Gastroenterology Coding Alert

Question: Our gastroenterologist recently performed a readmission assessment for a nursing home patient. I-ve not reported this type of service previously. What are the rules?


New York Subscriber
Answer: For 2006, CPT has completely revised its codes and rules for nursing facility assessments.

Old way: When a nursing facility patient underwent a substantial change that required the surgeon to issue a new treatment plan, you had to choose between three types of comprehensive nursing facility assessments. The structure of these services caused a lot of confusion for providers and payers alike.

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 (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 now choose a code based on the key components of history, examination and medical decision-making (MDM)--called -HEM.-

The new assessment codes, 99304-99306 (Initial nursing facility care, per day ...), replace 99301-99303 and are -consistent with the structure of the three levels of service for admission in the Initial Hospital Care section of the CPT codebook,- states the AMA's CPT Changes 2006: An Insider's View.

CPT has not yet established a time component for these new codes, so providers can have input on establishing typical times.

What this means for you: You-ll need to report nursing facility and skilled nursing facility (SNF) admissions by evaluating the physician's documentation of the history, exam and MDM (as you would any other E/M service) and choosing the appropriate service level from 99304-99306.

One more change: You should now report annual assessments for nursing home patients using 99318 (Evaluation and management of a patient involving an annual nursing facility assessment ...) rather than deleted code 99301.

Be aware that CPT instructs you not to report 99318 -on the same date of service as nursing facility services codes 99304-99316.- To ensure that patients receive the best service and that you can bill for all services rendered, patients should therefore receive their annual assessments on a date when no other services are necessary.