Internal Medicine Coding Alert

Get credit for comprehensive care without assessment using 99310

New 2006 nursing facility coding mirrors coding for inpatient services--and it allows you to capture care for highly complex patients.

The current (2005) nursing facility (NF) services coding structure is atypical. "To choose the right series of codes, you have to determine whether the physician treated the patient for a substantial change or basic illness," says Maria M. Torres, CPC, CMM, a coding consultant with Bermudez Medical Consulting in Tampa, Fla.

In 2006, you will no longer have to make a distinction between comprehensive NF assessments (99301-99303) and subsequent NF care (99311-99313). CPT 2006 deletes these code families and replaces them with:

• three new codes for the initial assessment (99304-99306)
• four new codes for the subsequent visits (99307-99310)
• a new code for the annual nursing facility assessment (99318).

Note: CPT did not change the discharge codes (99315-99316, Nursing facility discharge day management ...).

Use HEM to Code Initial Assessment

The nursing facility assessment code changes will make coding initial nursing facility care easier. "The current structure of the NF Services section of CPT is atypical and has been a source of confusion since its creation in 1992," states the American Medical Directors' Association (AMDA) in its CPT Coding Change Request.

Old way: When an NF patient undergoes a substantial change that requires the internist to issue a new treatment plan, you have to choose between three types of comprehensive nursing facility assessments, Torres says. Here is the 2005 breakdown:

• annual assessment--99301 (Evaluation and management of a new or established patient involving an annual nursing facility assessment ...)

• assessment involving a major permanent change of status--99302 (Evaluation and management of a new or established patient involving a nursing facility assessment ...)

• assessment at the time of facility (re)admission--99303 (Evaluation and management of a new or established patient involving a nursing facility assessment at the time of initial admission or readmission to the facility ...).

New method: Instead of determining the type of assessment, you'll choose 99301-99303's replacement codes based on the initial NF care's key components of history, examination and medical decision-making (MDM)--or HEM. The new assessment codes describe three levels of initial nursing facility services that are consistent with the initial hospital care codes' structure, according to the AMDA.

Assigning the new codes based on the same criteria for new hospital patient codes should alleviate payment problems. "We had a difficult time getting physicians and payers to understand that each of the assessment codes represented a specific nursing facility service process," says Dennis Stone, MD, MBA, CMD, who led the AMDA nursing facility codes revision efforts.

99304-99306's bottom line: NF codes 99304-99306 describe "Initial nursing facility care, per day, for the evaluation and management of a patient which requires these three key components": 

          History                     Exam                        MDM
99304 Detailed/comp           Detailed/comp             Straightfwd/low
99305 Comp                       Comp                         Moderate
99306 Comp                       Comp                         High

Capture Acutely Ill, Transferred Cases With 99310

CPT 2006's new codes for subsequent nursing facility care will allow you to indicate a more extensive E/M service than previously possible. Now, the "Subsequent Nursing Facility Care" subsection of CPT contains only three levels of service for established patients.

Problem: These codes restricted you to a detailed interval history and a detailed examination. When a nursing facility patient requires comprehensive subsequent care without a new assessment, the old codes don't accurately describe the situation "This sometimes leads to misuse of 99301-99303," says Peter A. Hollmann, MD, the AMA's CPT 2006 Coding and RBRVS Symposia's speaker on the nursing facility code changes.

Solution: CPT 2006 creates a new fourth level of service code (99310) for reporting a comprehensive level of service. Hollmann doesn't expect "99310 to be a high-volume code, but it will allow physicians to code a broader range of services," including the often miscoded scenarios included in the chart above:

Example 1: An internist performs a comprehensive history, comprehensive exam and high MDM for a nursing facility patient who has developed pneumonia and dehydration. "Although the acute illness represents a very significant change in the patient's condition because it isn't permanent in nature, 99302 is inappropriate," says  Hollmann, who is a practicing internist and senior medical director for BlueCross/BlueShield of Rhode Island. You should report 99310 for this service in 2006.

Example 2: An NF patient's family is unhappy with a previous physician and asks an internist to assume the individual's care. At the initial patient encounter, the internist performs a comprehensive history, comprehensive exam and moderate MDM.

"Because the care does not involve an admission or readmission, 99301 doesn't describe the situation," Hollmann says. In 2006, 99310 will represent this service. "Although the medical decision-making is moderate, the scenario contains two of the three key components that the level requires," he says.

99307-99310's nutshell: The old code descriptors for  subsequent nursing facility care (99311-99313) have basically been carried over to the new codes (99307-99310), which state "Subsequent nursing facility care, per day, for the evaluation and management of a patient ..." The new codes refer to E/M "of a patient," rather than "of a new or established patient." The service levels require two of these three key components:

Assign 99318 as New Annual Assessment Code

Starting Jan. 1, you'll look to a new subsection ("Other Nursing Facility Services") to code a comprehensive annual assessment. "This is a service that is unique to the NF setting," the AMDA states. The other E/M codes in this section do not accurately describe the extent of history and examination and the complexity of medical decision-making that an annual assessment involves.

99301/99318 action: When an internist performs an annual assessment, you should report 99318 (Evaluation and management of a patient involving an annual nursing facility assessment) instead of 99301. "New code 99318 is virtually identical to 99301 with slightly higher medical decision-making," says Stone, who is also chief medical officer for HomeQuality Management, a nursing facility company, in Louisville, Ky. The MDM requirement changes from "straightforward/low" to "low to moderate."

Delay Time-Based Coding for Now

CPT 2006 does not assign typical times to any of the nursing facility codes. "CMS' RBRVS panel and a physician payment survey could not agree on the average times some of the new levels would entail," Hollmann says. So they chose to leave this field blank.

The codes will eventually have time allotments--perhaps for CPT 2008, Hollmann says. "Until then, you will not be able to code prolonged services or use time as the key element when counseling and/or coordination of care dominates the encounter."

Codes 99304-99306 also eliminate the caveat that the physician must create "a new medical plan of care."