Internal Medicine Coding Alert

Question: An established patient with benign essential hypertension reports to the internist for a checkup. Based on the checkup, the internist decides that the patient needs nursing facility care. Later that day, the internist goes to the nursing facility to oversee the patient's admission. Can I report a code for each visit?

Nevada Subscriber

Answer: You can only report one code in this scenario. This information is from the introductory section of "Initial Nursing Facility Care" in CPT 2008:

"When the patient is admitted to the nursing facility in the course of an encounter in another site of service (e.g., hospital emergency department, physician's office), all evaluation and management services provided by that physician in conjunction with that admission are considered part of the initial nursing facility care when performed on the same date as the admission or readmission."

In a nutshell: All E/M services provided on the same day as an NF admission are considered part of the initial nursing facility care, so you won't be able to report 99211-99215 for the office visit. But be sure to report the NF code based on level of service.

So if your internist's notes indicate a level-two NF service, report 99305 (Initial nursing facility care, per day, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision-making of moderate complexity).

Also, append 401.1 (Essential hypertension; benign) to 99305 to represent the patient's hypertension.