Internal Medicine Coding Alert
99316 Represents Final Exam and Discussion
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Question: My internist documented a level-two nursing-home assessment and a nursing-home discharge that lasted longer than 30 minutes on the same day. How should I report this?
Maine Subscriber
Answer: Based on the information you've provided, you should probably report only 99316 (Nursing facility discharge day management; more than 30 minutes), but not assessment code 99302 (Evaluation and management of a new or established patient involving a nursing facility assessment ...).
The reason: You should report nursing-home discharge codes (99315-99316) for the total duration of time the physician spent for the patient's final examination and the discussion of the nursing facility stay, according to CMS guidelines. Remember, the time doesn't have to be continuous.
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