AAHPM — Spring Quarterly
Q&A on Facility Patients
We receive a number of questions from AAHPM members. In an effort to respond to common questions, here are a set of questions and answers on the topic of billing for patients in a facility.
Q. Can a hospice contract with a hospitalist group to do admissions for general inpatient care?
A. This is a more complicated question than it seems. The simple answer is yes, a hospice can contract with any physician to provide care; they are essentially functioning as medical directors for a specific group of patients. The complexity of this is based on who pays the hospitalist group. If they are employed by the hospital, then the hospice group will have to contract with the hospital and may end up paying the hospital rather than the hospitalist group. Some hospitals don’t like this because these patients tend to be complicated, which takes time away from the hospital’s patients. Some also feel that this creates a conflict of interest for the hospitalist when arranging disposition to hospice for hospitalized patients. Should the hospice group contract with a hospitalist group, the hospitalist would need to submit his or her billing to the hospice for reimbursement.
Q. I have had “billing experts” tell me that you can use home visit codes if a patient receives absolutely no services from the assisted living facility. Is this true?
A. The issue of services provided by the facility defines a skilled nursing facility versus a custodial or domiciliary facility, but it has no impact on what is considered to be “home.” The American Medical Association Current Procedural Terminology® coding manual defines codes 99324–99337 as being used to report services provided to a patient in a domiciliary, rest home, or custodial care facility. These codes are used to report services in a facility that provides room, board, and other personal assistance services, generally on a long-term basis. The facility’s services do not include a medical component. These codes are also used to report services provided in an assisted living facility (ALF). Home services are defined as services provided in a private residence, which seems unambiguous. If the patient lives in an ALF, you should use the ALF codes.
Q. If a nursing home patient had an initial visit billed, is discharged from the skilled nursing facility (SNF) for a hospital admission, and then returns to the SNF, can you bill an initial visit again or should it be a subsequent visit?
A. Initial visit codes are used for the first visit by a given practitioner for a specific episode of care. In this case, the answer is that after being discharged from the SNF for a hospital admission, the readmission to the SNF begins a new episode of care for which an initial visit can be billed. Initial/subsequent visits are inpatient codes and are related to the episode of care in the facility. They can be used with either new or established patients, as opposed to the new/ established outpatient codes that are based on your previous experience with the patient.
Q. Can an initial SNF visit code be used if the physician is “assuming care” from another physician who is not part of the same group?
A. This is another example of a lack of clarity with the new/established criteria and the initial/ subsequent criteria. If you are assuming care of a patient during his or her episode of care in a facility, you must use a subsequent billing code because the attending physician presumably already did an initial visit for that episode of care. In a different situation, if you were asked by the attending to consult on the patient, you could use an initial code, assuming the visit otherwise qualified for the code. The initial codes have replaced the initial consult codes. In this case, it would not matter if you had ever seen the patient before (presumably prior to coming to the facility). Initial codes can be used with either new or established patients.
Q. As a hospice medical director, if I have seen a patient in his or her home and billed for a new patient visit, and that patient then gets admitted to a skilled nursing facility and I visit him or her there, what billing code should I use?
A. New/established are outpatient billing codes. You can only use a new code once with a given patient, assuming that neither you nor a member of your group or your specialty has seen the patient in the past 3 years. When the patient moves into a facility, new/established codes become irrelevant unless they move out again. After they have moved into a facility (ie, become patients), you would use the inpatient codes, which are initial/subsequent and can be used regardless of whether the patient is new or established with the physician. These codes are based on the episode of inpatient care. The initial codes are used by the admitting physician once and can be used by a consulting physician—once per consult—regardless of whether the patient is new or established with the consulting physician