Coding Strategy

87 percent error rate leads to drastic measures.

If you think CMS is only watching your E/M codes when it comes to the office or hospital, think again. One MAC recently reviewed nursing facility care claims and was stunned at the findings.

NGS Medicare, a Part B payer in four states, announced on Jan. 26 that it had recently audited claims for code 99310 (Subsequent nursing facility care, per day), and found that only 13 percent of these claims were billed correctly.

Based on the outcome of the audit, NGS said that it “will be implementing a prepay edit for CPT code 99310.”

Know these quick facts before you report this nursing facility care code in the future.

1. Check documentation for comprehensive interval history, comprehensive exam, and/or highcomplexity medical decision-making. CPT requires documentation of at least two of these criteria before you can bill 99310.

“I imagine that doctors are habitually visiting all their nursing home patients at one time and not documenting enough to meet the level-three code,” suggests Crystal S. Reeves, CPC, CPC-H with The Coker Group in Alpharetta, Ga. Indeed, the NGS report indicates that “most errors occurred because the services were billed at a higher level than was substantiated by the documentation.”

2. If you’re coding based on time, be sure to document the pertinent details.

Ever since 2008, CPT has published average time spent on the nursing facility codes, allowing you to report them based on time. However, in order for you to bill these visits based on counseling and coordination of care time, the patient must be present during the visit, and you must document the amount of time spent in counseling.

“Documentation must include time spent face-to-face (or on the floor/unit) counseling and/or coordinating care, as well as the total time of the encounter,” says Wendy Owens-Frierson, CHM, CHI, CPC with PRSS, Inc. in Miami, Fla.

Resource: To read the results from the NGS audit, go here.

Look for an in-depth article about time-based E/M coding in next week’s Part B Insider. Download 2 FREE sample issues here.

Available on CD: The biggest mistakes that coders make with nursing facility E/M codes.

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Private nursing homes now cost $10 more than it did last year.

You may have to allot more on long term care from your budget as the yearly survey by a financial firm has found its costs are continuously on the rise.

According to long term care insurance provider Genworth Financial, adult day care and assisted living cost increased by 12 percent this year from 2009. The median daily rate for nursing care in both private and semiprivate rooms rose by more than 5 percent, while the cost of services for stay-at-home patients grew by about 3 percent.

Genworth’s study included about 13,000 long-term care providers in 436 regions nationwide, and did not say why the costs increased.

“Many facilities now provide services to residents who need continual care or supervision – while still providing a lower level of care to healthier individuals,” the report said. “As the range of services becomes broader, so does the range of monthly costs,” it added.

Private nursing home services are more expensive now, too – rising from $196 per day in 2009 to $206 this year. And the costs can get much higher with each state. For instance, private rooms cost about $51,056 a year in Louisiana, and over $200,000 in Alaska.

It is too early to tell if the recently-passed health care bill would have any impact on the cost, Genworth Senior Vice President Beth Ludden said.

Other health care services surveyed included:

• home health aide services grew by 2.7 percent this year from 2009;
• homemaker services, such as running errands and cooking, increased by 3 percent to a national median hourly rate of $18.