Internal Medicine Coding Alert

You'll need solid counseling/care coordination notes for new nursing facility codes

You'll finally be able to use time as the key element when coding counseling-dominated nursing facility encounters. CPT previously did not include time guidelines for coders to observe. The codes were listed based on the severity of the problem(s) or the patient's status.

In 2008: Each nursing facility care entry includes a typical timeframe for that level of visit.

The new definition of 99304 reads "Initial nursing facility care, per day, for the evaluation and management of a patient, which requires these three key components: a detailed or comprehensive history; a detailed or comprehensive examination; and medical decision-making that is straightforward or of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of low severity. Physicians typically spend 25 minutes with the patient and/or family or caregiver."

The last sentence of the definition, which provides a timeframe for 99304, was not part of the descriptor last year. "This change is a help to coders," says Quinten Buechner, ACS-FP/GI/PEDS, CPC, CCP, CMSCS, president of ProActive Consultants in Cumberland, Wis.

Benefit: The rewritten descriptors will make the prolonged services codes easier to report. However, "the trick is getting the physicians to document the time spent in counseling and coordination of care," Buechner says.

The other revised codes in the nursing facility section of CPT 2008 are:

• 99305 -- ... a comprehensive history; a comprehensive examination; and medical decision-making of moderate complexity. Usually, the problem(s) requiring admission are of moderate severity. Physicians typically spend 35 minutes with the patient and/or family or caregiver

• 99306 -- ... a comprehensive history; a compre-hensive examination; and medical decision-making of high complexity. Usually, the problem(s) requiring admission are of high severity. Physicians typically spend 45 minutes with the patient and/or family or caregiver

• 99307 -- Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: a problem-focused interval history; a problem-focused examination; straightforward medical decision-making. Counseling and/or coordi- nation of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is stable, recovering, or improving. Physicians typically spend 10 minutes with the patient and/or family or caregiver

• 99308 -- ... an expanded problem-focused interval history; an expanded problem-focused examination; medical decision-making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Physicians typically spend 15 minutes with the patient and/or family or caregiver

• 99309 -- ... a detailed interval history; a detailed examination; medical decision-making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient has developed a significant complication or a significant new problem. Physicians typically spend 25 minutes with the patient and/or family or caregiver

• 99310 -- ... a comprehensive interval history; a comprehensive examination; medical decision- making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. The patient may be unstable or may have developed a significant new problem requiring immediate physician attention. Physicians typically spend 35 minutes with the patient and/or family or caregiver

• 99318 -- Evaluation and management of a patient involving an annual nursing facility assessment, which requires these three key components: a detailed interval history; a comprehensive examination; and medical decision-making that is of low to moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is stable, recovering, or improving. Physicians typically spend 30 minutes with the patient and/or family or caregiver.

"Time descriptions are a tremendous help in CPT coding," says Denae Merrill, CPC, coder for Covenant MSO in Saginaw, Mich., and secretary of the MBS chapter of the American Academy of Professional Coders (AAPC). The new descriptors will allow providers to possibly code higher when it is medically necessary to spend significant time counseling and/or coordinating the patient's care, Merrill says.

The biggest potential benefit of these rewrites will come when your internist conducts longer visits to the nursing facility, "where the provider deals with family or the patient for counseling and coordination of care," Buechner says.

Consider this example from Merrill: The internist visits a nursing facility patient who requires oxygen and has end-stage chronic obstructive pulmonary disease (COPD) with a consistently low pulse oximetry reading. The physician sees the patient along with family members to discuss next steps and possible treatments. This counseling, and the subsequent coordination of the patient's care, takes 35 minutes of the provider's time, which was also the total duration of the visit.

Using the new nursing facility codes, you would report this encounter with 99310. Don't forget to attach 496 (Chronic airway obstruction, not elsewhere classified) to 99310 to represent the patient's COPD.

When you're filing this claim, Buechner recommends you document:

• total visit time,

• a summary of topics discussed, and

• a description indicating that more than half of the total visit time involved counseling and coordination.

Remember: In order for you to bill these visits based on counseling and coordination of care time, the patient must be present during the visit, Pride says.