nursing home visit billing codes

A step-by-step approach that saves time coding E/M office visits can now be tailored to hospital and nursing home E/M visits as well.

KEITH W. MILLETTE, MD, FAAFP, RPh

Fam Pract Manag. 2023;30(1):8-12

Author disclosure: no relevant financial relationships.

Following the major revisions to coding evaluation and management (E/M) office visits in 2021, 1 a similar revamp has been made for coding E/M visits in other settings. Effective Jan. 1, 2023, the history and physical examination requirements have been eliminated for coding hospital and nursing home visits. 2 As with office visits, hospital and nursing home coding is now based solely on medical decision making (MDM) or total time (except for emergency department visits, which must be coded based on MDM, and hospital discharge visits, which must be coded based on time). This further streamlines E/M coding, creating one unified set of rules for office, nursing home, and hospital visits.

Hospital and nursing home E/M visits are divided into three groups: initial services (i.e., admissions), subsequent services, and discharge services. According to the American Medical Association (AMA), initial visits are “when the patient has not received any professional services from the physician or other qualified health care professional or another physician or other qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, during the inpatient, observation, or nursing facility admission and stay.” 2 After the patient has received care from that group once, all other visits are subsequent until the discharge service. When the patient transitions from inpatient to observation, or vice versa, that does not begin a new stay eligible for an initial services visit.

CPT codes 99234-99236 are for patients admitted to the hospital and discharged on the same date. For patients with multi-day stays, use 99221-99223 for initial services, 99231-99233 for subsequent visits, and 99238-99239 for discharge services.

Initial nursing home visits are coded with 99304-99306. CPT is deleting the code for nursing home annual exams (99318), which will instead be coded as subsequent nursing home visits (99307-99310).

Two sets of observation care codes (99217-99220 and 99224-99226) should no longer be used as of Jan. 1. Observation services have instead been merged into the corresponding initial service, subsequent service, and discharge codes.

These changes open the door to a simpler, quicker coding process. Many of the principles that already apply to E/M office visit coding now apply to hospital and nursing home E/M coding, but there are some differences in the details. This short guide can help physicians navigate the changes.

Coding for evaluation and management (E/M) visits in hospitals and nursing homes is now much like coding E/M office visits.

This unified set of coding rules allows physicians to quickly code nearly all visits using a template that starts with total time.

There are a few key differences to be aware of, such as total time spent past midnight on the date of service can be counted for hospital E/M visits, but not for office E/M visits.

MEDICAL DECISION MAKING

Determining the level of MDM for hospital and nursing home visits is now much like doing so for office visits. 3 The four MDM levels are straightforward, low, moderate, and high. They are determined by three factors: the number and complexity of problems addressed, the amount and complexity of data reviewed, and the patient's risk of complications, morbidity, or mortality.

If you feel confident coding office visits based on MDM, you can use that knowledge to code hospital and nursing home visits based on MDM as follows:

A level 1 initial or subsequent hospital visit requires the same MDM components as a level 3 office visit,

A level 2 initial or subsequent hospital visit requires the same MDM components as a level 4 office visit,

A level 3 initial or subsequent hospital visit requires the same MDM components as a level 5 office visit.

Several medical decisions that are more common in hospitals than office settings carry enough risk that, when paired with high-level problems, they call for the top visit level. These include the decision to escalate hospital care (e.g., transfer to the intensive care unit), the decision to deescalate care or discuss do-not-resuscitate orders due to poor prognosis, the decision to use IV narcotics or other drugs that require intensive monitoring, and decisions regarding emergency surgery for patients with or without risk factors or non-emergency surgery for patients with risk factors.

There are new time thresholds for each level of service for initial hospital visits, subsequent hospital visits, and nursing home visits to use when you are coding by total time. Instead of offering a time range like office visits (e.g., a 99214 office visit requires 30–39 minutes), nursing home and hospital care visits require that you meet or exceed specific times (e.g., a 99232 subsequent hospital visit requires 35 or more minutes).

