As we have all experienced, our patients are getting discharged from the hospital “quicker and sicker.” While a typical rounding SNF doctor will have a mix of patients more and more are coming from the hospital with significant acuity and suffer from multiple co-morbidities. They may be recovering from CHF or COPD exacerbations, and their condition can turn on a dime. Such patients need to be seen sooner upon admission, ideally within 24-48 hrs, and require much closer monitoring.
The question which many doctors have in the back of their minds for such patients is this: How often am I allowed to see my patients and bill? Will I get in trouble for seeing them too frequently?
The short answer to this is:
You may see your patient as often as medically necessary. While this may sound like a non-answer, what this means is that if you are able to document a medical need, then you can see and bill for patients weekly, several times a week, or occasionally more often than that during a particular timeframe. Obviously you’ll need to provide justification for this in your progress note, and the level of severity of the visit will reflect the acuity and complexity of the case along with the completeness, breadth, and depth of your interim history questions and physical exam. CMS clarifies below:
Medicare will pay for E/M visits, prior to and after the initial physician visit, that are reasonable and medically necessary to meet the medical needs of the individual resident (unrelated to any state requirement or administrative purpose), but will not pay for additional visits that may be required by state law for an admission or for other additional visits to satisfy facility or other administrative purpose.
It’s true that reviewers and surveyors don’t want to have doctors who appear to be seeing patients daily without reason. Also, if one bills for more visits than seem reasonable for one human to perform in a day, one may have charts reviewed. CMS calls these “gang visits.”
“Gang visits” (claims for an unreasonable number of daily E/M visits by the same physician to multiple residents at a facility within a 24-hour period) may result in medical review to determine medical necessity for the visits.
When examining charts for medical necessity, billing accuracy, and physician involvement, surveyors and reviewers will look skeptically when a note appears to be “cut and pasted” from the previous visit, where there is little variation from the previous several notes, and where there are no changes in condition or course of therapy.
Nevertheless, the presence of notes which have details in proportion to the billing code used, and which clearly state the reason for the visit are viewed favorably in terms of patient care. The CHF patient on a multitude of medications with renal insufficiency whose fluid control must be delicately managed may warrant very close monitoring, even some consecutive daily visits (though perhaps not all high-acuity coding) if that makes the difference between getting through this difficult period and having a readmission for a worsened condition. As the patient improves, appropriately tapering the visits to weekly would then happen.
A diabetic patient with pneumonia being treated with IV antibiotics and steroids may require weekly visits to follow a rapidly changing condition.
The days of seeing every patient upon admission and then only every 30 days are becoming a thing of the past. I’m not saying that every patient needs to be seen weekly. What I am saying is that we need to reframe what we do relative to patient need. Ultimately, that is what this is all about. The vast majority of patients and their families will appreciate more frequent visits as well.
CMS, MLN Matters, MM4246, Jan 16, 2006, p.2
 ibid, p. 3.