Eli's Rehab Report

Published on Mon Jun 28, 2004 PDF

Question: A physiatrist 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 ...) or 99302 (Evaluation and management of a new or established patient involving a nursing facility assessment ...) based on whether the patient's change requires the physician to write a new medical plan.

If the problem results in a "major permanent change in status" that requires the physician to create a new medical care plan, you should use 99302 for the nursing facility visit. For instance, if a patient undergoes an initial assessment but suffers a debilitating fall several months prior to the annual assessment, a new assessment is in order because the patient's condition -- and the plan of care required -- has changed significantly. In contrast, you should 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, it probably won't cause a permanent change in status. So you should report 99313 if your physician documents two of the following three 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 should use 99302, as long as documentation supports all three key components that the nursing facility assessment code requires. Also, if the stroke patient is hospitalized and then returns to the nursing home, you should use 99303 for the readmission service.

-- You Be the Coder and Reader Questions were reviewed by Marvel Hammer, RN, CPC, CHCO, owner of MJH Consulting in Denver.