EXERCISES

1. EXERCISES

2. EXERCISE 1 • Scheduled nursing facility visit for an 84‑year‑old male with DM, chronic renal insufficiency, HTN, S/P CVA, MID, Depression, CHF, pressure ulcer hx, PVD, GERD, OA; on digitalis, ACE inhibitor, diuretics, oral anti-diabetic agent, PPI, SSRI, COX-2, plavix and insulin, requiring “minor” adjustments of medications; labs: BMP, CXR, BGs weekly; consults: cardio, wound team

3. SUBSEQUENT CARENew or Established • 99309 (TWO OF THREE) • DETAILED HX • DETAILED EXAM • MEDICAL DECISION MAKING: • MODERATE • 25 minutes • USED FOR • PATIENT DEVELOPED SIGNIFICANT COMPLICATION OR SIGNIFICANT NEW PROBLEM • “ROUTINE / REGULATORY” VISIT

4. EXTENT/LEVEL OF HISTORY - SUBSEQUENT

5. HISTORYHISTORY OF PRESENT ILLNESS – 2 Types • 1. BRIEF • 1 TO 3 ELEMENTS • 2. EXTENDED • 4 ELEMENTS -OR- • STATUS OF AT LEAST 3 CHRONIC OR INACTIVE CONDITIONS Elements: Location, Quality, Severity, Duration, Timing, Context, Modifying factors, Associated signs and symptoms

6. HISTORYREVIEW OF SYSTEMS – 3 Types • 1. PROBLEM PERTINENT • ONE SYSTEM • 2. EXTENDED • 2 TO 9 SYSTEMS • 3. COMPLETE • AT LEAST 10 SYSTEMS

7. HISTORYPAST, FAMILY, AND/OR SOCIAL HISTORY – 2 Types • 1. PERTINENT – 99304 • a review of the history areas directly related to the problem • 2. COMPLETE – 99304-6 • a review of two or all three of the areas • NOT REQUIRED FOR SUBSEQUENT NURSING FACILITY CARE

8. COMPLEXITY OF MEDICAL DECISION MAKINGSUBSEQUENT (2 OF THREE)

9. MEDCIAL DECISION-MAKINGNUMBER OF DIAGNOSES / MANAGEMENT OPTIONS 4 Types • 1. MINIMAL • 2. LIMITED • 3. MULTIPLE • 4. EXTENSIVE

10. MEDCIAL DECISION-MAKINGAMOUNT / COMPLEXITY OF DATA – 4 Types • 1. MINIMAL OR NONE • 2. LIMITED • 3. MODERATE • 4. EXTENSIVE

11. MEDCIAL DECISION-MAKING RISK OF COMPLICATIONS, MORBIDITY, MORTALITY • 3. MODERATE • 1 OR MORE CHRONIC ILLNESS W/ MILD EXACERBATION • 2 OR MORE STABLE CHRONIC PROB. • ACUTE ILLNESS W/ SYSTEMIC SYMPT. • UNDIAGNOSED NEW PROBLEM W/ UNCERTAIN PROGNOSIS • PRESCRIPTION MEDS • CMS EXAMPLES: • lump in breast • pyelonephritis, pneumonitis, colitis • head injury with brief loss of consciousness

12. EXERCISE 2 • Telephone call by nursing to assess patient with chronic atrial fibrillation with an abnormal Prothrombin time of INR 3.8, no bleeding noted, no other symptoms noted

13. Telephone Calls • E/M codes / $$ established, not paid for by CMS • Physician to patient, parent or guardian • E/M service not related to previous E/M service within 7 days or planned E/M service next 24 hours or soonest available appointment • CPT 99441 5-10 min $13.71 – 12.27 • CPT 99442 11-20 min $26.70 – 25.22 • CPT 99443 21-30 min $38.97 – 37.89 • CPT 99444 internet service, no time / $$

14. Telephone Calls • Can consider in care & coordination next visit - carefully • “Bundled” into NH visits • Suggestion : document calls, add into next progress note • Not delineated in Manual • Preservice (24hrs)/postservice (7 days)

15. EXERCISE 3 • Nursing facility assessment and creation of medical plan of care upon readmission to the nursing facility of an 82‑year‑old male who was previously discharged. The patient has just been discharged from the hospital where he had been treated for an acute gastric ulcer bleed associated with transient delirium. The patient returns to the nursing facility debilitated, protein depleted, and with a stage III coccygeal pressure ulcer.

16. 30.6.13 AVisits to Perform the Initial Comprehensive Assessment and Annual Assessments • Definition of “Initial Visit”: • “the initial comprehensive assessment visit during which the physician completes a thorough assessment, develops a plan of care and writes or verifies admitting orders for the nursing facility resident.” • Prior to/ after “Initial Visit”: • “other medically necessary E/M visits may be performed and reported prior to and after the initial visit, if the medical needs of the patient require an E/M visit.” “Qualified NPP may perform.”

17. 30.6.13 AVisits to Perform the Initial Comprehensive Assessment and Annual Assessments • “The principal physician of record must append the modifier “-AI”, Principal Physician of Record, to the initial nursing facility care code.” • “This modifier will identify the physician who oversees the patient’s care from other physicians who may be furnishing specialty care.”

