Primary Care Coding Alert

Welcome an annual assessment replacement code and expanded subsequent care levels in CPT 2006

CPT 2006 downgrades coding for nursing facility services from an advanced class to a basic-level class--and the standard E/M rules finally apply to these codes.

The current nursing facility services coding structure is atypical. -To choose the right series of codes, you have to determine whether the physician treated the patient for a substantial change or basic illness,- says Maria M. Torres, CPC, CMM, a coding consultant with Bermudez Medical Consulting in Tampa, Fla.

In 2006, you no longer have to make this distinction between comprehensive nursing facility assessments (99301-99303) and subsequent nursing facility care (99311-99313). CPT 2006 deletes these code families and replaces them with:

- three codes for an initial assessment, 99304-99306
- four new codes for the subsequent visits, 99307-99310
- a new code for the annual nursing facility assessment, 99318.

CPT did not change the discharge codes (99315-99316, Nursing facility discharge day management -).

1. Base Initial Assessment on Key Components

The nursing facility assessment code changes will make coding initial nursing facility care easier. -The current structure of the NF Services section of CPT is atypical and has been a source of confusion since its creation in 1992,- states the American Medical Directors- Association (AMDA) in its CPT Coding Change Request.

Old way: When a nursing home patient undergoes a substantial change that requires the family physician to issue a new treatment plan, you have to choose between three types of comprehensive nursing facility assessments, Torres says. Here is the 2005 breakdown:

- annual assessment--99301 (Evaluation and management of a new or established patient involving an annual nursing facility assessment -)

- assessment involving a major permanent change of status--99302 (Evaluation and management of a new or established patient involving a nursing facility assessment -)

- assessment at the time of facility (re)admission--99303 (Evaluation and management of a new or established patient involving a nursing facility assessment at the time of initial admission or readmission to the facility ...).

New method: Instead of determining the type of assessment, you-ll choose 99301-99303's replacement codes based on the initial nursing facility care's key components. The new assessment codes describe three levels of initial nursing facility service that are consistent with the initial hospital care codes- structure, according to the AMDA.

Assigning the new codes based on the same-level new hospital patient codes use should alleviate payment problems.-We had a difficult time getting physicians and payers to understand that each of the assessment codes represented a specific nursing facility service process,- says Dennis Stone, MD, MBA, CMD, chief medical officer for HomeQuality Management, a nursing facility company in Louisville, Ky.
  
99304-99306's bottom line: The initial nursing facility care codes (99304-99306) describe -Initial nursing facility care, per day, for the evaluation and management of a patient which requires these three key components:- 

          History                         Exam                             MDM
99304 Detailed/comp               Detailed/comp                 Straightfwd/low
99305 Comp                           Comp                             Moderate
99306 Comp                           Comp                             High 
 
CPT did not establish typical times for the codes and eliminated the caveat that the physician must create -a new medical plan of care.-

2. Capture Comprehensive Sub Care With 99310

CPT 2006's new subsequent nursing facility care codes will allow you to indicate a more extensive E/M service than previously possible. Now, the -Subsequent Nursing Facility Care- subsection of CPT contains only three levels of service for established patients.

Problem: You are restricted to coding as the highest level of service a detailed interval history and a detailed examination. -We never had a code for treating a highly complex nursing facility patient,- says Stone, who led the AMDA's nursing facility codes revision efforts. When CPT originally created the subsequent nursing facility care codes, this type of patient required level-three hospital care.

Solution: CPT 2006 creates a new fourth level of service code (99310) to permit you to report a comprehensive level of service. Unlike deleted subsequent nursing facility care codes 99311-99313, new codes 99307-99310 do not contain typical time units.

99307-99310's nutshell: The descriptors for the old subsequent nursing facility care codes (99311-99313) have basically been carried over to the new codes (99307-99310), whose definitions state, -Subsequent nursing facility care, per day, for the evaluation and management of a patient -- The new codes refer to E/M -of a patient,- rather than -of a new or established patient.- The service levels require two of these three key components:

3. Reserve 99318 for Annual Assessment

Starting Jan. 1, you-ll look to a new subsection (-Other Nursing Facility Services-) to code a comprehensive annual assessment. -This is a service that is unique to the NF setting,- the AMDA says. The other E/M codes in this section do not accurately describe the extent of history and examination and the complexity of medical decision-making that an annual assessment involves.

99301/99318 action: When an FP performs an annual assessment, you should report 99318 instead of 99301. -New code 99318 basically represents the same services 99301 described with slightly higher medical decision-making, but renumbered,- says Kent J. Moore, manager of Health Care Financing and Delivery Systems for the American Academy of Family Physicians in Leawood, Kan.

The descriptor for 99318 (Evaluation and management of a patient involving an annual nursing facility assessment) does not contain a typical time allotment, but it does require the following components:

- a detailed interval history
- a comprehensive examination
- low- to moderate-complexity MDM.