Medicare_Claims_Processing_Manual / CMS 100-04, Change Request 5968

Why This Topic Matters

The update affects how nursing facility services are reported and how contractors process claims under Medicare Part B. It is relevant to providers and billing professionals working with nursing facility visit categories and related time-based services.

Article Sections

1. Summary of Changes

   Overview of the manual update, including the subject area, effective dates, and the general category of Medicare guidance being revised.

2. Change Request Requirements

   Administrative requirements and contractor instructions tied to the transmittal, including implementation and provider education references.

3. General Information

   Background and policy context for the Medicare nursing facility services update, including the circumstances leading to the revision.

4. Business Requirements Table

   Structured contractor requirements associated with the change request and the related implementation responsibilities.

5. Provider Education Table

   Instructions related to provider education materials and dissemination of the change request information.

6. 30.6.13 - Nursing Facility Services (Codes 99304 - 99318)

   Core Medicare manual guidance for nursing facility E/M services, including setting-specific policy, visit categories, and related claims processing considerations.

7. A. Visits to Perform the Initial Comprehensive Assessment and Annual Assessments

   Guidance on initial and annual assessment visits in nursing facility settings, including who may perform them and the associated Medicare context.

8. B. Visits to Comply With Federal Regulations in the SNF and NF

   Federal-regulation-driven visit requirements for skilled nursing facilities and nursing facilities, including frequency and reporting framework.

9. C. Visits by Qualified Nonphysician Practitioners

   Rules and considerations for services performed by qualified nonphysician practitioners across nursing facility settings.

10. D. Medically Complex Care

    Discussion of Medicare payment policy for visits related to medically complex care in post-acute facility settings.

11. E. Incident to Services

    Limitations and setting-specific considerations for incident-to services in nursing facility environments.

12. F. Use of the Prolonged Services Codes and Other Time-Related Services

    Time-based service guidance related to prolonged services and counseling/coordination of care within nursing facility services.

13. G. Gang Visits

    Policy considerations involving multiple same-day visits in a facility and related medical necessity review issues.

14. H. Split/Shared E/M Visit

    Limits on split/shared evaluation and management reporting in nursing facility settings and the settings where that concept applies.

15. I. SNF/NF Discharge Day Management Service

    Guidance on discharge day management services for skilled nursing facility and nursing facility patients.