7 tips to maximize revenue for nursing home services

It’s probably difficult for most internists to imagine: Seeing patients when it’s convenient for the physician, largely avoiding high-deductible health plans, and ensuring a steady income with few interruptions. For Connecticut-based internist Jeffrey Kagan, MD, this dream is a reality thanks to the fact that he spends 20 percent of his time seeing patients in nursing homes. 

“There’s a myth out there that you don’t get paid much to see patients in the nursing home, and that’s just not true,” says Kagan. “With nursing homes, it’s actually a nice constant flow of revenue.” 

Kagan especially likes that he rarely sees denials unless a patient with Medicare switches to a Medicare Advantage plan (or vice versa) and doesn’t notify his office. “We try to get accurate information from the very beginning,” he adds. “If the patient’s insurance doesn’t change, then it works, and billing goes smoothly.”

Other physicians say nursing home services can be lucrative but not without challenges. Vishal Aggarwal, MD, a geriatrician at Elite Medical Clinic in Tulsa, Okla., previously spent 50 percent of his time seeing patients in nursing homes but decided to stop last year because of the difficulty in getting paid. One challenge was that Oklahoma Medicaid only paid for two nursing home visits per month. This meant that when Aggarwal saw Medicaid patients more than that, his work was unpaid-even when it was medically necessary. 

Connecticut Medicaid doesn’t limit the number of medically necessary visits per month, says Kagan. “For example, it would be medically necessary to see someone for an acute problem like pneumonia or vomiting but not necessary to adjust the dose of warfarin or insulin,” he says.

Another challenge for Aggarwal was that he often felt pressured by the nursing home to see patients even when he wasn’t a participating provider in their Medicare Advantage network. When this happened, patients were often responsible for the bill, and it was nearly impossible to collect from them, he says. “It was easier to not see the patient, but you can’t say that to the nursing home. It put me in a very difficult situation,” he adds. 

Kagan doesn’t have this problem because he participates with each of the local Medicare Advantage plans. 

Finally, when patients didn’t have a primary care physician or didn’t see any other physician during an Accountable Care Organization (ACO) performance year, the ACO to which Aggarwal belonged attributed nursing home patients to him. This meant he was responsible for providing a year’s worth of preventive care for patients he only saw once or twice. When he didn’t provide these services, the data falsely indicated that he wasn’t managing patients effectively, and his clinic’s reputation started to suffer.

Kagan says some ACOs can eliminate nursing home patients from a physician’s attributed list so they aren’t responsible for all of a patient’s care. Kagan’s ACO is revamping its process for nursing home patient attribution so he isn’t penalized when there are gaps in preventive care.  

Although physicians can’t control some of these payment barriers, there are certainly steps they can take to make nursing home services more lucrative, says Vanessa Moldovan, CPC, CPMA, senior billing specialist at Medic Management Group LLC, a healthcare consulting company in Akron, Ohio. Here are seven tips to consider. 

Do your homework before seeing patients in the nursing home. 

To avoid denials, physicians-and any non-physician providers they employ to treat patients in the nursing home-must be credentialed with every nursing facility in which they render services, says Michele Rodgers, certified medical manager at Healthstone Primary Care Partners, an internal medicine practice in Hollywood, Fla. 

The practice’s administrative staff should also contact the nursing home to obtain each patient’s demographic and insurance information to determine whether the physician is contracted with the patient’s insurance provider, says Rodgers. To minimize denials, this determination should take place as soon as possible. For patients with Medicare, it should take place before the first mandated visit, which Medicare states must occur within 48 hours of admission to the nursing facility, she adds. 

If the physician isn’t contracted with the patient’s payer, the services will likely be subject to the patient’s out-of-network benefits-and the patient could owe a significant co-insurance, says Rodgers. When patients have this information in advance, they may be more likely to follow through with payment or go to another nursing home that has an arrangement with a physician who’s in the patient’s network, she adds.

Know what codes to report.

Report a CPT code from the 99304-99306 code range for the initial nursing home visit, depending on the severity of the patient’s diagnosis and services rendered, says Moldovan. For all other medically necessary visits, report a CPT code from the 99307-99310 code range, she adds. This includes the federally-mandated visits for Medicare patients that occur every 30 days for the first 90 days after admission to the facility and at least once every 60 days thereafter.

