EM Coding Alert

Question: My physician performed an annual E/M for her NF patient. She reviews the patient’s history and examines him to see that he gained some of his strength back and that the previous respiratory issue is resolved. She reviewed the medical records and any test results and determined them to be of minimum complexity and that there’s minimum to no risk of complications. She documents a detailed level of history, a comprehensive exam, and straightforward decision making with no new diagnosis. From the notes I coded the E/M with 99318. Did I code this correctly?

Idaho Subscriber

Answer: No, you cannot report 99318 (Evaluation and management of a patient involving an annual nursing facility assessment, which requires these 3 key components: a detailed interval history; a comprehensive examination; and medical decision making that is of low to moderate complexity…) for this encounter. 

Here’s why: Reporting 99318 requires a detailed interval history (from last year through today), a comprehensive examination, and low to moderate decision-making complexity. You indicate that there was straightforward decision-making in the note you reviewed so this would not be an appropriate code. The physician’s documentation does not support the requirements of the code. 

The documentation only supports a subsequent nursing home visit (99307-99310, Subsequent nursing facility care, …). The proper code for this situation would be 99309 (Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: a detailed interval history; a detailed examination; medical decision making of moderate complexity…).