The results of recent recovery audit contractor (RAC) automated reviews of hospital services were outlined in the January 2013 Medicare Quarterly Provider Compliance Newsletter, Volume 3, Issue 2. Among the hot topics discussed was a significant issue for physician providers: the RACs identified that inappropriate current procedural terminology (CPT) codes were being assigned for related professional evaluation and management (E/M) services “rendered in swing bed facilities (with nursing facility levels of care)” in the same episode of care as an acute inpatient stay, when the patient was not “on a leave of absence from the hospital.”
Specifically, inpatient hospital CPT codes, i.e., hospital admission 99221-99223, hospital subsequent days 99231-99233 or hospital discharge 99238-99239, were assigned instead of the following nursing facility CPT codes:
- Admission (99304-99306)
- Subsequent Nursing Facility Care (99307-99310)
- Nursing Facility Discharge Services (99315-99316)
- Annual Nursing Facility Reassessment (99318)
Professional service codes are dictated by the status and location of the patient when he/she is seen face-to-face by the physician or non-physician practitioner. It has long been a source of confusion that Medicare requires the physician to write an order to “discharge” the patient, then write an order to “admit” or “transfer” the patient to “skilled nursing,” when the physician sees the patient in the same bed. If the patient is physically moved to a separate skilled nursing or swing bed unit within the four walls of the hospital, it is easier to identify a change in status or location, but often the provider will select an inpatient hospital CPT code to report a swing bed visit, because the patient is in the same building.
Patient status is continually updated in the hospital registration system during an episode of care and mirrors the facility acuity of care as the patient moves from outpatient to inpatient acute care and potentially to post-acute skilled nursing facility or swing bed skilled nursing care. Medicare Claims Processing Manual, Chapter 12, instructs “if the inpatient care is being billed by the hospital as inpatient hospital care, the hospital care codes apply. If the inpatient care is being billed by the hospital as nursing facility care, then the nursing facility codes apply.”
Therefore, when a patient status changes to “skilled nursing” or “swing bed,” the American Medical Association (AMA) Current Procedural Terminology code section for “nursing facility services,” i.e., 99304-99318, should be referred to for professional service code assignment.
In addition, the Medicare Claims Processing Manual states, “Contractors pay the hospital discharge code (codes 99238 or 99239) in addition to a nursing facility admission code when they are billed by the same physician with the same date of service” with the exception of a surgeon who is under a surgical global period.
In addition to accurate code assignment, the following also are required:
- Professional billing should reflect the date of service when the provider saw the patient face-to-face and performed the discharge and/or admission work.
- All required medical record documentation for the hospital discharge and the separate nursing facility or swing bed admission, i.e., care plan, must be completed by the performing provider.
- The CMS-1500 claim form must reflect the appropriate place of service based in part on insurance coverage:
- POS 31 – SNF/swing bed for Part A resident
- POS 32 – SNF/swing bed to Part B residents or non-Medicare covered stays
- For rural health clinic (RHC), federally qualified health center (FQHC) or community health center (CHC) providers, the UB-04 must reflect the appropriate revenue code:
- 524 – Visit to a member in a covered Part A stay at a SNF/swing bed
- 525 – Visit to a member in a SNF/swing bed (not in a covered Part A stay, NF or ICF MR) or other residential facility
What can you do to avoid potential errors and subsequent inaccurate reimbursement for these professional services? We recommend that providers do all of the following:
- Review and update communication tools/charge tickets.
- Query professional staff and/or verify patient status with the hospital registration department prior to charge entry.
- Perform concurrent or retrospective audits on a sample of skilled nursing facility or swing bed claims to identify errors.
- Educate professional, coding and billing staff on appropriate documentation and coding criteria for nursing facility services.
Promoting correct code assignment within your medical practice, RHC, FQHC or CHC will result in increased compliance, decreased areas of risk and potentially more accurate reimbursement.
For more information on professional code assignment for nursing facility site of service and claim form completion, contact your BKD advisor.