Primary Care Coding Alert

Good news for coders: CPT has revised the definitions for nursing facility care in its 2008 edition, which makes coding for these services much easier.

Impact: CPT previously did not include typical times for 99304-99310 and 99318 for coders to observe. The codes were distinguished only based on the key components (i.e., history, exam, and medical decision-making) and severity of the problem or the patient's status. Now, each nursing facility care entry includes a typical timeframe for that level of visit.

Here's the new definition of 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. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of low severity. Physicians typically spend 25 minutes with the patient and/or family or caregiver.

The last sentence of the definition, which provides a timeframe for 99304, was not part of the descriptor last year. "This change is a help to coders," says Quinten Buechner, ACS-FP/GI/PEDS, CPC, CCP, CMSCS, president of ProActive Consultants in Cumberland, Wis.

Benefit: The rewritten codes will make the prolonged services codes easier to report. However, "the trick is getting the physicians to document the time spent in counseling and coordination of care," he says.

The other revised codes in the nursing facility section of CPT 2008 are:

- 99305 -- - a comprehensive history; a comprehensive examination; and

medical decision-making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of moderate severity. Physicians typically spend 35 minutes with the patient and/or family or caregiver. - 99306 -- - a comprehensive history; a compre- hensive examination; medical decision-making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Physicians typically spend 45 minutes with the patient and/or family or caregiver.

- 99307 -- Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: a problem-focused interval history; a problem-focused examination; straightforward medical decision- making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is stable, recovering, or improving. Physicians typically spend 10 minutes with the patient and/or family or caregiver.

- 99308 -- - an expanded problem-focused interval history; an expanded problem-focused examination; medical decision-making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Physicians typically spend 15 minutes with the patient and/or family or caregiver.

- 99309 -- - a detailed interval history; a detailed examination; medical decision-making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient has developed a significant complication or a significant new problem. Physicians typically spend 25 minutes with the patient and/or family or caregiver.

- 99310 -- - a comprehensive interval history; a comprehensive examination; medical decision-making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. The patient may be unstable or may have developed a significant new problem requiring immediate physician attention. Physicians typically spend 35 minutes with the patient and/or family or caregiver.

- 99318 -- Evaluation and management of a patient involving an annual nursing facility assessment, which requires these three key components: a detailed interval history; a comprehensive examination; and medical decision-making that is of low to moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is stable, recovering, or improving. Physicians typically spend 30 minutes with the patient and/or family or caregiver.

"Time descriptions are a tremendous help in CPT coding," says Denae Merrill, CPC, coder for Covenant MSO in Saginaw, Mich., and secretary of the MBS chapter of the American Academy of Professional Coders (AAPC). "The new descriptors will allow providers to possibly code higher -- if they spend significant time counseling and/or coordinating the patient's care," she says.

The biggest potential benefit of these rewrites will come when your physician conducts longer visits to the nursing facility, "where the provider deals with family or the patient for counseling and coordination of care," Buechner says.

Consider this example from Merrill: The physician visits a nursing facility patient who requires oxygen and suffers from end-stage chronic obstructive pulmonary disease (COPD) with a consistently low pulse oximetry reading. The FP sees the patient along with family members to discuss next steps and possible treatments. This counseling, and the subsequent coordination of the patient's wishes, takes 33 minutes of the physician's time, which was also the total duration of the visit.

Using the revised nursing facility codes, you would report this encounter with 99310. Don't forget to attach 496 (Chronic airway obstruction, not elsewhere classified) to 99310 to represent the patient's COPD.

When you file this claim, Buechner recommends that you document:

- total visit time

- a summary of topics discussed

- a description indicating that more than half of the total visit time involved counseling and coordination.