The situation: You check in on a patient who is a resident at the local nursing home. A year has passed since he became a resident, and it is time to conduct his annual assessment. The patient has multiple chronic health problems: Alzheimer-type dementia (AD); stable, controlled hypertension; CAD; and gout. His wife visits him every day and has not come to terms with his illness. She insists that he will improve and wants everything possible done for him.

Your note reads as follows:

Annual physical examination

S:

• CC: Alzheimer-type dementia

• HPI: 74-year-old male with a history of AD for 3 years. Has been getting progressively worse. Nurse reports patient is less responsive to people and environment and communicates mostly in gibberish.

• PFSH: No change from complete PFSH taken during previous annual assessment (2/97) at this facility.

• ROS: Patient does not answer questions due to AD. Nurses indicate patient frequently seems frightened and confused by his surroundings. Nurses indicate BP has been stable. Patient does not appear to have any new problems since previous annual assessment.

O:

• Wt. 155; sitting BP 134/86; P 73 NSR

• Eyes: bilateral early cataracts obscure the fundi; conjunctivae clr

• ENT: EACs clr; teeth OK

• Neck: supple; thyroid nl size and midline; no nodes

• Lungs: clear to A and P; no difficulty breathing

• Cor: NSR, HS nl, no extra sounds; no carotid bruits; peripheral pulses absent in feet; no edema

• Chest: nl male breasts with no masses

• Abd: scar RUQ; soft, no tenderness, no masses; no organomegaly

• GU: scrotum and testes nl; prostate 2+ smooth, no nodules

• Lymph: no nodes axillae, groin

• Ext: no paralysis, moves all extremities well; poor muscle tone; walks slowly but without assistance; no cyanosis or clubbing

• CNS: will not follow commands; withdraws to pain all extremities; reflexes diminished, but bi-lat. equal

• Skin: no lesions; turgor nl

• Psych: will not respond to questions; appears to recognize wife and nurses

A:

• No new problems

• Chronic

• 1. AD; 2. Hypertension; 3. CAD; 4. Gout

P:

1. Continue donepezil (Aricept) 5 mg per day (upon insistence of wife)

2. Continue verapamil 180 mg each morning

3. Continue one baby aspirin per day

4. Routine CBC, UA, PPD

5. Flu immunization in Oct.

The challenge: Stop a minute and decide how you would code this visit.

Discussion: The correct code will be one of the evaluation and management (E/M) codes designated for comprehensive assessment in a nursing facility (99301–99303). Each of the codes requires that a comprehensive exam be performed and that a certain level of history and decision making be documented. The task performed and the context in which it is provided differentiate these codes from one another. Here's how the sample note matches up with the revised documentation guidelines.¹

1. History: The physician has documented his review of the PFSH by noting that there have been no changes and noting the date and location of the complete PFSH he took as part of the patient's last annual assessment. Because of the patient's inability to answer questions, nurses answer questions for purposes of the ROS. The nurses address the Psych and Constitutional systems, which makes the ROS extended. Again using information provided by the nurses, the note touches on more than three elements of the HPI, making it extended. The complete PFSH, extended ROS and extended HPI amount to a history that is detailed overall.

2. Exam: The revised documentation guidelines for E/M services stipulate that at least nine organ systems/body areas must be covered and that for each area/system selected, all the bulleted elements that HCFA includes in its definition of the general multisystem exam be performed when the exam is comprehensive. However, as few as 18 may be documented, i.e., at least two bulleted items for each area or system selected. The sample note meets the comprehensive exam requirements and goes quite a bit further. Twenty-six bulleted elements from a total of 12 systems/body areas and the portions of the note to which they refer are listed here:

• Eyes: Inspection of conjunctivae and lids (“Eyes: conjunctivae clr”);

• Eyes: Ophthalmoscopic examination of optic discs and posterior segments (“Eyes: bilateral early cataracts obscure the fundi”);

• Ears, Nose, Mouth and Throat: Otoscopic examination of external auditory canals and tympanic membranes (“ENT: EACs clr”);

• Ears, Nose, Mouth and Throat: Inspection of lips, teeth and gums (“ENT: teeth OK”);

• Neck: Examination of neck (“Neck: supple”);

• Neck: Examination of thyroid (“Neck: thyroid nl size and midline”);

• Respiratory: Percussion of chest (“Lungs: clr to A and P”);

