AMDA Efforts Result in New and Revised
Nursing Home Codes

Over the past two years, AMDA has been working to both redefine and obtain appropriate relative value units (RVUs) for the Nursing Facility (NF) Code family. This week, the AMA released the new family of codes. CPT codes 99301-99303 and 99311-99313 have been deleted. They are replaced by three new codes (99304-99306) for the initial assessment; four new codes for the subsequent visits (99307-99310); and a new code for the annual nursing facility assessment (99318). The discharge codes 99315 and 99316 were unchanged.

AMDA was joined in the effort to obtain new codes by the American Geriatrics Society (AGS), the American Academy of Family Physicians (AAFP), and the American Academy of Home Care Physicians (AAHCP). AMDA's efforts were led by Dennis Stone, MD, CMD, MBA, AMDA's Representative to the CPT Advisory Committee and Practice Expense Advisory Committee (PEAC) with the assistance of AMDA's RVS Committee members Charles Crecelius, MD, CMD; Arthur Snow MD, CMD; Leonard Gelman MD, CMD; David MacRae MD, CMD; Robert A. Zorowitz, MD, MBA, CMD; and George Taler, MD.

Background

On November 12, 2004, AMDA submitted a CPT Coding Change Request for the revision of the NF services section of CPT to the CPT Editorial Research and Development Department. In their letter, AMDA stated that the current structure of the NF Services section of CPT is atypical and has been a source of confusion since its creation in 1992. CPT includes three codes for Comprehensive Nursing Facility Assessments: an annual assessment (99301); an assessment for a major permanent change of status (99302); and, an assessment at the time of admission (99303). AMDA stated "To address the problems created by this coding structure, we recommend revising the structure of the current Comprehensive Nursing Facility Assessment codes to create three levels of service for admissions, consistent with the structure of the three levels of service for admission in the Initial Hospital Care section of CPT."

AMDA also stated that there currently are only three levels of service for established patients in the Subsequent Nursing Facility Care subsection of CPT, and that the highest level of service is restricted to a detailed interval history and a detailed examination. This is inconsistent with current clinical practice. To correct this problem, the association proposed a new fourth level of service code to permit the reporting of a comprehensive level of service.

Finally, AMDA recommended adding a new code in a new subsection (Other Nursing Facility Care) to allow the reporting of a comprehensive annual assessment. "This is a service that is unique to the NF setting and the extent of history and examination and the complexity of medical decision making are not well described by the other E & M codes in this section."

New NF Codes

Below are the new descriptors for the redefined Nursing Facility Code family. CPT Codes 99301-99303 and 99311-99313 have been deleted and have been replaced by 99304-99306 and 99307-99310, respectively.

99304 Initial nursing facility care, per day, for the evaluation and management of a patient which requires these three key components:

• a detailed or comprehensive history;
• a detailed or comprehensive examination; and
• medical decision making that is straightforward or of low complexity.

Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.

Usually, the problem(s) requiring admission are of low severity.

99305 Initial nursing facility care, per day, for the evaluation and management of a patient which requires these three key components:

• a comprehensive history;
• a comprehensive examination; and
• medical decision making of moderate complexity.

Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.

Usually, the problem(s) requiring admission are of moderate severity.

99306 Initial nursing facility care, per day, for the evaluation and management of a patient, which requires these three key components:

• a comprehensive history;
• a comprehensive examination; and
• medical decision making of high complexity.

Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.

Usually, the problem(s) requiring admission are of high severity.

There are now 4 codes for Subsequent Nursing Facility Care:

99307 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least two of these three key components:

• a problem focused interval history;
• a problem focused examination;
• straightforward medical decision making.

Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.

Usually, the patient is stable, recovering, or improving.

99308 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least two of these three key components:

• an expanded problem focused interval history;
• an expanded problem focused examination;
• medical decision making of low complexity.

Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.

Usually, the patient is responding inadequately to therapy or has developed a minor complication.

99309 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least two of these three key components:

• a detailed interval history;
• a detailed examination;
• medical decision making of moderate complexity.

Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.

The patient may be unstable or may have developed a significant new problem requiring immediate physician attention.

The Discharge Codes have remained the same:

99315 Nursing facility discharge day management; 30 minutes or less.

99316 Nursing facility discharge day management; more than 30 minutes.

This is the new annual assessment code:

99318 Evaluation and management of a 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 of low to moderate complexity.

Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.

Usually, the patient is stable, recovering, or improving.

At the same time the NF Code family was being revised, the nine codes of the Domiciliary Care Services family (99341-99350) also were given updated descriptors and vignettes.

For more information...

For more information on the new codes, AMDA will be revising its CPT Coding Booklet that will be available on the AMDA website in December 2005. The revised booklet will update the NF vignettes and frequently asked questions on physician visits, the use of nonphysician practitioners, hospice services, and domiciliary care.

On November 2, 2005, CMS published the Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule for Calendar Year 2006. AMDA has published a review of the fee schedule on the AMDA Government Affairs website at http://www.amda.com/federalaffairs/feeschedule2006.htm.

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