Internal Medicine Coding Alert

Published on Mon Apr 19, 2004 PDF

Question: A physician performs a history, evaluation and medical decision-making on a nursing facility patient who now has pneumonia in addition to previously diagnosed influenza. The patient requires intravenous antibiotics and nasal oxygen. Should I report the service with 99313 or 99302?

North Carolina Subscriber

Answer: You should report either 99313 (Subsequent nursing facility care, per day, for the evaluation and management of a new or established patient, which requires at least two of these three key components: a detailed interval history, a detailed examination, medical decision-making of moderate to high complexity ...) or 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, medical decision-making of moderate to high complexity ...) based on whether the patient's change requires the physician to write a new medical plan.
 
If the problem resulted in a "major permanent change in status" that requires the creation of a new medical care plan, you should use 99302 for the subsequent nursing facility care. Assign 99313 when the change in status is not permanent and a new medical care plan is unnecessary.
 
Although the patient's pneumonia (487.0, Influenza; with pneumonia) is serious, this condition probably wouldn't cause a permanent change in status. So you should report 99313 if your physician documented two of the three following components: a detailed interval history, a detailed examination, and moderate- to high-complexity medical decision-making.
 
If the same patient had a stroke (436, Acute, but ill-defined, cerebrovascular disease), the diagnosis would likely result in a permanent status change and require a new medical care plan. In this case, you would use 99302, as long as documentation supported all three key components that the nursing facility assessment code requires.