18. INTIAL NURSING FACILITY CARENew or Established • 99306 (THREE OF THREE) • COMPREHENSIVE HX • COMPREHENSIVE EXAM • MEDICAL DECISION MAKING: • HIGH • 45 minutes • USED FOR: • INITIAL ADMISSION / READMISSION • Usually, the problem(s) requiring admission are of high severity.

19. EXTENT/LEVEL OF HISTORY INITIAL

20. HISTORYHISTORY OF PRESENT ILLNESS – 2 Types • 1. BRIEF • 1 TO 3 ELEMENTS • 2. EXTENDED • 4 ELEMENTS -OR- • STATUS OF AT LEAST 3 CHRONIC OR INACTIVE CONDITIONS Elements: Location, Quality, Severity, Duration, Timing, Context, Modifying factors, Associated signs and symptoms

21. HISTORYREVIEW OF SYSTEMS – 3 Types • 1. PROBLEM PERTINENT • ONE SYSTEM • 2. EXTENDED • 2 TO 9 SYSTEMS • 3. COMPLETE • AT LEAST 10 SYSTEMS

22. HISTORYPAST, FAMILY, AND/OR SOCIAL HISTORY – 2 Types • 1. PERTINENT – 99304 • a review of the history areas directly related to the problem • 2. COMPLETE – 99304-6 • a review of two or all three of the areas

23. COMPLEXITY OF MEDICAL DECISION MAKING –INITIAL (3 OF THREE)

24. MEDCIAL DECISION-MAKINGNUMBER OF DIAGNOSES / MANAGEMENT OPTIONS 4 Types • 1. MINIMAL • 2. LIMITED • 3. MULTIPLE • 4. EXTENSIVE

25. MEDCIAL DECISION-MAKINGAMOUNT / COMPLEXITY OF DATA – 4 Types • 1. MINIMAL OR NONE • 2. LIMITED • 3. MODERATE • 4. EXTENSIVE

26. MEDCIAL DECISION-MAKING RISK OF COMPLICATIONS, MORBIDITY, MORTALITY • 4. HIGH • 1 OR MORE CHRONIC ILLNESSES W/ SEVERE EXACERBATION • ACUTE OR CHRONIC ILLNESSES THAT POSE A THREAT TO LIFE • ABRUPT CHANGE IN NEURO STATUS • SURGERY, PARENTERAL MEDS, DNR • multiple trauma, acute MI, pulmonary embolus, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness with potential threat to self or others, peritonitis, acute renal failure • seizure, TIA, weakness, sensory loss

27. EXERCISE 4 • Visit in skilled nursing facility by your nurse practitioner, who has a collaborative agreement with you, to an existing 70‑year old patient of yours following a 10‑day treatment of a cellulitis of the foot who continues to have swelling and redness of the foot.

28. 30.6.13 CVisits by Qualified Nonphysician Practitioners • State Regulations, State Scope of Practice • “All E/M visits shall be within the State scope of practice and licensure requirements where the visit is performed and all the requirements for physician collaboration and physician supervision shall be met when performed and reported by qualified NPPs.” • “General physician supervision and employer billing requirements shall be met for PA services in addition to the PA meeting the State scope of practice and licensure requirements where the E/M visit is performed.”

29. 30.6.13 D Medically Complex Care D. Medically Complex Care “Payment is made for E/M visits to patients in a SNF who are receiving services for medically complex care upon discharge from an acute care facility when the visits are reasonable and medically necessary and documented in the medical record.”

30. 30.6.13 D Medically Complex Care D. Medically Complex Care Physicians and qualified NPPs shall report E/M visits using the Subsequent Nursing Facility Care, per day (codes 99307 - 99310) for follow-up visits

31. 30.6.13 EIncident To Servicesin the Nursing Home • “Incident to” E/M visits, provided in a facility setting, are not payable under the Physician Fee Schedule for Medicare Part B.

32. EXERCISE 5 • Visit on day one of stay to gather information, perform a preliminary assessment and verify orders in skilled nursing facility by your nurse practitioner, who has a collaborative agreement with you, to a previously independently living 90‑year‑old male who suffered a recent cerebral vascular accident (CVA) and is transferred to the hospital subacute rehabilitation unit for further rehabilitation supportive services.

33. 30.6.13 AVisits to Perform the Initial Comprehensive Assessment and Annual Assessments • Definition of “Initial Visit”: • “the initial comprehensive assessment visit during which the physician completes a thorough assessment, develops a plan of care and writes or verifies admitting orders for the nursing facility resident.” • Prior to/ after “Initial Visit”: • “other medically necessary E/M visits may be performed and reported prior to and after the initial visit, if the medical needs of the patient require an E/M visit.” “Qualified NPP may perform.”

34. 30.6.13 CVisits by Qualified Nonphysician Practitioners • Federally Mandated Visits • SNF (31) • “Following the initial visit by the physician, the physician may delegate alternate federally mandated physician visits to a qualified NPP who meets collaboration and physician supervision requirements and is licensed as such by the State and performing within the scope of practice in that State.”

