Keys To Coding When You Are Seeing Patients In Nursing Facilities

The CPT codes 99304–99306 cover initial nursing facility care. Yes, podiatrists can absolutely submit initial nursing facility evaluation and management (E/M) codes for Medicare patients.

Medicare does not recognize consultation codes. When Medicare stopped recognizing consultation codes on January 1, 2010, it then instructed specialists, including podiatrists, to use the initial nursing facility codes when seeing a nursing facility patient for the first time during that patient's admission. Podiatrists should use initial nursing facility codes if that encounter qualified for what the facility would consider a “consult” and even if the specialist was not the admitting/primary doctor. Since there are now multiple doctors using those initial encounter codes, the admitting/primary doctor must use an “AI” modifier on the initial E/M encounter.  

This change did not alter the fact that in order to submit any E/M code, one must meet the thresholds of complexity for that code. Complexity refers to the key elements of E/M coding (history, exam, decision making) in what you performed, what you documented and what was medically necessary for that level. If counseling and coordinating dominate the visit, time may be used to select the appropriate level.

These thresholds and time requirements are relatively high for the lowest level initial nursing facility E/M (CPT 99304). Therefore, CMS clarified that it is appropriate for specialists to use the subsequent nursing facility E/M codes for initial encounters that do not meet the complexity thresholds for CPT 99304. This is an important point. Even though podiatrists can use initial nursing facility E/M codes for Medicare patients, every initial encounter does not automatically qualify for the use of an initial encounter E/M.

For non-Medicare payers that still recognize consultation codes, podiatrists should still use consultation codes for nursing home consults.

Dr. Lehrman is a Certified Professional Coder and is a consultant to the American Podiatric Medical Association Health Policy and Practice Department, serves as an expert panelist on Codingline, and is a Fellow of the American Academy of Podiatric Practice Management (AAPPM). Follow him on Twitter @DrLehrman.

References

1. APMA Coding Resource Center. Available at www.apmacodingrc.org .

2. CMS Medicare Learning Network SE10101 Questions and Answers on Reporting Physician Consultation Services. Available at  https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1010.pdf .