Initial NF Visit Billing and G8644

Keep Initial NF Visit Billing for the Physician

Question: You are receiving denial C0-170 (Payment is denied when preformed/billed by this type of provider) from Medicare when I bill for an initial nursing facility visit our physician assistant (PA) did. I am using place of service code 31 (Skilled Nursing Facility) as well as provider type 38 (Physician assistant). Why are you getting this denial?

Answer: You are not supposed to bill an initial visit in a skilled nursing facility (SNF) or nursing facility (NF) using 99304-99306 (Initial nursing facility care, per day, for the evaluation and management of a patient …) under a physician assistant (PA), according to Medicare medical coding and billing rules. Medicare says that a physician must carry out this type of service, per 42 Code of Federal Regulations (42 C.F.R. 483.40 [c] [4]).

As per CMS, the Social Security Act mentions in Section 1819(b)(6)(A) that "the medical care of every resident must be provided under the supervision of a physician." This implies that non-physician practitioners, including Pas, cannot carry out the initial comprehensive visit in SNFs.

Remember: CMS defines the initial visit as "the initial comprehensive assessment visit during which a physician completes a thorough assessment, develops a plan of care and writes or verifies admitting orders for the nursing facility resident."

Furthermore, according to the Long Term Care regulations (42 CFR 483.40 [c][4] and [e][2]), the physician may not give away a task that the physician must personally carry out. Consequently, the physician may not delegate the initial visit in a SNF to your PA.

Medical Coding and Billing Tip: This rule is also applicable to the NF (POS 32) with one exception: A qualified NPP, who is not employed by the facility, may carry out initial visit in the NF setting when the state law allows.

G8644 Applies For ‘No License' Exceptions

Question: Is HCPCS code G8644 used when a provider doesn't have authority as per federal law to write a prescription? Or does it point out that the eligible provider didn't have e-prescribing technology to submit an e-rx?

Answer: You must use G8644 (Eligible provider does not have prescribing privileges) for a physician or non-physician provider who would otherwise be needed to participate in the ePrescribe program however the provider does not have prescribing privileges (such as no license to prescribe). The one-time reporting of code HCPCS code G8644 was needed in 2011 for the provider to be granted an exception.

As per CMS's 2011 Electronic Prescribing (eRx) Incentive Program Update CMS has this to say about HCPCS code G8633: "there will be a G8644 code which can be used by eligible professionals to show that they do not have prescribing privileges.