When coding initial hospital visits by total time, you can count all the time you spend caring for the patient on admission even if some of it extends after midnight on the calendar day of the admission. According to the AMA, “a continuous service that spans the transition of two calendar dates is a single service and is reported on one calendar date. If the service is continuous before and through midnight, all the time may be applied to the reported date of service.” 3 This differs from office visits, for which you may count only the time on the date of the visit. Otherwise, the definition of total time for hospital and nursing home E/M visits is similar to that of office visits. It includes the time you personally spend on E/M for that patient before, during, and after the face-to-face services. It does not include staff time, time spent on separately reportable procedures, travel time, or teaching time.

A SIMPLER WAY TO CODE

Like the 2021 changes to office visit E/M coding, the 2023 changes should make coding hospital and nursing home E/M visits simpler and quicker.

The universal coding template suggests coding by time first if that will appropriately credit you for the work you did. It's the most straightforward and easy method. But if you believe MDM will credit you for a higher level of work, then step 2 is to determine what level of problems (low, moderate, or high) you addressed and whether you managed (prescribed, adjusted, or decided to keep the same) a prescription medication. Answering those two questions allows you to code most visits quickly using MDM. For the few visits that remain, you will need to proceed to steps 3 or 4, which may require you to tally data points and are therefore more time-consuming.

The template was adapted from a prior FPM article on office E/M coding 4 by adding nursing home and hospital visit times and relabeling office-visit level 3, 4, and 5 problems as low-, moderate-, and high-level problems.

UNIVERSAL CODING TEMPLATE

Step 3: MDM with simple data

Moderate-level problem PLUS one of the following:

• Interpret one study (e.g., “I personally looked at the x-ray, and it shows …”),
• Discuss patient management or a study with an external physician (one who is not in the same group practice as you or is in a different specialty or subspecialty),
• Modify workup or treatment because of social determinants of health.

EQUALS moderate-level visit, even without medication management (see codes in Step 2).

Step 4: MDM counting data points

Moderate-level problem PLUS at least three points from data counting (below),

EQUALS moderate-level visit (see codes in Step 2).

High-level problem PLUS at least two of these three:

• Interpret one study (e.g., "I personally looked at the x-ray, and it shows..."),
• Discuss patient management or a study with an external physician,
• At least three points from data counting (below),

EQUALS high-level visit (see codes in Step 2).

Data counting:

• Review/order unique test/study: 1 point for each,
• Review external notes: 1 point for each unique source,
• Assessment requiring use of an independent historian (family member or other person who can provide a reliable history for a patient who is unable to): 1 point max.

Documentation to support your coding should also be easier going forward. While documenting a medically appropriate history and physical exam is still certainly important for good patient care, it's no longer required for coding; therefore, you should be able to determine the code level from only a few lines of documentation. The quiz below provides some examples to pair with the coding template for practice.

Hopefully, using this step-by-step approach to the 2023 E/M coding changes will allow you to code many types of visits more quickly and accurately so you can spend more time with your patients and less time on the computer.

Millette KW. Countdown to the E/M coding changes. Fam Pract Manag . 2020;27(5):29-36.

CPT evaluation and management (E/M) code and guideline changes. American Medical Association. Accessed Nov. 2, 2022. https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf

Table 2 - CPT E/M office revisions level of medical decision making (MDM). American Medical Association. Accessed Nov. 2, 2022. https://www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf

Millette KW. A step-by-step time-saving approach to coding office visits. Fam Pract Manag . 2021;28(4):21-26.

Continue Reading

More in FPM

More in pubmed.

Copyright © 2023 by the American Academy of Family Physicians.

This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP.  See permissions  for copyright questions and/or permission requests.

Copyright © 2024 American Academy of Family Physicians. All Rights Reserved.

