REVISED NURSING FACILITY CPT CODES BETTER REFLECT COMPLEXITY OF CARE

Author(s): 

Linda Hiddeman Barondess,
Executive Vice-President

Though adjusting to the inevitable changes in Current Procedural Terminology (CPT) codes that kick in at the start of each year can be frustrating at times, this year’s changes in the Nursing Facility family of codes are cause for some celebration.

For the past two years, medical organizations involved in long-term care have advocated for the introduction of additional Nursing Facility Codes that better reflect the complexity of care provided to residents of long-term care facilities. The American Geriatrics Society, the American Academy of Family Physicians, and the American Academy of Home Care Physicians—in an effort spearheaded by the American Medical Directors Association—urged the adoption of revised codes that recognize more complex evaluation and treatment. The fact is, many patients in long-term care facilities, particularly older patients, have multiple, chronic health conditions. These can make evaluation and treatment complicated and time consuming. Existing codes, the medical organizations argued, didn’t reflect the investment of time and effort inherent in caring for residents with multiple comorbidities and complex health problems.

Thanks to some welcome changes that took effect January 1 of this year, the Nursing Facility family of codes now includes codes that recognize higher-level evaluation and treatment.

Previously, CPT had three codes for comprehensive nursing facility assessments for: (1) annual assessment; (2) assessment of a “major permanent change of status”; and (3) assessment at the time of admission. CPT had three additional codes for subsequent nursing care. While these subsequent nursing care codes allowed for gradations in the degree of complexity of evaluation and treatment, the highest level of service was characterized by only a detailed interval history and examination.

The revised CPT Nursing Facility codes address these shortcomings. For starters, there are three new codes for initial nursing facility care corresponding to: (1) evaluation and management of a patient, typically with problems of low severity, in which medical decision making is straightforward or of low complexity; (2) evaluation and management of a patient, usually one with problems of moderate severity, in which decision making is of moderate complexity; and (3) evaluation and management of a patient, typically with problems of high severity, involving medical decision making of high complexity.

In addition, there are now four codes for subsequent nursing facility care, each corresponding to a different level of care. For example, the first code corresponds to nursing facility evaluation and management of a patient, usually stable, recovering or improving, with at least two of the following: a problem-focused interval history, a problem-focused examination, and straightforward decision making. The fourth code, in contrast, corresponds to evaluation and management of a patient, who may be unstable or may have developed a new problem requiring immediate physician attention, with at least two of the following: a comprehensive interval history, a comprehensive examination, or medical decision making of high complexity.

These are all steps in the right direction.

So, try to keep the benefits of these changes in mind while making the sometimes bumpy transition to new coding. To make that transition easier, AGS has posted major coding changes, effective in January 2006, to the “Coding Corner” in the “MyAGS” section of its website. Members can sign in to Coding Corner by visiting www.americangeriatrics.org and clicking on “MyAGS” on the lefthand tool bar.

Regards