From: The Rheumatologist, November 2011

Coding Corner Answer

Skilled nursing facility patients

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This patient encounter should be coded as 99214-25, 20610-LT, 76942-26
Diagnoses: 714.0, 535.00, E943.8

Modifier -25 is used to indicate that the patient required a significant, separately identifiable evaluation and management (E/M) service on the same day as the patient received a minor procedure. E/M services that result in the decision to perform a procedure on the same day are considered to be part of the evaluation for the procedure and are not separately billable. However, this patient had a separate problem (gastritis) that required evaluation and management services and therefore the portion of the encounter related to the diagnosis and treatment of the patient’s gastritis are separately billable with the use of modifier -25. The E/M services related to the patient’s gastric symptoms included:

  • Expanded problem-focused history;
  • Detailed examination; and
  • Moderate complexity decision making—treatment side effect (gastritis) requiring change in medication therapy and additional prescription medication to treat gastritis.

Only the professional component of radiological procedures can be billed to Medicare Part B because the patient was residing in a skilled nursing facility at the time of service. An arrangement must be made with the skilled nursing facility to receive payment for the technical component of the ultrasound sound guidance procedure. This financial arrangement should be made prior to the patient’s visit. See this month’s coding article, “Skilled Nursing Facility Patients—Consolidated Billing,” for more information.

Before the claim can be billed out to the Medicare carrier, the skilled nursing facility’s name and Medicare number must appear on the claim.


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