Evaluation and Management (EM) in the Skilled Nursing Facility

by  Aimee Wilcox, CPMA, CCS-P, CST, MA, MT
October 16th, 2014

Evaluation and Management (EM) in the Skilled Nursing Facility

The first time I remember visiting a skilled nursing facility was after my grandmother's stroke.  She was rehabilitating there, trying to learn to speak again.  Once she was back to her normal activities, she returned to our home where she was taken care of until she passed away several years later.

What types of services are provided at a skilled nursing facility?

Skilled nursing facilities (SNFs) are also commonly referred to as nursing homes.  They offer care for different types of medical problems and patients such as:

Skilled nursing care for patients who need injections, dressing changes, medication administration, IV therapy, etc.

Rehabilitative care for patients who are recuperating from surgery, stroke, or injury who may need speech therapy, physical therapy, or even occupational therapy to partially or fully recover.  

Long-term care for patients who simply need help with activities of daily living (ADLs) such as bathing, eating, dressing, and even for part-time nursing care are not eligible for Medicare Part A benefits for SNF care but may be eligible for home health care services administered in their home.

Who can provide medical services in skilled nursing care?

Qualified non-physician practitioners (NP, PA, CNS) can provide care for all subsequent SNF visits but the initial visit must be performed by the admitting physician, as governed by the Long-Term Care Regulations.

Who manages the care patients receive in skilled nursing facilities?

Care is managed by the admitting physician who develops an official plan of care.  When a patient is admitted to a SNF, the admitting physician must perform an initial comprehensive assessment within 30 days of the admission.

What are the appropriate codes for reporting the initial comprehensive assessment?

An initial comprehensive assessment must follow these guidelines:

• Assessment of the patient (history, physical exam, and medical decision making including diagnoses, data review (x-ray, lab, etc), and risk assessment)
• Develop a Plan of Care
• Write or verify admitting orders for the nursing facility resident
• Complete the above within 30 days of admission. 

The initial visit is reported based on the same criteria as regular Evaluation and Management (EM) coding and is determined based on time or documentation including:

History

Physical Examination

Medical Decision Making

The CPT codes used to report the initial visit include 99304-99306.  As you can see below, the code description includes the level of documentation required for each service and the typical time spent with the patient.

99304 Includes a detailed history and physical exam and medical decision making of low complexity.  Typical time spent is 25 minutes.

99305 Includes a comprehensive history and physical examination and medical decision making of moderate complexity.  Typical time spent is 35 minutes.

99306 Includes a comprehensive history and physical examination and medical decision making of high complexity.  Typical time spent is 45 minutes.

It is important to remember that medically necessary EM visits are payable under the  Medicare Part B physician fee schedule and are considered separate from the Medicare Part A services.

Subsequent Visits: 99307-99310

Subsequent visits may be performed by a non-physician practitioners (NPP), as noted previously.  Subsequent visits are coded using the following codes:

99307 Problem-focused history 

Problem-focused examination 

Straightforward medical decision making

Typical time = 10 minutes

99308 Expanded problem-focused history 

Expanded problem-focused examination 

Low complexity medical decision making

Typical time = 15

99309 Detailed history 

Detailed examination 

Moderate medical decision making

Typical time = 25 minutes

99310 Comprehensive history 

Comprehensive examination 

High complexity medical decision making

Typical time = 35 minutes

Discharge Day Management Service:  99315-99316

Discharge day management services are reported for the face-to-face time with the patient on the date of the visit, even if the patient is discharged (physically) on another day.

99315 30 minutes or less

99316 More than 30 minutes

A physician or qualified physician extender may report a discharge day management service code when pronouncing the death of a patient.  

Providers, other than the admitting physician, who treat the patient while in a skilled nursing facility should verify patient billing with the skilled nursing facility before submitting claims to ensure proper billing and reimbursement.