Yes, specialists who are not the admitting / primary physician may submit CPT 99304 in certain situations.
CPT 99304 – Initial nursing facility care, per day, for the evaluation and management of a patient, which requires these 3 key components: a detailed or comprehensive history; a detailed or comprehensive examination; and medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the problem(s) requiring admission are of low severity. Typically, 25 minutes are spent at the bedside and on the patient’s facility floor or unit.
Medicare and United Healthcare (UHC) do not recognize consultation codes. When Medicare stopped recognizing consultation codes on January 1, 2010 they instructed specialists, including podiatrists, to use the initial nursing facility codes when seeing a nursing facility patient for the first time during that patient’s admission, even if that encounter qualified for what the facility would consider a “consult,” and even though the specialist was not the admitting/primary doctor. Since there may be multiple doctors using those initial encounter codes for Medicare and UHC patients, the admitting/primary doctor must append an “AI” modifier to their initial evaluation and management (E&M) encounter for those patients.
This change did not change the fact that in order to submit any E&M CPT code, the thresholds of complexity for that code must be met. Complexity refers to the three key elements of facility E&M CPT coding (history, exam, decision making) in what was performed, what was documented, and what was medically necessary for that level. If counseling and coordinating dominate the visit, time may also be used to guide complexity for facility E&M CPT level selection.
These thresholds and time requirements are relatively high for the lowest level initial nursing facility E&M (CPT 99304). Therefore, Medicare clarified that it is appropriate for specialists to use the subsequent nursing facility E&M CPT codes for initial encounters that do not meet the complexity thresholds for CPT 99304. This is an important point as even though specialists can use initial nursing facility E&M CPT codes for Medicare patients, every initial encounter does not automatically qualify for use of an initial encounter E&M code.
Conclusion
When submitting to Medicare, UHC, or any other third party payer that does not recognize consultation CPT codes, specialists may use CPT 99304. For non-Medicare and non-UHC payers that still recognize consultation codes, specialists should not use CPT 99304 and should still use consultation CPT codes for nursing facility consults.
References
- 2022 CPT Professional. Current Procedural Terminology (CPT®) is copyright 1966, 1970, 1973, 1977, 1981, 1983-2021 by the American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association (AMA).
- CMS Medicare Learning Network SE10101 Questions and Answers on Reporting Physician Consultation Services
