Internal Medicine Coding Alert

Question: One of our established Medicare patients is a resident at an assisted living facility. She has uncontrolled type II diabetes. How should we report E/M services the internist provides the patient at the facility? The only CPT codes I can find are 99339 and 99340, but these codes don't seem to match up to the service the internist provided.

Minnesota Subscriber

Answer: You should not use 99339 (Individual physician supervision of a patient [patient not present] in home, domiciliary or rest home [e.g., assisted living facility] requiring complex and multidisciplinary care  modalities ...; 15-29 minutes) or 99340 (... 30 minutes or more) for E/Ms conducted at an assisted living facility.   These codes are for care plan oversight of home care, not E/M services in assisted living facilities.

Instead, you should choose from 99334-99337 for face-to-face E/M services the internist provides to established assisted living patients, depending on the service level.

Suppose the internist travels to the assisted living facility and performs a detailed interval history, a detailed examination, and medical decision-making (MDM) of moderate complexity.

In this scenario, you would report:

 • 99336 (Domiciliary or rest home visit for the evaluation and management of an established patient,
which requires at least two of these three key components: a detailed interval history; a detailed examination; medical decision-making of moderate complexity) for the E/M

 • 250.02 (Diabetes mellitus without mention of complication; type II or unspecified type, uncontrolled) attached to 99336 to represent the patient's diabetes.

Exception: If the internist is seeing a new patient and providing an E/M service at an assisted living facility, choose from the 99324-99328 code set. Suppose the patient in the above example was a new patient. Instead of reporting 99336 for detailed history/examination and moderate MDM, you would submit:

 • 99326 (Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these three key components: a detailed history; a detailed examination; and medical decision-making of moderate complexity) for the E/M

 • 250.02 linked to 99326 to represent the patient's diabetes.