Neurology & Pain Management Coding Alert

Gaining correct reimbursement for nursing facility assessments (NFAs) (99301, 99302 and 99303) can be challenging. The coding rules that govern other E/M codes often do not apply to these institutions. These codes have high relative work values (RVUs), so correct coding
is vital.

Assessments Affect Total Reimbursement Outlook

Even more significant than the reimbursement amount for the assessments RVUs, is the fact that these codes affect a patients total care allowance for the year, says Laureen Jandroep, OTR, CPC, CCS-P, owner of A+ Medical Management and Education, a coding and reimbursement consulting firm and a national CPC training curriculum site in Egg Harbor City, N.J. With the prospective payment system (PPS) in the long-term care arena, the nursing facility assessment strongly affects reimbursement. It determines what needs the patient has, and how sick they are. During this, the neurologist determines whether the patient requires additional assistance or care, and those factors go into the calculation of the minimum data set (MDS) rate, which in turn determines the prospective reimbursement. In other words, the choice of an NFA code has significant impact not only on reimbursement, but also the level of care the patient will receive.

Coding for Nursing Facility Assessments

Follow these three rules when assigning NFA codes:

1. New and Established Patients. There is no distinction between new and established patients with assessment codes, says Mary Falbo, MBA, CPC, president of Millennium Healthcare Consulting Inc., a national healthcare consulting firm focusing on neurologist compliance, coding, billing and reimbursement, based in Lansdale, Pa. This often trips up coders. They want to apply the same rules they use with consultations or outpatient visits one series of codes for new patients and another for established. This rule of thumb doesnt apply with nursing facility assessments.

Most states, which are charged with licensing nursing facilities, require assessments at least once a year (99301). If the patient who has already had their annual assessment experiences a significant change in status requiring another assessment, 99302 should be billed. If a patient who has already had an annual assessment and then left the nursing facility but was readmitted before that one year period was up (eg, for hospitalization for a hip fracture) a new comprehensive assessment would be warranted (99303).

2. Change in Patient Status Equals Reassessment. To ensure quality care in long-term nursing facilities, it is vital for the neurologist to periodically evaluate the many factors that will have an impact on the patients well-being, says Falbo. As a result, the physician may perform a comprehensive NFA whenever it is necessary to enhance or maintain the patients physical and psychosocial functioning. Most carriers do not have a limitation on the number of times per year an NFA may be billed. However, this service must be performed when the patient experi-ences a change of status, either positive or negative. This alteration must also be documented in the record in the event of an audit or inquiry from a carrier.

3. Comprehensive assessments. There are times when a neurologist will have seen a patient in another setting and decide to admit or readmit to a nursing facility. All of the E/M services provided in these other situations (eg, neurologists office, hospital emergency department) on the same date of service would be included in the comprehensive assessment code and would contribute to the level of service reported, Falbo states.

The medical record for the assessment should refer to the previous E/M services, and confirm that they were performed on the same date as the admission or readmission, she states.

Hospital or observation discharge services performed on the same date as the assessment, however, may be reported separately. For example, if a patient is discharged from inpatient status on the same date of an admission or readmission, the discharge services should be reported with 99238-99239. If a patient was discharged from observation status on the same date of admission or readmission, the observation discharge should be reported with 99217. For a patient admitted and discharged from observation or inpatient status on the same date, use codes 99234-99236.

Determining the Level of Service

Because of the nature of care provided by nursing facilities, residents will undoubtedly have serious health conditions. The neurologist works with other caregivers, such as dietitians, physical, occupational and speech therapists and psychologists, to create a full picture of the patients condition so his or her plan of care can be written for the following year.

Whenever assigning 99301, 99302 or 99303, the neurologist must include the completion of a resident assessment instrument (RAI) in the chart, Falbo explains. An RAI is a comprehensive, standardized tool that allows the neurologist to measure each residents functional capacity. It will include an MDS that typically contains components such as the patients medical conditions, history and status; mental and physical functional status; sensory and physical impairment; nutritional information; mental and psychosocial condition; cognitive status; special treatments and protocols; discharge, activities and rehab potential; and drug therapy.

Jandroep offers the following examples:

Code 99301: This is for the annual assessment requirement, says Jandroep, when the patient must be assessed on all levels to determine whether their plan of care needs to be changed and to provide a comparison to the previous years status. For instance, a 52-year-old female patient suffering from multiple sclerosis has been a resident of a nursing facility for three years. During the previous year, the patients neurologist has periodically seen her for sick visits and routine preventive care, and to oversee the therapy plan. At the end of the year, the physician conducts an annual comprehensive assessment, utilizing the RAI and MDS. Services would typically be assigned the lowest code level, 99301.

Code 99302: When the patient has developed a significant complication or new problem and their status has permanently changed, says Jandroep, Level two is appropriate. For example, a 66-year-old male quadriplegic (344.00) patient suffers from a transient ischemic attack (TIA - 435.9) and exhibits a significant change in mental status. The neurologist might say, we need a complete assessment of this patient again, even though his annual wont be performed for another three months. These events trigger a new MDS, and the conditions involve medical decision-making of moderate complexity. Services would typically be assigned with 99302.

Code 99303: This third-level code is used for initial admission assessments, or for readmission, says Jandroep. It is generally the most comprehensive, because the patient normally hasnt been seen before, or seen with the same problems.

For instance, a 70-year old female resident has had two strokes (436) requiring hospitalization. Because of the severity of the condition and the complexity of the medical decision-making on readmission, the comprehensive assessment would typically be 99303.