Coding Consult

Homing in on nursing home codes

There are plenty of rules to know. Here's help.

Visits to long-term care facilities can present coding challenges even to experienced physicians.

Many coders assume that the comprehensive nursing facility assessment codes (99301-99303) are configured the same way as the outpatient E&M series (99201-99215), with each code reflecting an increasing level of complexity. Not so, the nursing home codes are designed to report three different services.

When you first admit the patient to the nursing home and create a medical plan, report 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 a comprehensive history and examination, and medical decision-making of moderate to high complexity).

Also use this code if you readmit the patient. However, if the readmission is for the same medical problem and occurs within 30 days of discharge, your local Medicare carrier may reject the claim, says Judy Richardson, a senior consultant at Hill and Associates, a physician coding and compliance consulting firm in Wilmington, NC. If the claim is rejected, ask for review because this is the code Medicare specifies for readmissions, says Richardson.

To report the required annual assessment of the patient, use 99301 (evaluation and management of a new or established patient involving an annual nursing facility assessment, which requires a detailed interval history; a comprehensive examination; and medical decision-making that is straightforward or of low complexity). Typically, you review and recertify the resident's care plan. The CPT manual notes that usually when this code is used, "the patient is stable, recovering or improving."

When the patient develops a complication or new problem that requires development of a new care plan, report 99302 (. . . requires a detailed interval history; a comprehensive examination; and medical decision-making of moderate to high complexity). It's appropriate to use this code, for example, when a patient who is in the nursing home for rehabilitation after hip surgery has a stroke. The CPT manual states: "Usually the patient has developed a significant complication or a significant new problem and has had a major permanent change in status. The creation of a new medical plan of care is required."