Primary Care Coding Alert

Comprehensive nursing facility assessments (99301, 99302 and 99303) have been known to confound the most expert coder because they dont always follow the same rules that govern other evaluation and management (E/M) codes.

There are a number of issues that make these codes unusual, says Mary Falbo, MBA, CPC, president of Millennium Healthcare Consulting Inc., a national healthcare consulting firm specializing in financial and healthcare management with a focus on physician compliance, coding, billing and reimbursement based in Lansdale, Pa. Coders must be alert to these key differences to assign them correctly. This is especially important given the high relative work values assigned to these codes. Correct coding can make a significant difference in the level of reimbursement received.

The definitions and relative value units (RVUs) for these codes are:

99301 evaluation and management of a new or established 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 straightforward or of low complexity (30 minutes at the bedside), 1.767 RVUs;

99302 evaluation and management of a new or established patient involving a nursing facility assessment which requires these three key components: a detailed interval history, a comprehensive examination, and medical decision making of moderate to high complexity (40 minutes at the bedside), 2.309 RVUs; and

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, which requires these three key components: a comprehensive interval history, a comprehensive examination, and medical decision making of moderate to high complexity (50 minutes at the bedside), 3.068 RVUs.

Each of the three codes describes initial and annual assessments (admission and readmission activities) a family physician would provide for patients being cared for in a nursing facility. These are complex evaluations because they not only appraise a patients medical condition but consider psychosocial functions as well, Falbo explains. Because the patient lives in the nursing facility, the scope of care is much broader. The family physician will play a central role in coordinating and overseeing a multidisciplinary treatment plan. Use these four key factors in determining how to code nursing facility assessments:

1. Assign 99301, 99302 and 99303 for services provided to both new and established patients. There is no distinction between new and established patients with these codes, Falbo notes. This is something that often trips up coders. They want to apply the same rules they use with consultations or outpatient visits one series of codes for new patients, and another for established. This rule of thumb doesnt apply with nursing facility assessments.

Note: Adding confusion to this issue is a second set of codes 99311, 99312 and 99313 reported for subsequent nursing facility care. These also apply to both new and established patients, and are assigned for physician visits that include a review of the medical record, notation of changes in the patients status and reviewing or signing orders. However, a comprehensive assessment or services provided to patients experiencing a significant change in condition is not included.

2. Comprehensive assessment codes encompass specific and detailed components. Whenever assigning 99301, 99302 or 99303, they must include the completion of a resident assessment instrument (RAI), Falbo says. An RAI is a comprehensive, standardized tool that allows the family physician to measure each residents functional capacity. The RAI will include a minimum data set (MDS) that typically includes the following components:

medically defined conditions;
medical history;
medical status;
mental and physical functional status;
sensory and physical impairment;
nutritional status and requirements;
mental and psychosocial status;
cognitive status;
special treatments and protocols;
discharge potential;
activities potential;
rehabilitation potential; and
drug therapy.

In addition, the RAI will incorporate a residents assessment protocol (RAP) that defines the quality of care and utilization standards for the nursing facility.

This comprehensive assessment is a lot of work, and all of these components must be referenced in the physicians notes, Falbo says. The information gathered produces a roadmap for the care of the patient, laying out the protocols for the multidisciplinary team involved in the patients care.

3. Coders can assign these codes more than one time during a patients stay in the nursing facility. Unlike other codes that are assigned only when a patient is initially admitted to a facility, codes 99301-99303 may be reported multiple times during a patients stay in the nursing facility. These codes are reported at least annually, and sometimes more frequently, Falbo says. To ensure quality care of patients in long-term nursing facilities, it is vital for the physician to periodically evaluate the many factors that will have an impact on their well-being. Most states, which are charged with licensing nursing facilities, require these comprehensive assessments at least once a year.

In addition, a comprehensive assessment would be conducted, reported and billed if the patient experienced a significant change in status. An elderly patient may have experienced a major stroke (i.e., 436, acute, but ill-defined, cerebrovascular disease) for instance, reducing his physical and mental status. This sort of event would have a substantial impact on the patients functions, and the physician would need to conduct an assessment and create a new plan of care, she says.

4. Comprehensive assessments include services related to the patients care that may have occurred at other sites on the same date. There are many times when a patient will have been seen by the family physician in another setting and the decision is made to admit or readmit him to a nursing facility, Falbo says. The patient may have been in the hospital or seen in the office or emergency department. All of the E/M services provided in these other situations on the same date of service would be included in the comprehensive assessment code and would contribute to the level of service reported.

The medical record for the assessment should refer to the previous E/M services, she says. For example, the physician may note, Please refer to the review of symptoms and medical history dictated earlier today and confirm the date these services were performed.

Hospital discharge or observation discharge services performed on the same date as the nursing facility assessment, on the other hand, may be reported separately.

Determining the Level of Service to Assign

Because of the nature of care provided by nursing facilities, residents will undoubtedly have serious health conditions. This creates a challenge for physicians and coders alike to determine which level of service to bill when comprehensive assessments are conducted.

According to Falbo, a key for determining the level of service is the complexity and nature of the presenting problems. If a condition does not signal a change in the patients functionality or create a need for a change in the treatment plan, 99301 is usually assigned. However, if there has been a major complication that signals a permanent change in a patients status, then the higher-level codes are probably more appropriate.

Joseph C. McAllister, MD, an internist practicing with the Abington Memorial Hospital in Abington, Pa., gives examples of when each level should be billed:

Example #1: Code 99301

A 90-year-old male patient has been a resident of a nursing facility for four years. The patient suffers from controlled hypertension (i.e., 401.0, essential hypertension, malignant) and chronic obstructive pulmonary disease (COPD) (i.e., 496, chronic airway obstruction, not elsewhere classified). During the previous year, the patient had been seen periodically by his physician for routine and preventive care. At the end of the year, the family physician conducts an annual comprehensive assessment, including the RAI and MDS. Services would typically be assigned the lowest level code, 99301.

Example #2: Code 99302

The resident is a 62-year-old female who suffers from end stage renal disease (585) and is on dialysis. She develops a sacral decubitus ulcer (707.0) and exhibits a significant change in mental status. These events trigger a new MDS, and the conditions involve medical decision making of moderate complexity. Services would typically be assigned the level-two code, 99302.

Example #3: Code 99303

A 70-year-old male has had two cerebrovascular accidents (CVAs or strokes), suffers from hypertension, carotid occlusion (433.10, occlusion and stenosis of precerebral arteries, carotid artery, without mention of cerebral infarction) and COPD. After the strokes, he is discharged from the hospital and admitted to a skilled-nursing facility. Because of the severity of the patients condition and the complexity of the medical decision making, the comprehensive assessment would typically be coded 99303.

Note: Remember, it is important to document the appropriate history, exam and medical decision making for each level of service, whether your practice or health system adheres to the 1995 or 1997 documentation guidelines.