Part B Insider (Multispecialty) Coding Alert

Use 99201 to report low-level new patient visits

If you're still using 99331-99333 to code for custodial care and receiving denials, it's because you're using the wrong codes. Learn the lowdown on why CPT threw those codes out of the window and get clear on what separates a rest home from other facilities.

First step: Before you submit rest home codes, you have to understand what differentiates the rest home, domiciliary or custodial care facility from other, similar places of service.

Specifically, the rest home, domiciliary or custodial care facility place-of-service 33 (POS 33)--as defined by both CPT and CMS--"provides room, board and other personal assistance services, generally on a long-term basis." Such facilities do not have a medical component, which distinguishes them from a nursing facility (POS 32), says Marvel J. Hammer, RN, CPC, CCS-P, CHCO, president of MJH Consulting in Denver.

New way: You should not be using 99331-99333 to describe services for custodial care patients for claims dated after Jan. 1, 2006. CPT deleted those codes and added nine new codes to describe services that the physician provides in rest home settings:

• 99324-99328---Domiciliary or rest home visit for the evaluation and management of a new patient ...

• 99334-99337---Domiciliary or rest home visit for the evaluation and management of an established patient ...
 
The AMA designed the new codes "to better capture the level of care provided in these settings consistent with increase of patients with complex disease who are eligible for this type of care ... [and] remain in non-medical facilities," according to the AMA's CPT Changes 2006: An Insider's View.

You should choose from among 99324-99337 almost exactly as you would choose from office outpatient visits 99201-99215, explains Hammer.

For instance, to report the lowest level new patient visit in a rest home, your physician will need to document a problem-focused history, problem-focused examination and straightforward medical decision-making (MDM)--exactly the same requirements for a level-one E/M service for a new patient visit in the office ( CPT 99201 , Office or other outpatient visit for the evaluation and management of a new patient). 

As with new patient office/   outpatient visits, you must meet all three requirements to report a given level of service with new patient custodial care codes 99324-99328.

Example: Your podiatrist visits a new patient with decubitus ulcers in a domiciliary for evaluation. The physician documents a comprehensive history and exam and MDM that qualifies as "low complexity."

In this case, you must choose 99325. Although the comprehensive history and exam point to 99327, this code requires MDM of moderate complexity. Because all three components must meet or exceed the requirements of the chosen service level, 99325--not 99327--is correct.