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This month's coding questions look at coding for transition of care for a nursing facility patient and on Annual Wellness visits.
Q: We have a patient that was in a nursing facility for a few months and just discharged last Friday. The doctor and staff has spent over an hour working with the patient's spouse trying to rearrange [health and home care] and [durable medical equipment] that the facility had already arranged for them. This started last week prior to discharge and has continued on every day this week. The patient is coming in tomorrow for hospital follow up. We want to charge a transition of care 99495 and also a 99358 for the coordination of care time spent since patient was sent home.
A: Good thinking with those codes, but you'll have to give up the 99495 if you want to use the 99358. The correct coding initiatives edits bundle the 99358 into a 99495.
As an option, you may be able to bill the office visit by time. Often those transitional visits are about counseling. Especially if the spouse is involved. When the patient came - any chance it lasted 40 minutes? If so, he can bill a 99215 based on time, it is the same relative value unit (RVU) as the 99495, and he can bill that with the 99358. If not, he may have to go with a 99358 and a 99214 - a net loss of about .6 RVU.
Remember that he could use a 99359 along with the 99358 if he documented that he spent an additional 75 minutes in non-face to face prolonged care.
Q: For Annual Wellness visits, I know the patient must complete some type of risk assessment/ history update form. I do something a bit different and use a work sheet which lists the required history items and assessments. I check the boxes to be sure all items are complete and scan this form. When the patient leaves their history forms at home, which happens every week I ask the questions at the visit and comment that this was done. Is this ok?
A: The AWVs do require a HRA [health risk assessment] - and most people use a form filled out by the patient. But to your point -it doesn't always work out that way. As long as it is recognizably an HRA, maybe just a case of labeling it so, then you have met the criteria.
Q:To capture all of the diagnoses for risk adjustment factor (RAF) scoring, I drop the pertinent ICD-10 code into assessment and plan, comment that this is managed elsewhere or stable, although all of these are not listed in the history of present illness (HPI). I indicate the management as appropriate. If I want to include some diagnoses for risk purposes, I use an auto text as follows: "Patient has a number of chronic conditions. Those managed this visit were discussed in HPI and assessment and plan. Others were also listed in the assessment and plan to accurately reflect the patient's medical conditions and health status"
When the patient is billed and EM and [given an] AWV, I put the diagnoses I manage first, then the wellness code, then the other diagnostic codes, which I am not managing at that visit below and use this comment: "Patient has a number of chronic conditions. Those managed this visit were discussed in HPI and assessment and plan."
Are these methods sound?
Answer. As far as the documentation in the A/P - you have arrived at very practical solution.
We are living in a time where both fee-for-service and risk adjustment reimbursement systems require expression in the A/P. You need to show the status and management of problems for both systems, with an emphasis on the scope of management for RAF.
Some providers do as you suggest, list the problems you managed today - with a clear status per problem, including prevention if appropriate, then add a section heading along the lines of 'Chronic Problems not Addressed Today.' This allows them to keep track of, or account for, other co-morbid conditions that may not be a central part of that day's visit. Your solution is a good real-world answer to a real-world issue.