When reporting E/M services for a patient in a nursing home, what must the coder determine first?

When reporting Evaluation and Management (E/M) services for a patient in a nursing home, the coder must first determine whether the care being provided is classified as initial or subsequent care. This distinction is crucial because it affects the coding and reimbursement process.

Initial care typically refers to the patient's first encounter with the healthcare provider in a specific setting, which requires a comprehensive evaluation and usually mandates more detailed documentation. Subsequent care refers to follow-up visits where the provider continues to manage the patient's care already initiated during the initial visit. Each of these categories has different coding guidelines and requirements, influencing the level of complexity, time spent, and documentation needed.

Understanding whether the care is initial or subsequent allows the coder to select the appropriate code that accurately reflects the services rendered and ensures compliance with coding standards set forth by the American Medical Association (AMA) and Centers for Medicare and Medicaid Services (CMS). This step is foundational for accurate coding before considering other factors such as the patient's insurance status, type of illness, or discharge status.