• For Ophthalmologists
• For Practice Management
• For Clinical Teams
• For Public & Patients

Museum of the Eye

• Managing Your Practice
• Managing Your Practice Topics
• Emergency Preparedness and Cybersecurity
• Practice Forms Library
• Practice Management News & Advice
• Lean Management
• Video Library
• My Green Doctor
• Ophthalmology Job Center
• Benchmarking & Salary Tools
• Academy Consultations
• Consultant Directory
• Coding Topics
• Ask the Coding Experts
• Cataract Surgery
• Codequest Events
• Coding for Injectable Drugs
• EM Documentation
• Ophthalmic Coding Specialist (OCS) Exam
• Savvy Coder
• Submit an Instruction Course
• Codequest Courses
• Mid-Year Forum
• Webinar Recordings
• Upcoming Webinars
• IRIS Registry
• Merit-Based Incentive Payment
• Medicare & MIPS
• Promoting Interoperability
• Improvement Activities
• Avoid a Penalty
• Medicare Participation Options
• Medicare Advantage Plans
• New Medicare Card
• Provider Enrollment, Chain and Ownership System (PECOS)
• Membership Benefits
• Renew/Pay Dues
• AAOE Membership
• AAOE Board of Directors
• Practice Views
• AAOE Content Committee
• Volunteer Opportunities
• For Practice Management /
• Ask the Coding Experts /
• Coding Physician Visits in Skilled Nursing Facilit...

Narrow Your Results

Select code type, select topic.

• Cataract/Anterior Segment
• Coding Competency
• Coronavirus
• Oculofacial
• Pediatric/Strabismus
• Revenue Cycle Management
• Telemedicine
• Testing Services
• Trauma Coding

Select Category

About Our Coding Experts

About Our Coding Experts

Our expert staff have decades of combined experience, covering all aspects of coding and reimbursement.

John T. McAllister, MD Secretary, Federal Affairs

Michael X. Repka, MD, MBA Medical Director, Government Affairs

Joy Woodke, COE, OCS, OCSR Director, Coding and Reimbursement

Matthew Baugh, MHA, COT, OCS, OCSR Manager, Coding and Reimbursement Heather H. Dunn, COA, OCS, OCSR Manager, Coding and Reimbursement

Ask the Experts!

Email  [email protected]

Note: Coding regulations and edits can change often. Academy coding advice is based on current information. Visit aao.org/coding  for the most recent updates. Information provided by our coding experts is copyrighted by the American Academy of Ophthalmology and intended for individual practice use only.

Coding Physician Visits in Skilled Nursing Facilities/Nursing Facilities

• Mark Complete

As of April 22, due to the COVID-19 public health emergency , CMS is waiving the requirement in 42 CFR 483.30 for physicians and non-physician practitioners to perform in-person visits for nursing home residents and allow visits to be conducted, as appropriate, via telehealth options. Prior to this, telehealth was only available for established patient visits.

Coding for Skilled Nursing Facility

• To be reported when the MD, DO, OD visits the patient in the Skilled Nursing Facility.
• Place of Service is 13.
• Initial Visit whether patient is new or established 99304, 99305, 99306
• Subsequent Skilled Nursing Facility visits performed in person or via telehealth: 99307, 99308, 99309, 99310

Coding for Nursing Home Visits

• To be reported when the MD, DO, OD visits the patient in a Nursing Home.
• Place of service is 13
• New Patient: 99324, 99325, 99326, 99327, 99328
• Established Patient: 99334, 99335, 99336, 99337
• Modifier -25

Note: When billing an intravitreal injection (or any minor surgery) the same day as an encounter, consider the definition of modifier -25 and although medically necessary, if the established patient exam is performed solely to confirm the need for the injection, the exam is not separately billable.

Coding for Home Visits

• To be reported when the MD, DO, OD visits the patient at their home.
• Place of service is 12
• New Patient: 99341, 99342, 99343, 99344, 99345
• Established Patient: 99347, 99348, 99349, 99350

View updates on telemedicine coding to use in your practice based on guidelines from CMS.

All content on the Academy’s website is protected by copyright law and the  Terms of Service . This content may not be reproduced, copied, or put into any artificial intelligence program, including large language and generative AI models, without  permission from the Academy.

