Highmark Medicare Services

12102, 12202, 12302

MAC Part A & B

L27485

Coverage of Services and Procedures in Nursing Facilities

L27485

CPT codes, descriptions and other data only are copyright 2007 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.

Title XVIII of the Social Security Act, Section 1862(a)(7).  This section excludes routine physical examinations.

Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

CMS On-line Manual Pub. 100-2, Chapter 15, Section 30.

CMS On-line Manual Pub. 100-3, Chapter 1, Section 70.3.

CMS On-line Manual Pub. 100-4, Chapter 12, Section 10.

Maryland, District of Columbia, Delaware

Central Office

For services performed on or after 07/11/2008

N/A

For services performed on or after N/A

N/A

Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.

Federal legislation has set forth requirements for skilled nursing facilities (SNFs) to participate in the Medicare program, and for nursing facilities (NFs) to participate in the Medicaid program. One requirement is that each SNF or NF resident must have an initial and a periodic comprehensive assessment, in order to institute a comprehensive care plan that meets the resident's medical (including functional), nursing, mental, and psychological needs. The care plan must be developed and revised by an inter-disciplinary team that includes at least the attending physician and a registered nurse with responsibility for the resident. The components of the care plan are then documented on the physician's order sheet, which is signed by the physician and the nurse.

The physician's order sheet is used to list the medications, diet, activities and hygienic needs of a resident of a SNF or NF. However, it has also been used to list various provider specialties which may render services and procedures for the resident, and various screening services which may be routinely performed on the resident. Provider specialties have often included audiology, optometry, podiatry, psychology, psychiatry, physical therapy and occupational therapy. Routine screening services have often included laboratory tests, electrocardiograms and portable chest x-rays. These so-called "p.r.n." or "standing" orders for care by other provider specialties and provision of routine screening services have resulted in considerable over utilization, and so are being addressed by this policy.

Indications

This policy applies to a "p.r.n." or "standing" order for any provider specialty or for any routine screening service (except as otherwise specified in manual instructions, e.g., MCM 2049.4 permits a standing order for pneumococcal pneumonia vaccinations) whether the order is written on the physician's order sheet integral to the patient's comprehensive care plan, or elsewhere in the patient's medical record.

This contractor will not cover any service or procedure that is performed on a patient of a SNF or NF, unless:

• The patient's attending physician evaluates the patient in person or evaluates the signs and symptoms described via telephone by the SNF/NF nursing staff and authorizes the order for the service, procedure, or for the referral of the patient to another provider specialty.
  
  
• A named physician, whose attendance is requested only by the patient or the patient's interested family member or legal guardian, evaluates the patient and authorizes the order for the service or procedure. The attending physician must be notified of any change in the patient's physical, mental or psychosocial status, or of the need to alter the patient's treatment significantly.

Orders for continuing laboratory studies must be frequently updated. The medical record must reflect that the attending physician has evaluated the results of any laboratory study previously ordered. Orders for continuing lab work must have a reasonable cutoff time frame and be re-ordered as necessary. Any laboratory study ordered on a continuing basis without a cutoff time frame and without documentation in the medical record supporting that the results of any previously ordered study were evaluated, will be considered a standing order and therefore, not reimbursable. Examples of acceptable time frames are as follows: daily for 4 days, weekly for 4 weeks, monthly for 3 months.

It should be noted that this policy does not prohibit a nursing home's Medical Director from authorizing services or procedures in emergency situations in a manner consistent with the Medical Director's obligations under state or federal law. In such instances, however, there must be documentation as to why the circumstances warrant intervention into the attending physician's role of caring for the patient.

Limitations

Services or procedures rendered in a nursing facility are not eligible in the following situations:

• A service or procedure is not clearly documented in a patient's medical record with respect both to its medical necessity and nature.
  
  
• A patient's attending physician does not evaluate the patient and authorize the order for a service, procedure, or for a referral of a patient to another provider specialty.
  
  
• Another physician, whose attendance is requested by a patient or a patient's interested family member or legal guardian, does not evaluate the patient and authorize the order for the service or procedure.
  
  
• A "p.r.n." or "standing order" is written for any provider specialty or for any routine screening service, either on the physician's order sheet or integral to the patient's comprehensive care plan, or elsewhere in the patient's medical record.
  
  
• Any laboratory study ordered on a continuing basis without a cutoff time frame and/or without documentation in the medical record supporting that the results of any previously ordered study were evaluated.

Nursing Home Care, Skilled Nursing Facility Care

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

N/A

Conditions that are not listed in the "ICD-9-CM Codes that Support Medical Necessity" section of this policy.

1. All documentation must be maintained in the patient’s medical record and available to the contractor upon request.
   
   
2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service(s)).  The record must include the physician or non-physician practitioner responsible for and providing the care of the patient.
   
   
3. The submitted medical record should support the use of the selected ICD-9-CM code(s).  The submitted CPT/HCPCS code should describe the service performed.
    
4. The medical necessity for, and nature of, each service or procedure must be clearly documented. Authorization of the order for the service or procedure or for referral of the patient to another provider specialty must be clearly recorded in the patient's medical record.
   
   
5. In those situations where an attending physician requests the services of another physician and where multiple visits by this physician are required to adequately treat an injury/illness, the medical record should indicate that the patient's attending physician is aware of such ongoing care, and that he/she agrees that the care is medically necessary.
   
   
6. Services of a physician that are requested by the patient and/or family member must be documented in the patient's medical record that they were rendered at the patient's or family members' request.
   
   
7. The medical record documentation must support the necessity of any laboratory study ordered on a continuing basis.

In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.

Other Contractor's Policies

Highmark Medicare Services Contractor Medical Directors

This policy does not reflect the sole opinion of the contractor or Contractor Medical Directors. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from the appropriate specialty (ies).

CAC/IAC Distribution:  04/01/2008

05/15/2008

05/23/2008

L27485

05/22/2008

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