Documentation and Coding

Abstract

The provision of care to residents in long-term care facilities entails different requirements in documentation and coding for physician and non-physician services than those used in the clinic and hospital setting. Both the documentation of care provided and the determination of the correct billing code are essential to ensure appropriate reimbursement for the level of services rendered. While CMS has issued documentation guidelines for the evaluation and management (E/M) services, the AMA is responsible for both the establishment and updating of the Current Procedural Terminology (CPT) codes. AMDA-The Society for Post-Acute and Long-Term Care Medicine, has issued a Guide to Post-Acute and Long Term Care Coding, Reimbursement and Documentation based upon the AMA’s CPT guidelines. It summarizes the documentation requirements and provides coding vignettes for several facility visit codes, in addition to those related to chronic care management, advance care planning and behavioral health integrated services.