Internal Medicine Coding Alert

Internists often provide care to elderly patients admitted to long-term care (LTC) facilities (also known as skilled nursing facilities) and to patients living in rest homes or boarding facilities that do not provide nursing care. Coders must understand the specific type of establishment to assign the correct codes for these visits.

Internal medicine coders should know how to choose the appropriate code for nursing facility services (99301-99303, comprehensive nursing facility assessments; 99311-99313, subsequent nursing facility care; and 99315-99316, nursing facility discharge services). Also, coders must understand the distinction between nursing facility services and similar services provided to patients in a nonmedical domiciliary, rest home or custodial care facility; these services are reported with separate codes (99321-99323, domiciliary, rest home or custodial care services, new patient; 99331-99333, established patient).

For services provided to patients in a licensed nursing facility, the coder must determine whether the physician performed the required annual nursing home assessment or was at the facility because the patient had a specific medical problem, says Kathy Pride, CPC, coding supervisor for Martin Memorial Medical Group in Port St. Lucie, Fla.

Comprehensive Assessments99301-99303

According to CPT, skilled nursing facilities that provide convalescent, rehabilitative or long-term care are required to conduct annual assessments of each residents functional capacity and condition, says Pride. The annual assessment involves the use of a specific clinical protocol known as the Resident Assessment Instrument (RAI). All RAIs include the Minimum Data Set (MDS), Resident Assessment Protocols (RAPs) and utilization guidelines, according to CPT guidelines.

If the physician performs this annual assessment, codes 99301-99303 should be used regardless of whether the patient is a new or established patient at the nursing facility.

Mainly, we use code 99301 for the annual nursing facility assessment, she explains. Every year, the patient has to be, essentially, recertified for nursing care. They have this assessment once every year, and specific paperwork must be filled out, the RAI, MDS, etc.

If a nursing facility patient develops a new problem that requires the assessment to be performed all over again, Pride uses code 99302. Code 99301 is for the basic assessment (that requires decision-making that is straightforward or of low complexity). We use 99302 when the patient has a new problem or needs a new treatment plan (requiring decision-making of moderate to high complexity), she say. This requires the same paperwork to be done over again even though it might not be time for the annual assessment visit.

Code 99303, the highest level of the comprehensive assessment codes and decision-making of moderate to high complexity, should be used when the patient is admitted initially to the nursing facility or readmitted after a stay in the hospital or other site of care.

Since the levels of examination and history are essentially the same (for all three codes), the medical decision-making is the main thing you are looking at with these visits, she says.

Subsequent Care99311-99313

Codes 99311-99313 are used for visits to nursing facility patients to treat a specific problem that does not involve a major, permanent change of status or for the physicians monthly visits to the patient (which are in addition to the annual assessment visits), say both Pride and Doris White, front desk supervisor for Senior Health Center in Atlanta. These codes are used for new patients and established patients, says White. They are for the physicians management of the patient during their stay.

Pride says code 99311 (subsequent nursing facility care, per day, for the evaluation and management of a new or established patient, which requires at least two of these three key components: a problem-focused interval history; a problem-focused examination; medical decision-making that is straightforward or of low complexity) is typically used for the physicians regular monthly visit to the patient. It is usually the protocol at the nursing home that the patient must be seen by a physician once a month, she explains. Codes 99312 ( ... an expanded problem-focused interval history; an expanded problem-focused examination; medical decision-making of moderate complexity) and 99313 (... a detailed interval history; a detailed examination; medical decision-making of moderate to high complexity) are used if the physician goes to check on the patient for a specific problem. For example, the patient fell out of bed and the doctor wants to check and make sure they are OK. Or the patient has a fever, and the physician goes over to examine the patient, maybe prescribing antibiotics or other medication.

All of the codes have specific documentation guidelines outlined in CPT that must be met for the level of service reported, she adds.

Nursing Facility Discharge Services99315-99316

Codes 99315 and 99316 are for discharge services and are based on the time the physician spends with the patient, says White. Code 99315 is for 30 minutes or less, and code 99316 is for time more than 30 minutes.

According to CPT, these codes are to be used to report the total duration of time spent by a physician for the final nursing facility discharge of a patient. The codes include the final examination of the patient, discussion of the nursing facility stay, even if the time spent on that day is not continuous.

The physician may need to spend time with the patients family or other care providers to give instructions on specific continuing care requirements, when and how to administer medications, etc.

Codes for Rest Home, Custodial Care

Coders must make sure they know whether the physicians service is provided to a patient in a nursing facility, or to a patient in a domiciliary or rest home that lacks a medical component.

Different codes are used to report services to patients in a facility other than a skilled nursing facility (99321-99323, new patient; 99331-99333, established patient). It is not always easy to tell, advises Pride. Some facilities even have different wings, with one wing being a nursing facility, and another wing custodial care or domiciliary.

When in doubt, Pride recommends calling the facility to ask how they are licensed to be certain of the type of facility and assign the appropriate coding.

"I usually make a call when we have a new one open and our doctors start going over there.