Evaluation and Management FAQs

Skilled Nursing Facility Services

Please define rules for initial and subsequent SNF services, when the same provider has treated the patient at another site on the same date of service.

Answer: This depends on the site of the prior service. When a provider has performed an earlier service on the same date in either the office or ED setting, and then performed an initial SNF admission service, only the SNF admission service is payable. The office or ED services are bundled into the payment for the initial SNF service. Of note, although the office or ED services are not separately payable, time spent on those earlier services can be added to the time spent on the initial SNF service, and may qualify toward prolonged service time expectations.

If, however, the earlier service on the same date was performed in the inpatient hospital setting (e.g., a hospital discharge service) and the provider is now performing an initial SNF admission, in the role of attending physician, then both the discharge and SNF admission services are payable on the same date.

This latter rule only applies to services by the attending physician. When a consultant physician has seen a patient initially during the hospital stay, services performed at the SNF are billed as subsequent care services.
When a patient is admitted to a SNF by the same physician who provided the prior hospital care and discharge, what is the appropriate coding for the initial SNF visit?

Answer: As an exception to the “one service/one provider/one patient” per day rule, the provider who has provided discharge hospital care may perform and bill an initial SNF service when admitting the patient to the SNF. Modifier AI is added to the initial SNF service to denote it as service by the attending physician.

Please define the rule for an initial service for a SNF patient.

Answer: When a SNF patient is initially admitted to a SNF, an initial SNF service by the attending physician is appropriate. If a SNF patient is transferred to a hospital and is admitted, the attending provider’s visit upon return to the SNF is considered a new initial SNF visit, since there is additional work needed in re-evaluating the patient’s clinical status and plan of care. This is true even when the same attending provider performs the hospital discharge service and the initial service upon return to the SNF.

How does a consulting provider bill for SNF services?

Answer: A consulting provider in the SNF may bill with the initial or subsequent set of SNF service codes, based on whether this is an initial or subsequent evaluation of the patient. Please note that a consultant who has previously billed for an initial consultation at another site, prior to the patient’s SNF transfer/admission, may bill subsequent care only with SNF subsequent service codes.

Is examination a required element of a SNF discharge service?

Answer: History and examination are expected to be performed on the basis of medical necessity, on a medically appropriate scope and detail.

May the SNF discharge service be performed on a date other than the actual date the patient leaves the SNF?

Answer: Yes, a SNF discharge visit may be performed and billed on a date prior to the patient’s actual departure. It cannot be performed after the patient’s departure since it requires a face-to-face contact by the provider with the patient.
When a SNF patient receives a service(s) in an outpatient setting (e.g., office) what is the correct POS coding for the claim?

Answer: Coding for an outpatient service for a SNF patient must reflect the patient’s inpatient status. For example, a service provided in a cardiology office (e.g. 99204 or 99214) for a SNF patient would be coded with POS 31 or POS 32.

Please define the rule for death pronouncement for a SNF patient.

Answer: A SNF discharge service (99315-99316) may be billed for death pronouncement and associated work only when the pronouncement is performed by the attending/ billing physician. Pronouncement by SNF nursing staff is not billable to Medicare.

When provider care relative to an initial nursing facility service (99306) and/or prolonged time for those services (G0317) covers a timespan of several days, what are the appropriate DOS for those services?

Answer: In CY 2023, care relative to the initial nursing facility service (99306), and prolonged time for the service (G0317), may occur over a 5-day timespan. This includes the date prior to 99306, the date of on which 99306 is completed and the 3 dates subsequent to the 99306.

For example, 99306 performed on January 5th would include the timespan of January 4th through January 8th for services by the same billing provider/group. Since 99306 requires 95 minutes of time before prolonged service(s) can be added, 99306 may be performed over a period of more than one date. When this is the case, 99306 should be billed for the DOS on which the 95 minute timeframe has been completed. Prolonged services performed beyond the date of 99306 should be billed with the DOS on which they were completed, within a 3 day timeframe after the date of 99306.

When a Part A outpatient service is performed for a patient designated as a SNF inpatient, what are the billing guidelines?

Answer: In this circumstance, the facility providing the outpatient Part A service must seek compensation directly from original facility, which is the SNF at which the patient resides. The original facility includes the Part A outpatient service on its inpatient claim, which is referred to as “under arrangement” billing.

When a Part B outpatient service is performed for a patient designated as a SNF inpatient, what are the guidelines for the Part B claim?

Answer: The Part B claim must be coded to reflect the patient’s current inpatient status. This means that the E/M CPT code sets for such services would be in the range of 99304-99318, and the POS 31 would be appropriate. The important thing is that the CPT and POS codes must correlate and both must reflect the patient’s inpatient status.

Reviewed 10/8/2024