Neurology & Pain Management Coding Alert

Gaining correct reimbursement for nursing facility assessments (NFAs) (99301, 99302 and 99303) can be challenging. The coding rules that govern other E/M codes often do not apply to these institutions. These codes have high relative work values (RVUs), so correct coding
is vital.

Assessments Affect Total Reimbursement Outlook

Even more significant than the reimbursement amount for the assessments RVUs, is the fact that these codes affect a patients total care allowance for the year, says Laureen Jandroep, OTR, CPC, CCS-P, owner of A+ Medical Management and Education, a coding and reimbursement consulting firm and a national CPC training curriculum site in Egg Harbor City, N.J. With the prospective payment system (PPS) in the long-term care arena, the nursing facility assessment strongly affects reimbursement. It determines what needs the patient has, and how sick they are. During this, the neurologist determines whether the patient requires additional assistance or care, and those factors go into the calculation of the minimum data set (MDS) rate, which in turn determines the prospective reimbursement. In other words, the choice of an NFA code has significant impact not only on reimbursement, but also the level of care the patient will receive.

Coding for Nursing Facility Assessments

Follow these three rules when assigning NFA codes:

1. New and Established Patients. There is no distinction between new and established patients with assessment codes, says Mary Falbo, MBA, CPC, president of Millennium Healthcare Consulting Inc., a national healthcare consulting firm focusing on neurologist compliance, coding, billing and reimbursement, based in Lansdale, Pa. This often trips up coders. They want to apply the same rules they use with consultations or outpatient visits one series of codes for new patients and another for established. This rule of thumb doesnt apply with nursing facility assessments.

Most states, which are charged with licensing nursing facilities, require assessments at least once a year (99301). If the patient who has already had their annual assessment experiences a significant change in status requiring another assessment, 99302 should be billed. If a patient who has already had an annual assessment and then left the nursing facility but was readmitted before that one year period was up (eg, for hospitalization for a hip fracture) a new comprehensive assessment would be warranted (99303).

2. Change in Patient Status Equals Reassessment. To ensure quality care in long-term nursing facilities, it is vital for the neurologist to periodically evaluate the many factors that will have an impact on the patients well-being, says Falbo. As a result, the physician may perform a comprehensive NFA whenever it is necessary to enhance or maintain the patients physical and psychosocial functioning. Most carriers do not have a limitation on the number of times [...]