Evaluation and Management Coding Still Puzzles Providers, as Recovery Auditors Discover

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Original story posted on: March 6, 2013

Even though evaluation and management (E&M) CPT® codes have been around for many years, they are still problematic for providers. It’s not surprising that recovery auditors include E&M services on their lists of “issues,” and here’s one reason why.

Physicians and non-physician practitioners (NPPs) are inappropriately billing hospital visit codes for evaluation and management (E&M) services rendered in swing-bed facilities. By reviewing previous comprehensive error rate testing (CERT) reports, recovery auditors found a high percentage of errors on E&M claims. Instead of billing hospital visit codes, physicians should be billing nursing facility visit E&M codes, which properly define the type of care provided in a swing-bed setting.  (See below for these codes.)

Hospital Visit Codes

99221–99223*  Initial hospital care

99231–99233*  Subsequent hospital care

99238 and 99239     Hospital discharge day management

Nursing Facility Visit Codes

99304–99306*         Initial nursing facility care

99307–99310*         Subsequent nursing facility care

99315 and 99316     Nursing facility discharge services

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*Note that the American Medical Association revised these codes in 2013 CPT.

The Centers for Medicare & Medicaid Services (CMS) addressed this recovery audit finding in the January 2013 issue of its Medicare Quarterly Compliance Newsletter. To illustrate the problems uncovered by the auditors, it provided the following two examples:

Example 1: An 86-year-old female was admitted to a hospital with swing-bed approval for nursing facility care on November 2, 2010, and was discharged on November 30, 2010. A physician billed CPT code 99231 (subsequent hospital care) for the date of service (DOS) November 3, 2010.

Example 2: A 92-year-old female was admitted to a hospital with swing-bed approval for nursing facility care on April 30, 2010, and was discharged on May 6, 2010. A physician billed code 99232 (subsequent hospital care) for a DOS of May 5, 2010.

Findings: In both of the examples above, data analyses confirmed that the patient was not on a leave-of-absence from the hospital on the DOS. Therefore, in both cases, the physician’s billing codes were inappropriate and resulted in the overpayment.

Basic Swing-Bed Rules

Hospitals, as defined in Section 1861(e) of the Social Security Act, or critical access hospitals (CAHs) with a Medicare provider agreement may, with CMS’s approval, furnish swing-bed services to provide either acute or skilled nursing facility (SNF) level care. As explained by CMS in the January 2013 issue of the Rural Health Fact Sheet Series, these approved facilities serve the following purposes:

  • Increase Medicare patient access to post-acute SNF care.
  • Maximize the efficiency of operations by meeting unpredictable demands for acute and long-term care.

Hospitals paid under the acute-care hospital inpatient prospective payment system (IPPS) and CAHs may use most acute-care beds within the hospital or CAH to provide swing-bed services. Excluded from this rule are beds within the IPPS-excluded rehabilitation or psychiatric unit within an intensive-care-type unit, and newborn beds.

Medicare beneficiaries must receive acute care as a hospital or CAH inpatient for a medically necessary stay of at least three consecutive calendar days to qualify for coverage of SNF level services. Like the IPPS, the SNF PPS excludes certain specified services, which are separately billable to Part B. These services include, but are not completely limited to, professional provider services. 

Avoiding the Problem

As stated previously, physicians and NPPs may bill for E&M services provided to a patient in a swing bed but must bill with nursing facility levels of care instead of inpatient hospital visit codes. In order to assign a code from the correct E&M category, physicians should verify the status of the patient. If the hospital is billing the inpatient care as nursing facility care, then the physician must also bill the nursing facility codes.

In addition to assigning the correct codes, physicians and NPPs can avoid these problems by:

  • Develop or enhance edits to identify hospital care codes billed when the patient was admitted to a hospital with swing-bed approval for nursing facility care.
  • Provide education to physicians and NPPs to increase awareness about the correct use of nursing facility codes.

Note that these points above do not apply to hospitals.

About the author

Becky Rodrian is director of physician consulting services at Panacea Healthcare Solutions, Inc., St. Paul, MN.

Contact the author

brodrian@panaceahealthsolutions.com

To comment on this article please go to editor@racmonitor.com

Do You Know Your Recovery Audit Contractors?

Becky Rodrian, CPC, CEMC, CBCS, MBS

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