1. Pre-Test/Post-Test Questions Regulatory and Coding Issues Valisa Saunders APRN, GNP-BC

2. What legislation first authorized Advanced Practice Nurses & Physician’s Assistants to do regulatory or “required visits” in SNFs? A. OBRA 1987 B. BBA, 1997 C. MMA, 2003 D. Medicare 1965 ANSWER: A; The Omnibus Reconciliation Act of 1987

3. What legislation authorized direct reimbursement to APNs/PAs for Medicare Part B services? A. OBRA 1987 B. BBA, 1997 C. MMA, 2003 D. Medicare, 1965 ANSWER: B; Balanced Budget Act, 1997

4. What legislation authorized NPs only, to act as “attending” for Hospice patients ? A. OBRA 1987 B. BBA, 1997 C. MMA, 2003 D. Medicare, 1965 ANSWER: C; Medicare Modernization Act

5. The Annual Nursing Facility Assessment was previously coded as a “Comprehensive Assessment” coded as a 99301. What code is used now? A. 99304 (“Initial”) B. 99305 C. 99309 D. 99318 ANSWER: D; Requires Comprehensive History and Exam – low to moderate medical decision making (MDM)

6. Which CPT set of codes would the APN (or MD) use for medically necessary care visits? A. 99304-99306 B. 99315-99318 C. 99307-99310 D. 99311-99313 E. None of these ANSWER: C as of January 1, 2006 Codes 99307-99310 replaced 99311-99313

7. What Subsequent Care CPT code would be generally used for 30 and 60 day required visits by the APN? A. 99304 (“Initial”) B. 99307 C. 99309 D. 99318 ANSWER: C, review of three or more chronic conditions (interval history) counts as the HPI for Required visits

8. What Set of CPT codes are used for “INITIAL” visits for SNF patients by the physician? A. 99304-99306 B. 99307-99310 C. 99315-99318 D. 99301-99303 ANSWER: A, Only the MD can use 99304-99306 for SNF patients “Initial” visits

9. Can the APRN ever use CPT codes 99304-99306 “INITIAL” visits? (short answer) ANSWER: Yes, but only for Nursing Facility patients (NF), in states that have adopted laws or rules allowing APNs not employed by the facility to do initial visits as allowed by CMS rules in 42 CFR 483.40 (f)

10. Initial Visit Codes require how many key elements (history, exam, medical decision making [mdm] at the level coded? • Two out of three key elements • Two out of three key elements if the visit takes an hour or more • Three out of three key elements • Three out of three key elements if the visit takes an hour or more ANSWER:C, Time elements have not been established for LTC CPT codes (2006)

11. Subsequent Care Codes 99309 and 99310 require how many key elements at the level coded? • Two out of three key elements • Two out of three key elements if the visit takes an hour or more • Three out of three key elements • Three out of three key elements if the visit takes an hour or more ANSWER: A , but would require moderate or high level medical decision making

12. Which of the following Medicare providers can sign the Medicare “post-Hospital care SNF” need certification or recertification? • Any Medicare provider with a UPIN • MD • NP/CNS employed by outside agency • NP/CNS employed by facility E. PA employed by outside agency ANSWER: B & C. APN employed by facility can’t sign any. APN not employed by facility CAN sign all. PA can’t sign any regardless of employment status

13. Which of the following Medicare providers can bill for the Medicare “post-Hospital care SNF” need certification or recertification? • Any Medicare provider with a UPIN • MD • NP/CNS employed by outside agency • NP/CNS employed by facility E. PA employed by outside agency ANSWER: Nobody can bill for signing the certification – its for payment only. Bill for medically necessary visits.

14. Who can bill for the SNF patients’ “Initial” Visit? • Any Medicare provider with a UPIN • MD • NP/CNS employed by outside agency • NP/CNS employed by facility E. PA employed by outside agency ANSWER: B – MD only (see slide #8)

15. True/false: APNs that are employed by the facility can do and bill required visits for SNF patients. • True • False ANSWER: A TRUE for alternate required visits, after the Initial visit by MD and delegated by MD

16. T/F APNs employed by the facility are permitted to perform other (than required) visits and write orders based on these visits • True • False ANSWER: A. True. The BBA, 1997 gave this authority independently of the required visit language from the original enabling legislation of OBRA, 1987.

17. T/F APRNs employed by the facility that do medically necessary visits need MD co-signatures on their orders • True • False ANSWER: A. True - See memo from CMS dated Nov. 13, 2003.

18. Can the APN do the 14 day required visit? Short answer question ANSWER: There is NO 14 day required visit. There is a 14 day “recertification” for SNF payment to the facility for the patient on Medicare benefits. It does NOT require a visit.

19. The APN can order therapy for a NF patient, if : A. Allowed by state laws B. If they are not employed by the facility C. If the patient has Medicare ANSWER: A; While the BBA, 1997 authorized payment for therapy ordered by an APN under Medicare part B, the ordering of therapy is a scope of practice issue for the APN, and legal issue for the therapist. In some states the therapist may not be authorized to take orders from APNs until their practice act is amended.

20. How is the ability of the NP to do the required visits in a SNF determined? A. By Federal Regulation B. By MD delegation C. By State LTC licensing laws D. A & B E. None of these ANSWER: D, There may be other factors such as facility or employer policy

21. The CPT code 99318 is used: A. To bill the Annual Nursing Facility Assessment B. In place of a required visit C. In addition to a 60 day required visit D. A & B E. When a patient is re-admitted from the hospital ANSWER: D, You can’t bill for both 99318 and a subsequent care code on the same day. It should be on the required visit cycle

22. How did you do? Please tell me how you scored on your pre-test and what your background is. If you don’t understand the questions after you have reviewed the materials on the website, you can email me for further clarification, or other questions. Watch for updates and further development of this content on the website. Mahalo, Valisa Saunders APRN, GNP-BC Honolulu, Hawaii Email: Valisa@hawaii.rr.com