• About the Academy
• Jobs at the Academy
• Financial Relationships with Industry
• Medical Disclaimer
• Privacy Policy
• Terms of Service
• Statement on Artificial Intelligence
• For Advertisers

FOLLOW THE ACADEMY

Medical Professionals

Public & Patients

• (800) 516-5234
• [email protected]
• 134 N 4th St, Brooklyn, NY 11249

iRCM is an industry leader with innovative technology and an expert team. We are a complete Revenue Cycle Management solution that streamlines reimbursements and delivers remarkable results.

• 134 N 4Th Street Brooklyn, NY 11249
• 718-303-0763
• Terms and Conditions
• Solo/Private Practices
• ASC Billing
• SNF Billing

• View All Services
• View All Specialties

Understanding Nursing Home Billing – Codes and Workflow

What Is Nursing Home Billing and How Does It Work?

• Billing frequency specified in the contract
• Inclusion of basic charges and ancillary servicess Rates influenced by care complexity, service level, room type, and amenities

Components of Nursing Home Billing Codes and Procedures

• Assessment of Care Level
• Insurance Plans Coverage
• Billing Period Overview
• Coding Framework
• Specific CPT Codes in Use
• Modifiers Enhancing Specificity

Assessment of Care Level in Nursing Home Billing

Primary care:.

• Serving as the foundation of healthcare, primary care involves general practitioners, such as physicians, nurse practitioners, and physician assistants.
• These healthcare professionals provide a broad range of medical services, acting as the initial point of contact for patients and playing a crucial role in the healthcare system.

Secondary Care:

• As the next stage in the healthcare continuum, secondary care entails primary care providers referring patients to specialists like pathologists and oncologists.
• Specialists in secondary care offer in-depth treatment and management of specific conditions, contributing expertise to the diagnosis and treatment of complex medical issues.

Tertiary Care:

• Representing the highest level of specialty care, tertiary care employs advanced technologies and procedures to address complex and severe cases.
• Specialized facilities, such as dialysis and neurosurgery centers, provide highly specific care, significantly impacting patient outcomes and enhancing overall quality of life.

Quaternary Care:

• At the forefront of healthcare, quaternary care offers the most advanced and experimental treatments.
• Limited to select institutions, these treatments often involve a multidisciplinary approach, pushing the boundaries of what is achievable in healthcare and contributing to the advancement of medical knowledge.

Insurance Coverage in Nursing Home Billing

Billing period overview in nursing home billing.

• The billing cycle, typically calculated on a monthly basis, defines the timeframe for each billing occurrence.
• In cases where a resident’s stay doesn’t initiate on the first day of the billing cycle, the nursing home employs a proration approach.
• The prorated amount is calculated by multiplying the per-day charge for room and board by the number of days spent in the facility during the admission month.
• To provide residents with foresight into upcoming costs, some care facilities issue a pre-bill for the forthcoming month.

Coding Framework in Nursing Home Billing

ICD-10 codes: Dedicated to conveying patient diagnoses, ICD-10 codes are pivotal in the billing landscape, ensuring the inclusion of medical procedures and services in nursing home bills.

HCPCS codes : Designed to highlight specific services or supplies offered to patients, HCPCS codes find application in billing procedures, particularly for Medicare and Medicaid transactions.

CPT codes: Offering granularity, CPT codes play a vital role in pinpointing the exact procedures or services administered to patients. In nursing home billing, these codes are fundamental for accurately billing private insurance.

Revenue codes: Functioning as identifiers for the type of service provided, revenue codes are instrumental in the billing processes associated with Medicare and Medicaid in nursing home facilities.

This coding framework not only establishes a standardized approach but also ensures the meticulous representation of the diverse services within nursing homes. It underpins the integrity of billing procedures, aligning with regulatory guidelines and fostering transparency in financial transactions.

Specific CPT Codes in Nursing Home Billing

99304-99306: Initial Nursing Facility Care

These codes specifically designate the billing for the initial care provided to residents entering a nursing facility. They encompass a range of services during the initial evaluation and consultation phase.

