The scenario involving Sally, an 80-year-old preparing for surgery with no local family, involves the completion of advanced directives. In medical coding, the appropriate codes for the nurse's time spent on these tasks are reported using Evaluation and Management (E/M) codes.
These codes describe the complexity of the medical decision-making and the extent of the nurse's involvement.
The specific code(s) used would depend on the level of service provided, considering factors such as the complexity of the discussion, the time spent, and the comprehensiveness of the advanced directives completed.
Common E/M codes for such services include 99497 (Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face) and 99498 (each additional 30 minutes, face-to-face). These codes appropriately capture the nurse's effort in ensuring comprehensive advanced directives for Sally.