Mandated visits in a nursing facility

February 11th, 2009 - Codapedia Editor
Categories:   Coding   Evaluation & Management (E/M)  
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What are mandated nursing home visits and who mandates them?  May either a physician or qualified Non-Physician Practitioner (NPP) perform these?

CMS mandates that residents in nursing homes be assessed by a physician or NPP at periodic intervals.  This is a requirement for the nursing home's condition of participation, and is the reason the nursing home keeps track, and calls the physician office when a visit is due.  Many nursing homes have hired physicians or NPPs to provide this service, as well.

The physician comprehensive nursing facility assessment must occur within the first 30 days of admission.  This assessment may occur after the NPP has seen the patient on one of their earlier days in the nursing facility.  See the article on nursing home admissions for more detail about billing this comprehensive assessment.  Many nursing homes require this physician assessment much sooner than 30 days.

A patient in skilled nursing facility status (SNF) must be seen every 30 days during the first 90 day of admission and every 60 days after that.  The physician and NPP may alternate these visits.

A patient in nursing facility status must be seen every 30 days during the first 90 days, and every 60 days after that.  The physician may delegate all of these visits to the NPP.

A physician or NPP may use a problem oriented visit as one of the federally mandated visits, if called to see the patient at the time period for the mandated visit.

There is no limit on the number of nursing home services that may be provided to a patient, however all visits must be medically necessary.  Seeing all of your patients "as long as I'm here" is not considered medical necessity.

What codes are used for these services?  Whatever was provided: the comprhensive nursing facility assessment is used by the physician for the "admission" 99304-99306, subsequent nursing facility visits, 99307--99310, the annual assessment 99318 or discharge from the nursing home, 99315, 99316.

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