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Coding Consult: Homing in on nursing home codes


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


Coding Consult

Homing in on nursing home codes

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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."

"The key point to note in the description is that there is 'a major permanent change in status' that requires development of a new medical care plan," says Jean Ryan-Niemackl, a compliance analyst for MeritCare Health System, a multispecialty health system in Fargo, ND.

CPT descriptions are crucial for follow-up codes

Use 99311-99313 for regular checkups. (Medicare requires one visit by a physician every 30 days for the first three months, and one visit every 60 days after that.) These codes are also for problem visits for both new and established patients.

While the key components are mandatory in code selection, Ryan-Niemackl says coders should be careful to read the entire definition of these codes in the CPT manual. The last paragraph of each section, which describes the nature of the presenting problem and the typical amount of time spent by the physician, is as valuable in the code-selection process as the key components.

When the patient is "stable, recovering, or improving," the CPT manual says, the coder should use 99311. If you make several visits to a patient within a few weeks, don't report 99311. "If you use this particular code more than once a month, chances are Medicare is going to say, 'If this patient is that stable, why are you going back more than once a month?' " Richardson says.

Let's say a patient is not recovering or is seen for a complication—influenza, for example. Document the patient's fever, congestion, and other evidence supporting the diagnosis, then bill under 99312 (an expanded problem focused interval history; an expanded problem focused examination; medical decision-making of moderate complexity). For 99312 to apply, "usually the patient is responding inadequately to therapy or has developed a minor complication," the CPT manual reads.

When the patient has a serious problem, code 99313 (a detailed interval history; a detailed examination; medical decision-making of moderate to high complexity). "Usually, the patient has developed a significant complication or a significant new problem," the CPT manual reads. Richardson recommends using 99313 when the patient with influenza in the example above is also diagnosed with pneumonia that requires IV antibiotics and nasal oxygen.

Sometimes when a patient has a complication, coders are unsure whether to report 99313 or 99302, says Ryan-Niemackl. In defining both codes, the CPT manual notes a "significant complication or a significant new problem" has developed. The differentiating factor is whether that change necessitates the writing of a new medical care plan. Use 99302 when the problem has resulted in a "major permanent change in status" that requires the creation of a new medical care plan. Use 99313 when the change in status is not permanent and a new medical care plan is not necessary.

When you discharge the patient from the nursing home, use 99315 if the process takes 30 minutes or less, and use 99316 if it takes longer.

Assisted living facilities have separate codes

Many retirement homes have an assisted living wing as well as a nursing home section. Many elderly also reside in stand-alone assisted living centers.

There's a lot of confusion about how to code physician visits to residents of these assisted living facilities. Medicare's Transmittal 1690, issued in 2001 and later revised in Transmittal 1709 to correct errors in the place-of-service codes, says that the domiciliary, rest home, or custodial services CPT codes 99321-99333 should be used to report E&M services provided to residents of a facility that provides "room, board, and other personal assistance services, generally on a long-term basis." The transmittal notes that these facilities, which do not have a medical component, are often referred to as "adult living facilities or assisted living facilities." List codes 99321-99323 for new patients and 99331-99333 for established patients.

Coders who report home services codes for E&M services provided in assisted living centers are in error, according to the transmittal. Medicare says that 99341-99350, the home services codes, are for use only when E&M services are provided to a patient in his or her "own private residence and not any type of facility."

Another key in coding visits to long-term care facilities is noting the correct place of service. Putting the wrong number on the claim form can lead to rejection, notes Richardson.

Code 31 is the POS for a skilled nursing facility (short-term care or rehab SNF), 32 is for a nursing facility (long-term care), 33 is for assisted living centers. "The coder needs to find out how the facility designates itself," says Richardson. If you're unsure of the facility's designation or which wing the patient resides in, call the facility.


This information provided by The Coding Institute. For a free sample issue or information on how to subscribe to any of 29 specialty-specific coding newsletters, please contact The Coding Institute, 2272 Airport Rd. South, Naples, FL 34112; phone 800-508-2582; fax 800-508-2592; or visit www.codinginstitute.com.


Coding Consult: Homing in on nursing home codes. Medical Economics 2002;15:24.

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