Re: : Nursing Home vs Office Codes RVU's --> better pay seeing them in the nursing home?

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"The deal" actually varies from state to state. 1. Assisted Living regulations vary widely from state to state. 2. Medicaid reimbursement (which is most nursing home patients) varies widely from state to state. So, what works in one state might not apply to another. In Wyoming, Medicaid reimburses same as Medicare (or so I've heard). In California, it is about half. So in Wyoming, nursing home care can be financially rewarding for someone with an office overhead, whereas in California, it usually is not. Similarly, I have assisted living patients where nothing goes through the facility- it only goes through the family- similar to a home visit. Unlike Medicare, I think it is hard to generalize economic advice about nursing home care across state lines. Padma wrote: OK, here is the deal:Nursing homes and Assisted Living Facilities (Domiciliary) are 2 totally different settings. You have use the matching POS and 99xxx codes.First let me tell you my experience with Assisted Living Facilities---pays much higher--for the equivalent of 99214, office visit pays $86, and Assisted Living codes( 99336) pay $107. But not worth it, believe me. I worked at 2, when I first started practice, and quickly built up to 40-50 patients. It was a

NIGHTMARE. Way worse compared to NHs. That is because, the nurses are not allowed to take verbal/phone orders. Every single order has to be manually signed, even stupid things like: say you raise the dose of Colace from 100 to 200mg, you have to send an actual Rx for the 200mg, then another signed Rx: "D/C Colace 100mg dose". Even Aspirins and Multivitamins need Rxs. For antibiotics etc limited day Rxs, they would pester me to rewrite the Rx stating: "....for 10 days, then stop". They do not measure fingersticks or check BP. There is generally 1 nurse who is so bogged down with paperwork that she had no knowledge about the patients. I could not use my handy e-fax, because they needed manual signatures. I felt totally harassed, quit both, and increased the NH load. Phew!Now NH: (codes 99304-99310, and D/C code are separate): for a monthly medication review and renewal, 99309--equivalent of 99214--pays about what

your excel file states, probably a little less in our area, I have to look it up. But each visit goes so fast once you get to know the patient. We have been given a form to address the key issues the State is looking for. I fill in the various fields by hand (they did not want me using my computer, and the form actually saves me a lot of time). I review labs, consults, examine the patient, and do the note in 15 min or less per patient. The nurses do all the work, no scripts need to be written--just in the order section. Then there are a lot of really quick visits--rashes, conjunctivitis, not eating well, behavior issues, UTIs etc, that you can bill for, as you are required to write a note anyway. So if I spend about 3-4 hr, I can do an admit, 6-7 renewals, and 3-4 problem visits ( 99307/8), sign off on consults and labs. No phone calls for refills from patients, no keeping track of whether the patient went for

their mammogram or Ophthal appt. Psychiatrists round there as well, saving me a lot of time typically needed to manage depression/anxiety. Dietitians counsel the patients, aides and nurses know everything about them, and history taking is quick as well. Now I am so organized, I see all the patients, review with staff, scratch down key points, then sit down and do all the notes. --Padma>> Out of curiosity, I looked up the RVU's for office and nursing home codes.> > These are from 2006.> > Link to an Xcel file is in the pdf located here...> > http://www.acc.org/advocacy/pdfs/2006RVUsandNationalAverageMedicarePayments1> 22305.pdf> > If I'm reading this correctly, does the similar nursing home visit (time,> complexity, etc) pay better than the same type of office visit?> > Could someone who is experienced in nursing home visits please explain and> confirm the issues with coding nursing home visits when you see the patient> in the nursing home and not in the office?>

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I've been working almost exclusively in skilled nursing homes for the

last 14 years, so let me clarify a few things discussed in the last

few days:

Most skilled nursing home patients BEDS are paid for by Medicaid, but

their DOCTORS VISITS are still paid for by Medicare part B. Even

when a patient is admitted to the skilled section for rehab (Medicare

part A for rehab or IV services, after a hospitalization) they still

have their Medicare part B for DOCTORS VISITS. Many physicians avoid

nursing home patients thinking they only have Medicaid, when their

Medicare part B does NOT lapse on admission. MOST NURSING HOME

PATIENTS HAVE MEDICARE FOR US. This should not be regional or state

specific, if I am wrong and there are states taking nursing home

patients' medicare part B away when they qualify for medicaid, please

let me know, that would be terrible. Given that Medicaid is state

run, but Medicare is ultimately a federal program, I'm not certain

how that could happen. The exception, of course, would be a patient

who never qualified for medicare in the first place. That is a

minority in most nursing homes, given their average population ages.

For 2008, until July 1, when they may change the reimbursements yet

again, physicians seeing patients in SNF's are getting huge pay

raises, for some codes up to 23%! Yes, it now pays better to visit

nursing home patients than in many years, and as well as visiting

hospital patients. In addition, medicare claims they are re-

instituting the extended visit codes, which they had dropped for SNF

work, due to the high complexity and extended time spent on some

patients. These pay very well, in addition to the regular visit

codes. Take your time with the patient, document well and get paid

well.

You must understand the level of care of the facility that you are

visiting. Absolutely do not bill for office visits in the nursing

home or nursing home visits if you went to see the patient in an

assisted living. Also, independent living apartments are often

associated (built next to) assisted living, those should be billed as

house calls, which pay very well under Medicare.

Care plan oversight used to be a great payor, but at least here in

Florida, so many docs abused the privilege, that it is now under

close scrutiny. The codes still pay, but take the time to document

carefully.

All of these are great supplements to an office based practice or are

great low-overhead medicine in and of themselves.

Hope that helps.

Oh, and Dr. Locke, thanks for the article posted.

geriatric rehab doc / subacute SNF specialist

> >

> > Out of curiosity, I looked up the RVU's for office and nursing

home

> codes.

> >

> > These are from 2006.

> >

> > Link to an Xcel file is in the pdf located here...

> >

> >

>

http://www.acc.org/advocacy/pdfs/2006RVUsandNationalAverageMedicarePay

> ments1

> > 22305.pdf

> >

> > If I'm reading this correctly, does the similar nursing home

visit

> (time,

> > complexity, etc) pay better than the same type of office visit?

> >

> > Could someone who is experienced in nursing home visits please

> explain and

> > confirm the issues with coding nursing home visits when you see

the

> patient

> > in the nursing home and not in the office?

> >

>

>

>

>

>

>

> ---------------------------------

> Never miss a thing. Make Yahoo your homepage.

>