• Respiratory: Auscultation of lungs (“Lungs: clr to A and P”);

• Cardiovascular: Auscultation of heart with notation of abnormal sounds and murmurs (“Cor: HS nl, no extra sounds”);

• Cardiovascular: Examination of carotid arteries (“Cor: no carotid bruits”);

• Cardiovascular: Examination of pedal pulses (“Cor: peripheral pulses absent in feet”);

• Cardiovascular: Examination of extremities for edema and/or varicosities (“Cor: no edema”);

• Gastrointestinal (Abdomen): Examination of abdomen with notation of presence of masses or tenderness (“Abd: soft, no tenderness, no masses”);

• Gastrointestinal (Abdomen): Examination of liver and spleen (“Abd: no organomegaly”);

• Genitourinary: Examination of scrotal contents (“GU: scrotum and testes nl”);

• Genitourinary: Digital rectal exam of prostate gland (“GU: prostate 2+ smooth, no nodules”);

• Lymphatic: Palpation of lymph nodes in the neck (“Neck: no nodes”);

• Lymphatic: Palpation of lymph nodes in the axillae (“Lymph: no nodes axillae, groin”);

• Lymphatic: Palpation of lymph nodes in the groin (“Lymph: no nodes axillae, groin”);

• Musculoskeletal: Examination of gait and station (“EXT: walks slowly but without assistance”);

• Musculoskeletal: Inspection and/or palpation of digits and nails (“EXT: no cyanosis or clubbing”);

• Skin: Palpation of skin and subcutaneous tissue (“SKIN: no lesions; turgor nl”);

• Neurologic: Examination of deep tendon reflexes with notation of pathological reflexes (“CNS: reflexes diminished, but bi-lat. equal”);

• Neurologic: Examination of sensation (“CNS: withdraws to pain all extremities”);

• Psychiatric: Description of patient's judgment and insight (“Psych: will not respond to questions”);

• Psychiatric: Brief assessment of mental status, including orientation to time, place and person (“Psych: appears to recognize wife and nurses”).

The terms and abbreviations used in the note to describe systems and body areas don't match those used in the guidelines, nor are the exams of those systems and body areas documented in the same order as in the guidelines. According to HCFA and the AMA, that's OK. The auditor must look throughout the note for the required information.

3. Decision making: The decision-making tables included in FPM's Pocket Guide to the Documentation Guidelines indicate that the score for diagnosis and management options in the vignette is 5, which qualifies as extensive: 1 for the established, previously diagnosed problem (the AD) + 1 because the AD is worsening + 1 for the hypertension + 1 for the CAD + 1 for the gout. The score for the amount and complexity of data reviewed is 1. Given that the patient's problems include more than one chronic illness that requires treatment with prescription drugs, the risk level is probably moderate. Overall, then, the decision-making elements amount to moderate complexity.

The documentation in the note and the context in which the services were provided support code 99301, “Evaluation and management of a new or established patient involving an annual nursing facility assessment,” [italics added] which requires a detailed interval history, a comprehensive exam, medical decision making that is straightforward or of low complexity, and review and affirmation of the plan of care. According to CPT, the patient is usually “stable, recovering or improving.”

If the patient had developed a “significant complication or a significant problem,” such as a decubitus, that resulted in a revised plan of care, a case could be made for coding 99302, “Evaluation and management of a new or established patient involving a nursing facility assessment,” provided these additional requirements were met: a detailed interval history, a comprehensive exam, medical decision making of moderate to high complexity and the creation of a care plan. According to CPT, 99302-level services often are also characterized by a “major permanent change in status.”

The remaining code in this category, 99303, covers an assessment provided at the time of initial admission or readmission to the nursing facility. It requires a comprehensive history, comprehensive exam, decision making of moderate to high complexity and the creation of a medical plan of care.

A key to knowing when to use the comprehensive nursing facility assessment codes is the Minimum Data Set/Resident Assessment Instrument (MDS/RAI). Nursing facilities are required to complete the MDS/RAI annually and update it quarterly and as needed. When an MDS/RAI is completed and a comprehensive exam is performed, codes 99301-99303 can be used, provided the respective requirements for history and decision making are met.

Editor's note: While Coding Challenge represents our best efforts to provide accurate information and useful advice, we cannot guarantee that third-party payers will accept the coding recommended.