CPT® 99310; Subsequent nursing facility care, per day, for the evaluation and management of a patient, 45 minutes - JE Part B
CPT® 99310; Subsequent nursing facility care, per day, for the evaluation and management of a patient, 45 minutes
In order to fulfill its contractual obligation with CMS, Noridian Healthcare Solutions (Noridian), your Medicare Contractor, performs pre-payment reviews in accordance with CMS direction. CMS is required by the Social Security Act to ensure that payment is made only for those medical services that are reasonable and necessary. Medical review assesses submitted documentation to validate provider compliance with Medicare payment rules and regulations, including coverage, coding and billing guidelines.
This is to update providers of the claim review findings for CPT® 99310; Subsequent nursing facility care, per day, for the evaluation and management of a patient, 45 minutes. The results of this focused review are not a reflection on providers' competence as a health care professional or the quality of care provided to patients. Specifically, the results are based on the documentation requested by Medicare and/or your facility's compliance with the required documentation.
The Jurisdiction E, Part B Medical Review Department is conducting a Targeted Probe and Educate (TPE) review of CPT® 99310; Subsequent nursing facility care, per day, for the evaluation and management of a patient, 45 minutes. The quarterly edit effectiveness results from July 1, 2024 to September 30, 2024, are as follows:
Top Denial Reasons
- The requested records were not received
- The documentation submitted supported the key elements and/or reasonable necessity of a lower level of service
- The documentation submitted does not support the medical necessity of the level of service billed
Educational Resources
Education
Subsequent nursing facility care service codes describe visits that occur after the first encounter of the patient's nursing facility admission by the supervising qualified clinician. Codes are reported per day and do not differentiate between new or established patients. All services require a medically appropriate history and/or examination. Code selection is based on the level of medical decision making (MDM) or total time personally spent by the physician and/or other qualified health care professional(s) on the date of the encounter. Factors to be considered in MDM include the number and complexity of problems addressed during the encounter, amount and complexity of data requiring review and analysis, and the risk of complications and/or morbidity or mortality associated with patient management.
Failure to Return Records
The Internet-Only Manual (IOM) addresses timeframes for submission of records for pre-payment reviews in the Medicare Program Integrity Manual, Publication 100-08, Chapter 3, Section 3.2.3.2.
"When requesting documentation for prepayment review, the MAC and ZPIC shall notify providers that the requested documentation is to be submitted within 45 calendar days of the request. The reviewer should not grant extensions to providers who need more time to comply with the request. Reviewers shall deny claims for which the requested documentation was not received by day 46."
Incomplete And/or Insufficient Documentation
When additional documentation has been requested to verify compliance with the CPT® code billed and the submitted documentation lacks evidence to support that, the claim will be denied as the documentation submitted was incomplete and/or insufficient. Refer to Internet Only Manual (IOM), Publication (Pub) 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8(C)
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