According to the most recent Centers for Disease Control statistics, 1.4 million Americans reside in nursing homes. Federal and state laws require that nursing home residents be under the care of a physician and that those physicians routinely evaluate, manage and direct the patient’s care.

The Social Security Act strictly prohibits coverage for routine care. However, there are provisions in those same laws – in conjunction with the Centers for Medicare and Medicaid Services policy – that allow for reimbursement for the required visits.

The medical record documentation for these visits is not the type that is usually expected of an evaluation and management visit in other settings. We have found that most providers are not aware of these specific requirements.

Did you know, for example, that you must indicate that the encounter is for the federally mandated visit and that you must review all of the patient’s diagnoses?

Most Medicare Administrative Contractors are in the process of reviewing all levels of nursing home services. All of these contractors advise providers to perform internal reviews to monitor reported codes.

If you provide care in a nursing home setting and are not feeling confident in the documentation for the charges you submit, we can help. Please contact Angie Babb (ababb@blueandco.com) for more information.