Skilled Nursing Facility 3-Day Rule Billing

To qualify for Skilled Nursing Facility (SNF) extended care services coverage, Medicare patients must meet the 3-day rule before SNF admission. 

The 3-day rule requires,

• Three-day-consecutive inpatient hospital stay. 
• Three-day-consecutive stay counts inpatient setting.
• Starting with the calendar day of hospital admission.
• Doesn’t include the day of discharge or any pre-admission time spent in the ER or outpatient observation.

SNF extended care services are an extension of care a patient needs after a hospital discharge or within 30 days of their hospital stay (unless admitting them within 30 days is medically inappropriate).

Example

A 68-year-old male patient went to the hospital ER after falling on May 17th from his home and a physician admitted him to the hospital on the same day. On subsequently May 20, the hospital discharged him to SNF extended care services. 

For this case, the patient did qualify the 3-day rule. Hospitals can count the admission day (May 17th to May19th), but not the discharge day (May 20). 

Tips

Medicare considered inpatients meet the 3-day rule by staying 3 consecutive days in 1 or more hospital(s) as well.

See Inpatient Guidelines

New ICD codes for COVID-19

In March 2020 the Novel Coronavirus Disease, COVID-19, was declared a pandemic by the World Health Organization.

The Centers for Disease Control (CDC), under the National Emergencies Act Section 201 and 301, is announcing further additions to the ICD-10-CM Classification related to COVID-19, which will become effective January 1, 2021.

As a result of the ongoing COVID-19 public health emergency, the Centers for Disease Control and\ Prevention’s National Center for Health Statistics (CDC/NCHS) is implementing additional codes into ICD-10-CM for reporting to include,

• Encounter for screening for COVID-19  - Z11.52
• Contact with and (suspected) exposure to COVID-19 - Z20.822
• Personal history of COVID-19 - Z86.16
• Multisystem inflammatory syndrome (MIS) - M35.81
• Other specified systemic involvement of connective tissue - M35.89
• Pneumonia due to coronavirus disease 2019 - J12.82
• COVID-19 Positive - U07.1

These new codes will be effective January 1, 2021, to identify conditions resulting from COVID-19.

Check Related information

Cognitive Assessment Written Care Plan

A patient presents with cognitive impairment and or identified during the encounter then Medicare covers a separate visit for a cognitive assessment.

So, the provider can more thoroughly evaluate the patients for cognitive function and help with care planning.

Any clinician eligible to report evaluation and management services can offer this service, including physicians (MD and DO), nurse practitioners, clinical nurse specialists, and physician assistants.

The Cognitive Assessment & Care Plan Services (CPT code 99483) typically start with a 50-minute face-to-face visit that includes a detailed history and patient exam.

The physician can collect the information from the physical examination to create a written care plan.

The resulting written care plan includes initial plans to address as following,

• Neuropsychiatric symptoms
• Neurocognitive symptoms
• Functional limitations

The Patient and or caregiver referrals to community resources, as needed, with initial education and support.

Effective from January 1, 2021, Medicare increased payment for these services to $282 when provided in an office setting, added these services to the definition of primary care services in the Medicare Shared Savings Program, and permanently covers these services via telehealth.

Click here for Guidelines

Frequently Used Place of Service - POS

The below-mentioned place of service codes is used more frequently. Check the detail updates following,

Frequently Used Place of Service

• 2 Telehealth
• 11 Office
• 12 Home
• 13 Assisted Living Facility
• 15 Mobile Unit
• 19 Off Campus-Outpatient Hospital
• 20 Urgent Care Facility
• 21 Inpatient Hospital
• 22 On Campus-Outpatient Hospital
• 23 Emergency Room – Hospital
• 24 Ambulatory Surgical Center
• 31 Skilled Nursing Facility
• 32 Nursing Facility
• 33 Custodial Care Facility
• 34 Hospice
• 49 Independent Clinic
• 51 Inpatient Psychiatric Facility
• 52 Psychiatric Facility-Partial Hospitalization

Insight about Place of Services

 

POS - 2 The location where health services and health-related services are provided or received, through a telecommunication system.