35. Medicare Claims Processing Manual, Pub.100-04, • 30.6.13 - Nursing Facility Services Medically Necessary Visits “Medically necessary E/M visits for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member are payable under the physician fee schedule under Medicare Part B”

36. EXERCISE 6 • Visit on day two of stay to evaluate a fever in skilled nursing facility by your nurse practitioner, who has a collaborative agreement with you, to 79‑year‑old male, who has not yet been seen for an initial physician assessment, who suffered a recent fractured hip and is transferred to the facility for further rehabilitation services.

37. 30.6.13 AVisits to Perform the Initial Comprehensive Assessment and Annual Assessments • Definition of “Initial Visit”: • “the initial comprehensive assessment visit during which the physician completes a thorough assessment, develops a plan of care and writes or verifies admitting orders for the nursing facility resident.” • Prior to/ after “Initial Visit”: • “other medically necessary E/M visits may be performed and reported prior to and after the initial visit, if the medical needs of the patient require an E/M visit.” “Qualified NPP may perform.”

38. Medicare Claims Processing Manual, Pub.100-04, • 30.6.13 - Nursing Facility Services B. Visits to Comply With Federal Regulations (42 CFR 483.40) “E/M visits, prior to and after the initial physician visit, that are reasonable and medically necessary to meet the medical needs of the individual patient (unrelated to any State requirement or administrative purpose) are payable under Medicare Part B.”

39. EXERCISE 7 • Nursing facility visit to develop a new plan of care for an amputee with atherosclerosis obliterans who has refused to eat for three days and has developed decreased urinary output.

40. 30.6.13 D Medically Complex Care D. Medically Complex Care “Physicians and qualified NPPs shall report initial nursing facility care codes for their first visit with the patient.” “The principal physician of record must append the modifier “-AI” Principal Physician of Record, to the initial nursing facility care code when billed to identify the physician who oversees the patient’s care from other physicians who may be furnishing specialty care.” Physicians and qualified NPPs shall report E/M visits using the Subsequent Nursing Facility Care, per day (codes 99307 - 99310) for follow-up visits

41. Medicare Claims Processing Manual, Pub.100-04 • SEC. 30.6.1 - Selection of Level of Evaluation and Management Service • D. Use of Highest Levels of Evaluation and Management Codes • “Carriers must advise physicians that to bill the highest levels of visit and consultation codes, the services furnished must meet the definition of the code (e.g., to bill a Level 5 new patient visit, the history must meet CPT’s definition of a comprehensive history).”

42. SUBSEQUENT CARENew or Established • 99310 (TWO OF THREE) • COMPREHENSIVE HX • COMPREHENSIVE EXAM • MEDICAL DECISION MAKING: • HIGH • 35 minutes • USED FOR • The patient may be unstable or may have developed a significant new problem requiring immediate physician attention.

43. EXTENT/LEVEL OF HISTORY - SUBSEQUENT

44. HISTORYHISTORY OF PRESENT ILLNESS – 2 Types • 1. BRIEF • 1 TO 3 ELEMENTS • 2. EXTENDED • 4 ELEMENTS -OR- • STATUS OF AT LEAST 3 CHRONIC OR INACTIVE CONDITIONS Elements: Location, Quality, Severity, Duration, Timing, Context, Modifying factors, Associated signs and symptoms

45. HISTORYREVIEW OF SYSTEMS – 3 Types • 1. PROBLEM PERTINENT • ONE SYSTEM • 2. EXTENDED • 2 TO 9 SYSTEMS • 3. COMPLETE • AT LEAST 10 SYSTEMS

46. HISTORYPAST, FAMILY, AND/OR SOCIAL HISTORY – 2 Types • 1. PERTINENT – 99304 • a review of the history areas directly related to the problem • 2. COMPLETE – 99304-6 • a review of two or all three of the areas • NOT REQUIRED FOR SUBSEQUENT NURSING FACILITY CARE

47. COMPLEXITY OF MEDICAL DECISION MAKINGSUBSEQUENT (2 OF THREE)

48. MEDCIAL DECISION-MAKING RISK OF COMPLICATIONS, MORBIDITY, MORTALITY • 4. HIGH • 1 OR MORE CHRONIC ILLNESSES W/ SEVERE EXACERBATION • ACUTE OR CHRONIC ILLNESSES THAT POSE A THREAT TO LIFE • ABRUPT CHANGE IN NEURO STATUS • SURGERY, PARENTERAL MEDS, DNR • multiple trauma, acute MI, pulmonary embolus, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness with potential threat to self or others, peritonitis, acute renal failure • seizure, TIA, weakness, sensory loss

49. EXERCISE 8 • On rounds, you are asked to be seen by one of your nursing facility patients sitting in the hallway, who was not scheduled to be seen, and who is complaining of new acute onset right lower extremity pain and swelling with shortness of breath over the past 2 hours.

50. 30.6.13 D Medically Complex Care D. Medically Complex Care “Payment is made for E/M visits to patients in a SNF who are receiving services for medically complex care upon discharge from an acute care facility when the visits are reasonable and medically necessary and documented in the medical record.”