It can get tricky when a patient with Medicare or a commercial plan leaves the nursing facility and returns a short time later. Kagan provides this example: A patient is discharged to rehab following a hip repair. On the third day of rehab, the patient develops respiratory distress and is re-hospitalized for acute hypoxic respiratory failure due to pneumonia. 

Physicians must determine whether the return to the nursing facility is considered an initial visit or subsequent, says Kagan. He provides this guidance: Unless the patient or their family pays to hold the bed in the patient’s absence-typically $300 to $400 per day-physicians can report an initial services code upon that patient’s return. If the patient or their family pays to hold the bed, then the original nursing home stay continues, and physicians must report a subsequent visit code when the patient returns. 

However, physicians should keep in mind that Medicare and many commercial payers track all admission and discharge dates, says Moldovan. If a physician tries to bill an initial visit before the nursing home discharges the patient, the payer will likely deny payment for the visit, she adds. 

Something else to keep in mind: Medicaid requirements may differ from state to state. For example, Connecticut Medicaid requires nursing homes to hold the bed for 14 days, says Kagan. If a patient with Medicaid is readmitted to the nursing home during that time, the physician must report a subsequent services code. If it’s after 14 days, the physician can report an initial services code, he adds.

If there’s any question as to whether the service is initial or subsequent, Kagan suggests contacting the director of admissions or biller at the nursing facility. Physicians shouldn’t assume that every patient is a readmission because they could be missing out on approximately $48 or more per visit (the difference between the initial and subsequent visits for a patient of similar clinical complexity), he says. 

Report CPT codes 99315 or 99316 for nursing facility discharge services, depending on the time spent performing these services. Discharge services include final examination of the patient, providing continuing care instructions to relevant caregivers, preparing the discharge records, completing referrals, and ordering prescriptions. Report CPT code 99318 for the annual nursing facility assessment. 

Double-check the place of service (POS) code. 

Many physicians incorrectly use POS code 11 (office) rather than POS code 31 (skilled nursing facility) or 32 (nursing facility), says Moldovan. Physicians must report the correct POS code in two places on the claim form-next to the name and address of the facility where services are rendered and next to the CPT code itself, she says. Some EHRs pre-populate the facility name and/or the POS code, and physicians may need to override one or both manually, she adds.

Append modifiers, when necessary. 

To be paid appropriately for providing nursing home services to Medicare patients receiving hospice care, physicians must append one of the following modifiers: -GV (when a provider performs a service related to the problem for which a patient was admitted into hospice) or modifier -GW (when the service is not related to the hospice patient’s terminal condition), says Rodgers. “If providers don’t usually treat patients on hospice, they may not be aware of these modifiers,” she explains.

Ensure documentation supports each CPT code. 

“Providers using these codes must familiarize themselves with what they need to document to substantiate the bill,” says Rodgers. 

Each code requires a chief complaint, history, exam, and medical decision-making, says Jane Miller, practice manager and auditor at a two-physician primary care practice in southern Ohio. “These codes require just as much documentation as regular office visit codes, she says. 

As with office visit E/M codes, higher-level nursing facility codes can raise questions with payers if documentation is sparse, says Miller. She provides the example of CPT code 99310-the highest-level code for a subsequent nursing facility service. “You have to be really careful with this code, and you need to make sure that documentation reflects severity,” she adds.

Distinguish between nursing and assisted living facilities. 

The CPT manual describes assisted living facilities as those that provide room, board, and other personal assistance services, generally on a long-term basis. These facilities do not include a medical component. When physicians render services in an assisted living facility, they should report a CPT code from the 99324-99328 code range for new patients and the 99334-99337 code range for established patients, says Moldovan. Report POS code 13 with these CPT codes, she adds.

Don’t forget prolonged services. 

Kagan says he bills CPT codes 99358-99359 (prolonged services without direct patient contact) for time spent on the phone with nurses, family, or other physicians. Note that these codes must be reported in addition to an E/M code, and they require at least an additional 60 minutes of services beyond what’s typically associated with the E/M code. Physicians can also report CPT codes 99354-99355 for prolonged services with direct patient contact.

“Seeing patients in a nursing home can be rewarding in several ways,” says Kagan. “The schedule is flexible, and the patients and staff are very appreciative. Also, a dedicated nursing home practice requires minimal overhead and can be quite ­profitable.”