Neurology & Pain Management Coding Alert

The first point to remember when choosing a comprehensive nursing facility assessment code is that, unlike many other E/M services, these codes do not differentiate between "new" and "established" patients. Whether the physician has attended to the same patient within the last three years makes no difference. The assumption is that the physician must perform the same high-level evaluation regardless of how well he or she knows the patient. This is in contrast to office visits, for example, when codes for an established patient at a given level are valued less than those for a new patient at the same level (for example, 99213 has been assigned fewer relative value units than 99203) because CMS assumes that evaluation of an established patient is less intensive due to the physician's familiarity with the patient.

Comprehensive assessment codes encompass very specific components. For instance, when you assign 99301-99303, the chart must include a completed resident assessment instrument (RAI), which is a comprehensive, standardized tool that allows the physician to measure the resident's functional capacity. The RAI should include a "minimum data set," or MDS, which should touch on the patient's medical conditions, history and status; mental and physical functional status; sensory and physical impairment; nutritional status; mental and psychosocial status; cognitive status; special treatments and protocols; discharge, activities and rehab potential; and drug therapy, among other components, says Dennis Stone, MD, MBA, CMD, chief medical officer of HealthEssentials in Louisville, Ky., and a past president of the American Medical Directors Association.

Assuming that the physician meets the basic documentation criteria, you should choose among 99301-99303 according to the reason for the evaluation. Code 99301 is for the annual assessment to determine whether the patient's plan-of-care needs must be altered, as well as to provide a comparison to the previous year's status. This assumes that the patient has undergone at least one previous assessment to determine the initial plan of care.

For example, a 52-year-old female patient with multiple sclerosis (340) has been a resident of a nursing facility for three years. During the previous year, the neurologist saw the patient for a problem-oriented (sick) visit (99311-99313) and routine preventive care (99396), and to oversee the patient's therapy plan. At the end of the year, the neurologist conducts an annual comprehensive assessment, which he or she should report using 99301.

Code 99302, in contrast, is correct if the patient has developed a significant complication or new problem resulting in a permanent change in status and therefore requires a new plan of care. For instance, if a patient undergoes an initial assessment but suffers a debilitating fall several months prior to the annual assessment, a new assessment is in order because the patient's condition and the plan of care required has changed significantly.

Finally, 99303 describes a patient's initial assessment at the time of admission (or readmission) to the nursing facility. For example, a 70-year-old female resident has had two strokes that required hospitalization. Because of the severity of the patient's condition and the complexity of the medical decision-making on readmission, the physician should report 99303.

Comprehensive assessments include services related to the patient's care that may have occurred at other sites on the same date. For instance, the physician may have seen the patient in another setting, such as the office or hospital  emergency department (ED), and decides to admit/readmit the patient to a nursing facility at that time. All of the E/M services provided in the office or ED on the same date of service should be included in the comprehensive assessment. The medical record for the assessment should refer to the previous E/M services. Documentation could state, for instance, "Please refer to the review of systems and medical history dictated earlier today."

But hospital discharge or observation discharge services performed on the same date as the nursing facility assessment are separately reportable. "Many coders don't realize it, but it's right there in black and white in CPT that you can charge both a hospital discharge and a nursing-home admission on the same day," says Kathy Pride, CPC, CCS-P, HIM applications specialist with San Rafael, Calif.-based QuadraMed. Just be sure to append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the nursing facility assessment code to indicate that it was separate from the discharge service.

Codes 99311-99313 describe subsequent nursing facility care, which is distinct from the assessments described by 99301-99303 (although, like 99301-99303, 99311-99313 do not differentiate between "new" and "established" patients). Rather, subsequent care codes usually describe visits for isolated illness such as a persistent cough, pain, weight loss, etc., and do not involve the level of examination required of a comprehensive assessment. (Think of the subsequent care codes as a "sick visit" in the nursing facility.)