SNF Billing Changes 2023

[Ogliodendrocyte]

Beyond the obvious changes- that History and Physical no longer taken into account based on level of which you can bill. It looks like there have been some changes to the MDM that seem to make it harder to bill for 99306?

Old guidelines showed that MDM was broken into 3 categories: Problem Points, Data Points, and Risk- you needed 2 out of the 3 to qualify for appropriate level
99306 (High MDM) could be >4 Problem points, >4 data points or High Risk
It was easy to get 4 problem points (Admission Dx, then 3 additional chronic illness that may impact rehab etc) and 4 data points (Labs, imaging, review discharge summary)

Now the new table for MDM has changed- the problem points classification has changed and so has the data points.

For 99306 you need- 1 severe exacerbation of chronic illness, or acute/chronic illness that may pose threat to life or bodily function (these are easy enough to achieve I think). But you longer can add up the number of problems being addressed.

Then the amount of data review has 3 categories- you can't just add up points of reviewed old records, labs, imaging, etc

The 3 categories are: 1.Tests/documents 2. Independent interpretation of tests (not separately reported) 3. Discussion of management or test interpretation with external provider

So, it's not enough to list hospital labs, summarizing documents, imaging- now you must include independent interpretation of tests and/or discuss with another provider.

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[DMBandFan86]

For 99306 you need- 1 severe exacerbation of chronic illness, or acute/chronic illness that may pose threat to life or bodily function (these are easy enough to achieve I think).

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I still don’t know if I understand this, and I only do inpatient, but I think it is the same concept from level 2 to level 3 billing.

How do people / coders interpret this? What constitutes a chronic illness that may pose a threat to life or bodily function? And how is that clearly worse than a chronic illness with exacerbation, progression or side effect (the chart I am using does not say “mild” illness)? People are going to interpret this different ways. For instance, DM is a chronic illness that may pose threat to bodily function forever without exacerbation. However, the examples they gave in the link you provided wouldn’t be a patient at a SNF at least in the acute phase. If they had a PE or acute MI but were treated, how long can you code the high MDM?

I watched a coding lecture and they said acute means 1 year and chronic was 1+ years. Which is crazy to me and still am not sure how accurate that is.


So that leads to my personal interpretation that rarely in a SNF or IPR is high complexity. Unless you get to end of life care or a send out that you are actively treating before they go to the ER. No one in SNF or IPR should be having acute life threatening illnesses or severe chronic exacerbations unless they are hospice or being shipped out.

I made a post on this prior, but I feel like these coding changes are a pay cut to inpatient and also likely also to SNF physiatrists. Where is AAPMR?

 

[Ogliodendrocyte]

Threat of life or bodily function. The bodily function is what would be the emphasis for rehab, unless they are more specific what that entails.

I think how most people do it- is initial eval you have with they patient counts as high risk given the diagnosis. Subsequent visits- its not a new problem the patient has under your care thus would fall into moderate risk. I imagine that's how most go about coding visits, otherwise you're right it would be high level forever but then if they have an actual new problem, that is in fact a new complication to the patient under your care is what would change the complexity

 

[RangerBob]

I still don’t know if I understand this, and I only do inpatient, but I think it is the same concept from level 2 to level 3 billing.

How do people / coders interpret this? What constitutes a chronic illness that may pose a threat to life or bodily function? And how is that clearly worse than a chronic illness with exacerbation, progression or side effect (the chart I am using does not say “mild” illness)? People are going to interpret this different ways. For instance, DM is a chronic illness that may pose threat to bodily function forever without exacerbation. However, the examples they gave in the link you provided wouldn’t be a patient at a SNF at least in the acute phase. If they had a PE or acute MI but were treated, how long can you code the high MDM?

I watched a coding lecture and they said acute means 1 year and chronic was 1+ years. Which is crazy to me and still am not sure how accurate that is.


So that leads to my personal interpretation that rarely in a SNF or IPR is high complexity. Unless you get to end of life care or a send out that you are actively treating before they go to the ER. No one in SNF or IPR should be having acute life threatening illnesses or severe chronic exacerbations unless they are hospice or being shipped out.

I made a post on this prior, but I feel like these coding changes are a pay cut to inpatient and also likely also to SNF physiatrists. Where is AAPMR?

Agree. It’s a pay cut for us as the vast majority of level 3 inpatient follow-ups were billed on time, not complexity. But now that we need 50+ minutes level 3 visits are going to be exceedingly rare. PM&R really doesn’t have a place with the new coding.

Per my partner who’s very involved with all the advocacy stuff (but no longer an AAPMR member as he felt they were useless), the whole point behind these coding changes—was to shift to more inpatient level 2 visits, specifically for acute care hospital follow ups. Most groups supported the changes as documentation is simplified and most codes get a small pay increase.

Our hospitalists on the other hand feel like the “decision regarding hospitalization,” while perhaps meant more to refer to outpt physicians deciding if they need to hospitalize their patient, means that they can now code all inpatient follow ups as a level 3–since everyday they make a decision on whether the patient requires continued hospitalization.

We (PM&R) however cannot justify that—perhaps for team conference day when we decide on how long their LOS will be, but otherwise we know their dc date. Unless something major occurs/we have significant time spent with the pt (it will rarely be worth billing on time though), the best my partner thinks we can do is code for level 3’s the day after admission (when you’re conferring the most with consulting hospitalist, following up in admission labs/making sure they’re stable to stay on rehab), and then again at team conference.

On the other hand, it seems very easy to meet the level 2 requirements since all our patients have multiple stable-ish chronic conditions and we’re regularly talking with other healthcare professionals (therapy, RN, consulting internists, etc).

I think my notes may now read more like the surgeon notes I see:

S: We discussed stroke recovery. Reviewed knee pain with PT Sara.
O: Vitals/labs per chart
Breathing comfortable on room air
Extremities warm
Stable R hemiparesis
P: (probably keep this more or less the same)

That should be sufficient for level 2 billing as long as you document 3 chronic issues in A/P, whether you spent 5 min or 30 with the pt. The nice thing is we can focus on spending our time with patients and cut out the majority of documenting requirements, which we all want. But PM&R takes an unfair disproportionate hit with respect to reimbursement here.