POS - 11 Location, other than a hospital, skilled nursing facility (SNF), military treatment facility, community health center, state or local public health clinic, or intermediate care facility (ICF), where the health professional routinely provides health examinations, diagnosis, and treatment of illness or injury on an ambulatory basis.

POS - 12 Location, other than a hospital or other facility, where the patient receives care in a private residence.

POS - 13 Congregate residential facility with self-contained living units providing assessment of each resident's needs and on-site support 24 hours a day, 7 days a week, with the capacity to deliver or arrange for services including some health care and other services.

POS - 15 A facility/unit that moves from place-to-place equipped to provide preventive, screening, diagnostic, and/or treatment services.

POS - 19 A portion of an off-campus hospital provider based department which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.

POS - 20 Location, distinct from a hospital emergency room, an office, or a clinic, whose purpose is to diagnose and treat illness or injury for unscheduled, ambulatory patients seeking immediate medical attention.

POS - 21 A facility, other than psychiatric, which primarily provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services by, or under, the supervision of physicians to patients admitted for a variety of medical conditions.

POS - 22 A portion of a hospital’s main campus which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization. (Description change

POS - 23 A portion of a hospital where emergency diagnosis and treatment of illness or injury is provided.

POS - 24 A freestanding facility, other than a physician's office, where surgical and diagnostic services are provided on an ambulatory basis.

POS - 31 A facility which primarily provides inpatient skilled nursing care and related services to patients who require medical, nursing, or rehabilitative services but does not provide the level of care or treatment available in a hospital.

POS - 32 A facility which primarily provides to residents skilled nursing care and related services for the rehabilitation of injured, disabled, or sick persons, or, on a regular basis, health-related care services above the level of custodial care to other than individuals with intellectual disabilities.

POS - 33 A facility which provides room, board and other personal assistance services, generally on a long-term basis, and which does not include a medical component.

POS - 34 A facility, other than a patient's home, in which palliative and supportive care for terminally ill patients and their families are provided.

POS - 49 A location, not part of a hospital and not described by any other Place of Service code, that is organized and operated to provide preventive, diagnostic, therapeutic, rehabilitative, or palliative services to outpatients only.

POS - 51 A facility that provides inpatient psychiatric services for the diagnosis and treatment of mental illness on a 24-hour basis, by or under the supervision of a physician.

POS - 52 A facility for the diagnosis and treatment of mental illness that provides a planned therapeutic program for patients who do not require full-time hospitalization, but who need broader programs than are possible from outpatient visits to a hospital-based or hospital-affiliated facility.

To learn about modifier information click here

Update for COVID -19 CPT 87637

The Modifier QW is defined as a Clinical Laboratory Improvement Amendment (CLIA) waived test and it is used to identify waived tests and would be submitted in the first modifier field.

The modifier QW is accepted by CMS for CPT 87637 and effective from date October 06,2020 and the implementation date July 06, 2021.

Also, the modifier QW allowed for HCPCS code 0240U & 0241U

87637 - Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), influenza virus types A and B, and respiratory syncytial virus, multiplex amplified probe technique

0240U - Infectious disease (viral respiratory tract infection), pathogen-specific RNA, 3 targets (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2], influenza A, influenza B), upper respiratory specimen, each pathogen reported as detected or not detected

0241U - Infectious disease (viral respiratory tract infection), pathogen-specific RNA, 4 targets (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2], influenza A, influenza B, respiratory syncytial virus [RSV]), upper respiratory specimen, each pathogen reported as detected or not detected

Return related information 

Home Monitoring PT INR Guidelines

The beneficiary requires chronic oral anticoagulation with warfarin for a mechanical heart valve, chronic atrial fibrillation, or venous thromboembolism inclusive of deep venous thrombosis and pulmonary embolism on warfarin.

