Coding in Long Term Care

Educational Tools and Resources

AMDA Resources

• Annual Meeting Highlight - AMDA members and long-time coding experts Alva S. Baker, III, MD, CMD; Charles A. Crecelius, MD, PhD, CMD; and Leonard Gelman, MD, CMD present their popular course “Update on Billing and Coding” at the annual symposium.
  Course description: Choosing the correct CPT code for Evaluation and Management Services performed in settings where providers perform such services is frequently confusing and challenging to physician and non-physician providers. However, the process for correctly choosing the appropriate code is straightforward.  Extensive resources are available to assist providers in this process.  This session will provide detailed information about the correct process for accurately establishing the appropriate CPT billing code for services provided in a variety of settings, including the nursing home, assisted living facilities, and patients’ homes.
  To purchase the audio and slide presentation from this course, or any other course from Long Term Care Medicine - 2010, please visit www.prolibraries.com/amda.
  
• Ask the Expert (Members Only) - Please review questions already asked in Ask the Expert and consult educational publication below. If you have additional questions regarding CPT Coding please submit your question via Ask the Expert.
• AMDA's Guide to Coding
• CMS and Joint Commission Requirement for Physician Visits

Centers for Medicare & Medicaid Services (CMS) Resources

• CMS’ Medicare Claims Processing Manual - CMS’ Medicare Claims Processing Manual Chapter 12 provides claims processing instructions for physician and non-physician practitioners. The manual includes nursing facility service codes (99304-99318), home and domiciliary care (99324-9935), and prolonged service codes (99354-99360).
• CMS’ Evaluation & Management Services Guide (updated July 2008) - This guide provides a more detailed description of evaluation & management codes including details on the three key elements of service – history, examination, and medical decision making.
• CMS Transmittal 808/Change Request 4246/Updated Processing Manual- This transmittal revises the Claims Processing Manual, Pub. 100-04, Chapter 12, §30.6.13 with the new code changes by the American Medical Association Current Procedural Terminology (CPT) 2006 for reporting evaluation and management visits in the skilled nursing facility (SNF) or nursing facility (NF) settings (codes 99304 - 99306 for the initial visit; codes 99307 - 99310 for subsequent nursing facility visits and code 99318 for an annual assessment visit) and who may use these codes. This transmittal identifies the federally mandated visits per the Long Term Care regulations and also clarifies the "initial visit" definition, medically necessary visits, "incident to" services, prolonged services, split/shared evaluation and management services, gang visits, and discharge day management in the SNF and NF settings.
• Medicare & Medicaid Program Memos and Transmittals - Program transmittals are used to communicate new or changed policies, and/or procedures that are being incorporated into a specific (CMS) program manual.
• CMS Local Coverage Determinations - click here to search for local coverage determinations made by your local contractors.

Additional Information

Prolonged Service Codes (99356-99357)

Threshold Times for Prolonged Service Codes

Change Request 5972 - This transmittal updates Chapter 12, §§30.6.15.1 and 30.6.15.2 and provides guidance on the proper use of prolonged service codes.

CMS’ MedLearn Matters MM5972  – This article provides additional clarifications and information on the proper use of prolonged service codes.

CMS’ Medicare Learning Network- This provides additional clarification and information on the proper use of prolonged service codes.

CMS’ Medicare Learning Network- This provides additional clarification and information on the proper use of prolonged service codes.

Ask the Expert (Members Only) - For additional information please refer to questions answered on Ask the Expert. If you have further questions regarding the use of prolonged service codes please post them there.

NCCI Edits Issued
The Centers for Medicare & Medicaid Services (CMS) updates annually its National Correct Coding Initiative (NCCI) Coding Policy Manual for Medicare Services (Coding Policy Manual).  The Coding Policy Manual is available on CMS’ NCCI Website and should be utilized by carriers and fiscal intermediaries as a general reference tool that explains the rationale for NCCI edits.  The purpose of the NCCI edits is to prevent improper payment when incorrect code combinations are reported.  The NCCI contains two tables of edits.  The Column One/Column Two Correct Coding Edits table and the Mutually Exclusive Edits table include code pairs that should not be reported together for a number of reasons explained in the Coding Policy Manual.

CPT codes, descriptions, and material only are Copyright © 2011 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.