309DDMN/A 99310CCHN/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 LevelHistoryExamComplexityTime 99315N/A <30 minutes 99316N/A >30 minutes

Home Visit : New Service LevelHistoryExamComplexityTime 99341PPS EEL DDM CCM CCH75 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 LevelHistoryExamComplexityTime 99347PPS EEL DDM CCM/H60 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 ( ) – Inpatient setting ( ) 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