Primary Care Coding Alert

When your FP visits a long-term-care facility, pay close attention to the language in the nursing home code descriptors and your practice will receive its rightful reimbursement.

For an FP's visit to a nursing facility, coders must know the following:

the purpose of the physician's visit (admission, readmission, annual assessment or other visit)
the nature of the presenting problem (patient stable or recovering, has minor complication or has major complication)
the location of the patient (skilled nursing/nursing facility or assisted-living center). This information will help you determine the correct E/M series, the proper E/M code in that series, and the appropriate place-of-service code. Know the Nursing-Home Basics Many coders assume that the comprehensive nursing-facility assessment codes (99301-99303) are configured the same way as the outpatient E/M series (99201-99215), with each code reflecting an increased level of complexity. However, these codes are designed to report three different services: the patient's admission or readmission to the nursing facility, the annual assessment required for all patients in nursing homes, and the physician's reassessment of the patient after a new problem develops that necessitates a new medical care plan. When the patient is first admitted to the nursing home and a medical plan of care is created, report 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, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision making of moderate to high complexity).

This code is also used if the patient is readmitted to the nursing home after being discharged. If that readmission is for the same medical problem and occurs within 30 days of discharge, however, the claim may be rejected by Medicare, says Judy Richardson, RN, MSA, CCS-P, a senior consultant at Hill and Associates, a consulting firm in Wilmington, N.C. If a claim for 99303 is rejected, appeal and ask for review because this is the code Medicare specifies for readmissions, Richardson says.

To report the annual assessment of the patient, use 99301 (Evaluation and management of a new or established patient involving an annual nursing facility assessment which requires these three key components: a detailed interval history; a comprehensive examination; and medical decision making that is straightforward or of low complexity). This is the required yearly visit, when the physician reviews and recertifies the resident's care plan. The CPT manual notes that when this code is used, "Usually, the patient is stable, recovering or improving."

When the patient develops a complication or new problem that requires development of a new care plan, report 99302 (Evaluation and management of a new or established patient involving a nursing [...]