Neurology & Pain Management Coding Alert

Question: An 86-year-old established patient with worsening dementia due to early-onset Alzheimer’s disease reported to the physician for a medication checkup. During the office visit, the physician decided that the patient needed immediate nursing facility care to deal with his dementia, which was marked with several behavioral disturbances. Notes indicate that the physician performed an office E/M service before admitting the patient to the nursing facility on the same day. Can I report an office E/M code in addition to the nursing facility admission code?

California Subscriber

Answer: You cannot report an office E/M code on the same date of service as you report an initial nursing facility admission.

Per CPT^®, “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, 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.” (Italics added for emphasis.) That said, the documentation for both services can be used to support the initial nursing facility service. The codes also provide a clue as they indicate a “per day” charge.

Alternative: Roll the office E/M into the overall work units for the entire encounter. Your best bet is to consider the encounter one big E/M service, starting when the patient reported to the practice and ending when the physician completed the nursing facility admit. Then, choose one of the following codes for the entire encounter:

• 99304, Initial nursing facility care, per day, for the evaluation and management of a patient, which requires these 3 key components: a detailed or comprehensive history; a detailed or compre­hensive examination; and medical decision making that is straightforward or of low complexity …
• 99305, … a comprehensive history; a compre­hensive examination; and medical decision making of moderate complexity …
• 99306, … a comprehensive history; a compre­hensive examination; and medical decision making of high complexity …

ICD-10 alert: You’ll need to report a pair of ICD-10 codes for this encounter: F02.81 (Dementia in other diseases classified elsewhere with behavioral disturbance) to represent the patient’s dementia and G30.0 (Alzheimer’s disease with early onset) to represent the patient’s Alzheimer’s. List the acute issue first and then the underlying conditions after that on the claim. In this patient, the behavioral disturbances were what prompted the decision; thus, you should code those symptoms first.