The patient has been anticoagulated for at least three months prior to use of the home INR device and he/she undergone a face-to-face educational program on anticoagulation management and demonstrated the correct use of the device prior to its use in the home.

The patient continues to correctly use the device in the context of the management of the anticoagulation therapy following initiation of home monitoring and home-testing with the device occurs no more frequently than once a week

Managing Anti-Coagulation

There are at least three strategies for managing warfarin anticoagulation,

• Physician office-based testing and management
• Anticoagulation clinics
• Home PT/INR monitoring with patient reporting or physician-directed self-management.

Most patients being anticoagulated are managed through physician offices, the "usual care" approach.

Individual physicians manage their patients and PT/INR test frequency is generally once every 4-6 weeks. 

The physician's service is billed with procedure code G0250, no more frequently than once every 4 weeks or every 28 days (7 days/week x 4 = 28 days). There must be 28 days between each submission of G0250.

Clinical Example

• Patient tests 4 times, on Fridays, in April of 2021
• The patient tested on April 2, 9, 16, and 23
• Physician bills G0250 on April 23,2021
• A physician can only bill G0250 once every 4 weeks (28 days)

Covered ICD Codes

• I26.93       Single subsegmental pulmonary embolism without acute cor pulmonale
• I26.94       Multiple subsegmental pulmonary embolism without acute cor pulmonale
• I48.0         Paroxysmal atrial fibrillation
• I48.11       Longstanding persistent atrial fibrillation
• I48.19       Other persistent atrial fibrillation
• I48.20       Chronic atrial fibrillation, unspecified
• I48.21       Permanent atrial fibrillation
• I48.3         Typical atrial flutter
• I48.4         Atypical atrial flutter
• I48.91       Unspecified atrial fibrillation
• I48.92       Unspecified atrial flutter
• I49.02       Ventricular flutter
• O88.211    Thromboembolism in pregnancy, first trimester
• O88.212    Thromboembolism in pregnancy, second trimester
• O88.213    Thromboembolism in pregnancy, third trimester
• O88.219    Thromboembolism in pregnancy, unspecified trimester
• O88.22      Thromboembolism in childbirth
• O88.23      Thromboembolism in the puerperium       
• T82.01XA Breakdown (mechanical) of heart valve prosthesis, initial encounter
• T82.02XA Displacement of heart valve prosthesis, initial encounter
• T82.03XA Leakage of heart valve prosthesis, initial encounter
• T82.09XA Other mechanical complication of heart valve prosthesis, initial encounter
• T82.110A  Breakdown (mechanical) of cardiac electrode, initial encounter
• T82.111A  Breakdown (mechanical) of cardiac pulse generator (battery), initial encounter
• T82.118A  Breakdown (mechanical) of other cardiac electronic device, initial encounter
• T82.119A  Breakdown (mechanical) of unspecified cardiac electronic device, initial encounter
• T82.120A  Displacement of cardiac electrode, initial encounter
• T82.121A  Displacement of cardiac pulse generator (battery), initial encounter
• T82.128A  Displacement of other cardiac electronic device, initial encounter
• T82.129A  Displacement of unspecified cardiac electronic device, initial encounter
• T82.190A  Other mechanical complication of cardiac electrode, initial encounter
• T82.191A  Other mechanical complication of cardiac pulse generator (battery), initial encounter
• T82.198A  Other mechanical complication of other cardiac electronic device, initial encounter
• T82.199A  Other mechanical complication of unspecified cardiac device, initial encounter
• Z95.2         Presence of prosthetic heart valve
• Z95.3         Presence of xenogenic heart valve
• Z95.4         Presence of other heart-valve replacement
• Z95.5         Presence of coronary angioplasty implant and graft
• Z95.810     Presence of automatic (implantable) cardiac defibrillator
• Z95.811     Presence of heart assist device
• Z95.818     Presence of other cardiac implants and grafts
• Z95.9         Presence of cardiac and vascular implant and graft, unspecified

Tips

• Self-testing with the device is limited to a frequency of once per week.

