Question

1. Lily Wilson, a new patient, is seen by the physician in a skilled nursing facility for an initial nursing facility assessment. Mrs. Wilson recently suffered a cerebral thrombosis with residual dysphasia and paresis of the left extremities. She was transferred from an acute care hospital to the skilled nursing facility for concentrated rehabilitation. Mrs. Wilson also has an arteriosclerotic heart disease with a permanent pacemaker in place, rheumatoid arthritis, urinary incontinence, and a macular degeneration in her left eye. The physician, who did not know Mrs. Wilson prior to her transfer, performs a comprehensive history and physical examination. Given the patients multiple diagnosis and the moderate amount of data the physician has reviewed the MDM is of high complexity

CPT code     _________

Answer 1

99306

Initial nursing facility care, per day, for the evaluation and management of a patient, which requires these 3 key components: a comprehensive history; a comprehensive examination; and medical decision making of high complexity. Usually, the problem(s) requiring admission are of high severity. Typically, 45 minutes are spent at the bedside and on the patient's facility floor or unit.

•Comprehensive history: Requires 4 or more elements of the history of present illness (HPI) OR documentation of the status of THREE chronic medical conditions. At least one item each from past history (illnesses, operations, injuries, treatments), social history and family history is also required. In addition, a complete review of systems is also required (10 or more organ systems).

•Comprehensive examination: The CMS E&M services guide on pages 29 and 30 describe the acceptable body areas and organ systems for physical exam. Either a general multi-system examination or complete examination of a single organ system .

•Medical decision making of high complexity (MDM):