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Initial Nursing Facility Care (GEN)
Posted November 12, 2007
The Medical Review Department recently conducted a service-specific review (SSR) of initial nursing facility care services (99306) billed by physicians of specialty 01 (General Practice), 08 (Family Practice), 11 (Internal Medicine), 25 (Physical Medicine & Rehabilitation), and 38 (Geriatrics). A complete description of this code may be found in the Current Procedural Terminology (CPT) Manual.
This SSR (initiated in April 2007 and completed in October 2007) involved review of 100 claims (for dates of service October 1, 2006 - January 31, 2007) chosen at random by our computer system. Medicare contractors conduct these reviews to identify widespread problems by monitoring usage of procedure codes among the provider community.
On completion of SSRs, a provider error rate is calculated. An explanation of how error rates are calculated may be accessed in the Medicare Program Integrity Manual, Chapter 3, §3.11.1.5.
The SSR resulted in an overall error rate of 32 percent, with a down-coded/denial change rate of 81 percent. Below is a summary of the major issues and billing problems that were identified:
- Documentation supported a lower level of evaluation and management (E/M) service than billed to Medicare.
- Documentation was not presented for the requested date of service (DOS).
- An incorrect procedure code was reported to Medicare.
- Services rendered "incident to" in place of service (POS) 31 or 32.
- Based on the documentation, an incorrect DOS was reported.
- Rendering provider unknown.
- Handwriting difficult to read or is illegible.
The 1995 Documentation Guidelines for Evaluation and Management Services, can be found at www.cms.hhs.gov/MLNProducts/Downloads/1995dg.pdf and the 1997 Documentation Guidelines for Evaluation and Management Services can be found at www.cms.hhs.gov/MLNProducts/Downloads/MASTER1.pdf on the Centers for Medicare & Medicaid Services (CMS) Web site.
Per the 1995/1997 Documentation Guidelines for Evaluation and Management (E/M) Services, "Because the level of E/M service is dependent on two or three key components, performance and documentation of one component (e.g., examination) at the highest level does not necessarily mean that the encounter in its entirety qualifies for the highest level of E/M service."
The guidelines also state, "The number of possible diagnoses and/or the number of management options that must be considered is based on the number and types of problems addressed during the encounter, the complexity of establishing a diagnosis and the management decisions that are made by the physician."
Per Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §60.1, "Incident to a physician's professional services means that the services or supplies are furnished as an integral, although incidental, part of the physician's personal professional services in the course of diagnosis or treatment of an injury or illness."
Per MLN Matters article SE0441, titled, "'Incident to' Services," "The intent of this article is to clarify "incident to" services billed by physicians and non-physician practitioners to carriers. "Incident to" services are defined as those services that are furnished incident to physician professional services in the physician's office (whether located in a separate office suite or within an institution) or in a patient's home."
When billing Medicare for services rendered, providers are to follow Medicare guidelines which can be accessed on the CMS Web site at www.cms.hhs.gov/Manuals. |
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