• Testing more frequently than once per week is generally considered not medically necessary.

• Billing units of service include 4 tests

• The date of service should be considered as - End date of the final test.

PT/INR - Home Monitoring Codes are, G0248, G0249 & G0250,

• G0248 - The provider demonstrates the use and care of an INR monitor,

• G0249 - For home INR monitoring supplies,

• G0250 - Physician review, interpretation, and patient management of home INR testing for patient 

Note: 

The billing of CPT code G0250 is subject to a 28-day rule. This means that the physician cannot submit a claim for G0250 earlier than 28 days from the date of the last bill for the same service for the same patient. 

There must be 28 full days between each submission date. If G0250 is submitted within 28 days, the claim will be denied.

Check RPM (Remote Patient Monitoring) Guidelines 

RPM - Remote Physiologic Monitoring

Remote physiologic monitoring (RPM) technology comes in various devices that monitor glucose levels, BP, weight management, sleep patterns, heart rate, vital signs, and many other types of patient data.

RPM allows patients to be involved in their own care by giving them access to their health data in real-time.

For providing RPM services to the patients and staff time spent monitoring the respective beneficiary. These actions are billable through four CPT codes,

• 99453 - Initial set up and patient education
• 99454 - Supply of devices and collection, transmission, and summary of services
• 99457 - First 20 minutes of remote physiologic monitoring by clinical staff/MD/QHCP
• 99458 - For an additional 20 minutes of remote physiologic monitoring by clinical staff/MD/QHCP

Initial Set-Up & Patient Education - CPT 99453

• It is reported for each episode of care.

• An episode of care is defined as beginning when the remote monitoring physiologic service is initiated and ends with the attainment of targeted treatment goals.

• CPT 99453 should not be reported, “If monitoring is less than 16 days.” If, for example, a patient receives and is educated on the device, but no data is transmitted by the device, one could not bill for CPT 99453.

Supply of Device - CPT 99454

• It is used to report the supply of the device for daily recording or programmed alert transmissions over a 30-day period provided monitoring occurs at least 16 days during the 30-day period.

• CPT 99453 & 99454 should not be reported “when these services are included in other codes for the duration of time of the physiologic monitoring service" (e.g., 95250 for continuous glucose monitoring requires a minimum of 72 hours of monitoring).

Monitoring & treatment Management services - CPT 99457 & 99458

• It requires live, interactive communication with the patient/caregiver and 20 minutes or more of clinical staff/physician/other qualified health care professional time in a calendar month.

• Can be billed once in 30 days.

• Time spent by clinical staff may be counted toward the 20 minutes only if services are furnished under direct supervision.

CPT Guidelines

• Time of fewer than 20 minutes during a calendar month cannot be billed with CPT 99457.

• Time over 20 minutes in one month cannot be carried forward to the next month.

• 99457 may be reported during the same service period as chronic care management services (99487, 99489, 99490), transitional care management services (99495, 99496), and behavioral health integration services (99484, 99492, 99493, 99494). 

• However, time spent performing these services should remain separate and no time should be counted toward the required time for both services in a single month.

• Report CPT 99457 one time regardless of the number of physiologic monitoring modalities performed in a given calendar month.

• “live interactive communication,” means a face-to-face visit, an interactive video conference (e.g., Face Time), or a conversation by telephone or text message would be sufficient. A record of such communication should be included within the documentation for the service.

RPM Billing Requirements

• The place of service would be the location at which the billing physician maintains his or her practice (i.e., physician office vs. hospital outpatient department).

• A beneficiary may have two monitoring devices with one supplied by the physician monitoring one chronic condition and one by another physician monitoring another condition, and both physicians would be eligible for payment.

See Complex Chronic Care Service