Part B Insider (Multispecialty) Coding Alert

Get ready to master a whole slew of new nursing facility and domiciliary care codes that go into effect Jan. 1

You’ll soon find yourself faced with an alien-looking CPT section--and rampant denials--if you don’t get familiar with new codes for nursing facility and domiciliary care.

Good news: New 2006 codes in the Nursing Facility Services and Domiciliary, Rest Home or Custodial Care Services sections are “much more clearly defined than the old codes,” says Kathy Pride, CPC, CCS-P, a consultant with QuadraMed in Port St. Lucie, FL. The revisions will also offer more levels of service and different criteria for selecting a level. You should be familiar with the following changes:

Change #1: Nursing Facility Services adds new subsection and new codes.

Details: CPT 2006 introduces an Initial Nursing Facility Care subsection (new codes 99304-99306) to replace the Comprehensive Nursing Facility Assessments subsection (deleted codes 99301-99303). The old codes were based on the type of nursing facility assessment the physician made, “whereas the new codes are based on the three key components: history, exam and medical decision making,” Pride says.

The descriptors for new codes 99304-99306 are “consistent with the structure of the three levels of service for admission in the Initial Hospital Care section of the CPT codebook,” states CPT Changes 2006: An Insider’s View. CPT has not yet established a time component for these new codes so that providers can have input on establishing typical times.

What this means for you: Starting Jan. 1 you’ll need to report nursing facility and skilled nursing facility (SNF) admissions by evaluating the physician’s documentation of the history, exam and medical decision-making (as you would any other E/M service) and choosing the appropriate level of service from 99304-99306.

Change #2: Subsequent Nursing Facility Care subsection gets new codes and level of service.

Details: CPT 2006 deletes codes 99311-99313 and replaces them with 99307-99310 for subsequent nursing facility care. These new codes do not yet have a time component. The most significant change in this subsection is the addition of 99310, which creates a fourth level of service “to allow the reporting of a comprehensive level of care,” states CPT Changes 2006.

What this means for you: Now you will be able to evaluate all subsequent nursing facility care services according to four possible levels of E/M service.

Remember: “All levels of subsequent nursing facility care include reviewing the medical record and reviewing the results of diagnostic studies and changes in the patient’s status… since the last assessment by the physician,” notes CPT at the beginning of the Subsequent Nursing Facility Care subsection. These codes have always required a review and affirmation of the plan of care, but CPT didn’t state this clearly in the coding manual until now, Pride explains.

Change #3: New annual assessment code 99318 finds home in Other Nursing Facility Services subsection.

Details: The law mandates that all nursing home patients have an annual assessment, says Gary Phillips, a SNF management and operations consultant with BKD Health Care Group in Springfield, MO. The creation of new code 99318 (Evaluation and management of a patient involving an annual nursing facility assessment…) sets this annual assessment service apart from other nursing facility E/M services by placing the code in a new subsection: Other Nursing Facility Services.

What this means for you: Code 99318 replaces code 99301 (Evaluation and management of a new or established patient involving an annual nursing facility assessment…), so don’t select that now-deleted code by mistake when your physician renders an annual assessment, Pride says.

Also, be aware that CPT instructs you not to report 99318 “on the same date of service as nursing facility services codes 99304-99316.” To ensure the patient receives the best service and that you can bill for all services rendered, patients should therefore receive their annual assessments on a date when no other services are necessary.

Example: Your physician visits the nursing home to perform an annual assessment on an 86-year-old diabetic patient, but the patient is having extreme difficulty breathing and has dangerously high glucose levels. The physician treats the patient’s immediate problems, and you report the appropriate level subsequent nursing facility care code, such as 99308 or 99309. The physician must return at a later date to perform the annual assessment, and then you bill 99318 for the service.

Change #4: Domiciliary, Rest Home, or Custodial Care Services section gets all new codes.

Details: CPT 2006 will delete new patient codes 99321-99323 and established patient codes 99331-99333 from the Domiciliary, Rest Home, or Custodial Care Services section. In their place you will have new patient codes 99324-99328 and established patient codes 99334-99337, meaning you will have more levels of service to choose from, Phillips says.

Advances in diagnostic and therapeutic technologies have made it possible for more patients with complex diseases to remain eligible for this type of care in non-medical facilities, explains CPT Changes 2006. The new code sets will “allow reporting higher levels of services provided to both new and established domiciliary and rest home patients with increasing medical complexity and frailty, due to mandates for movement of these patients from the hospital setting.”

What this means for you: You can now recoup more deserved reimbursement by reporting a higher level code when your physician renders a complex service to a domiciliary or rest home patient.

Change #5: CPT adds 99399 and 99340 to differentiate care plan oversight in the domiciliary or rest home setting.

Details: CPT already offers two codes in the Care Plan Oversight Services section that allow you to report care plan oversight services for nursing facility patients: 99379 (Physician supervision of a nursing facility patient [patient not present]…; 15-29 minutes) and 99380 (…30 minutes or more). However, the nursing facility designation of these codes created some limitations for coders who need to report care plan oversight services “for patients receiving care in their home, domiciliary, or rest home (eg, assisted living facility) not provided under the auspices of a home health agency or hospice program,” explains CPT Changes 2006.

CPT 2006 creates a new section titled Domiciliary, Rest Home (e.g., Assisted Living Facility), or Home Care Plan Oversight Services, which will contain the following new codes:

• 99339--(Individual physician supervision of a patient [patient not present] in home, domiciliary or rest home [e.g., assisted living facility]…;15-29 minutes)

• 99340--(… 30 minutes or more).

What this means for you: You’ll have to use a discerning eye when you select a care plan oversight code from now on.

“Codes 99339 and 99340 are intended to report care plan oversight services of children and adults with special health care needs and chronic medical conditions provided by primary care physicians who coordinate the medical care and management with other medical and nonmedical service providers and family,” states CPT Changes 2006. Furthermore, “these codes may encompass oversight of work or school programs the patient may be attending where therapy is provided.”

Example: Your physician oversees the ongoing care of a 20-year-old Down’s syndrome patient who lives with his family and has hypothyroidism and auditory problems, offers CPT Changes 2006. If the physician adequately documents 25 minutes in a one-month period that he spent reviewing test results, consulting with other medical providers and discussing care plans with the family, you could report 99339 for that month’s care plan oversight services.

Remember: Don’t report codes 99339 and 99340 “for patients under the care of a home health agency, enrolled in a hospice program, or for nursing facility residents.” For these types of patients, you should continue to use already-established care plan oversight codes 99374-99380.