99307-99310: Subsequent Nursing Facility Care

Covering subsequent care visits within the nursing facility, these codes capture the ongoing medical services and consultations provided to residents after the initial phase.

99315-99316: Nursing Facility Discharge Services

These codes are utilized for billing services related to the discharge of residents from the nursing facility. They encompass the management and coordination involved in the discharge process.

This utilization of specific CPT codes in nursing home billing ensures a detailed and accurate depiction of the diverse medical services provided at different stages of a resident’s stay. It facilitates a systematic approach to billing, aiding in transparent financial transactions and adherence to regulatory standards.

Modifiers in Nursing Home Billing - Refining Specificity

Modifiers, integral in nursing home billing, enhance the precision of services and procedures documented with Current Procedural Terminology (CPT) codes. Employed alongside these codes, modifiers clarify modifications made to healthcare interventions, contributing to detailed billing information.

Modifier 25: Indicates a separately identifiable Evaluation and Management (E/M) service on the same day as a procedure, highlighting comprehensive care.

Modifier 59: Designates a distinct or independent procedure or service, ensuring clear differentiation between healthcare interventions.

Modifier 51: Signifies multiple procedures during a single session, offering insight into the complexity of medical services.

Modifier -52: Indicates partial reduction or elimination of a procedure, providing transparency on adjustments made during care.

Modifier -53: Denotes discontinuation of a procedure due to extenuating circumstances, explaining instances where healthcare interventions may not be completed as planned.

Modifier -74: Highlights procedures performed in a teaching setting by a resident under direct supervision, emphasizing educational context.

Use of modifiers may vary by payer, necessitating collaboration with the billing department and insurers. Facilities may impose restrictions, requiring consultation with the billing department for accurate guidance.

Optimizing Financial Transparency in Nursing Home Billing

Financial transparency is paramount in nursing home billing to build trust and ensure clarity for residents and their families. Here, we explore strategies to optimize financial transparency in the billing process: Transparent Fee Structures: Clearly outline charges for core services and additional amenities in the fee structure.

Detailed Billing Statements: Provide residents with comprehensive monthly billing statements, detailing costs and associated services.

Accessible Payment Policies: Communicate easily understandable payment policies, including deadlines, accepted methods, and penalties for late payments.

Implementing these measures promotes financial transparency, contributing to a positive experience for residents and their families in navigating nursing home billing processes.

Final Thoughts

Table of contents, recent post.

5 Signs Your Medical Claims Might Be Underpaid

Third-Party Medical Billing and How Can it Drive Revenue Growth

A Guide to CPT Code for Laser Therapy

What is bundling and unbundling in Medical Billing?

RVUs in Medical Billing – The Key to Fair Provider Compensation

Medical billing services, credentialing & enrollment, medical coding services, quality payment program, front office management, professional staffing solutions, get customized billing quote, our services.

• (718) 303-0763

ASC billing code and payment. SNF billing Guide

Ambulatory surgical center billing code guidelines and how to get payment from insurance. ASC denial, CPT CODES , Authorization and referral Guide. Multiple procedure, Surgical procedure tips. What to get the correct reimbursement in ASC billing setup. SNF billing Guide, tips to use correct CPT AND POS.

• NEW proposed ASC CPT CODE 2016 list
• Payment for Multiple surgery under ASC setup
• Services included and not included in ASC billing
• Skilled Nursing Facility (SNF) Billing Guide

Friday, June 3, 2016

Cpt 99304, 99305, 99306, 99307, 99308, 99309 - snf visit codes, no comments:, post a comment, popular posts.

• What is revenue code - 760, 761, 450, 360 , 271 - 279 Revenue Code Revenue codes are 3-digit numbers that are used on hospital bills to tell the insurance companies either where the patient wa...
• CPT 99304, 99305, 99306, 99307, 99308, 99309 - SNF visit codes Procedure code and Description CPT/HCPCS Codes G9685 Evaluation and management of a beneficiary's acute change in condition in a nu...
• place of service for UB 04 claim and modifier reporting field Place of Service Codes Place of service codes do not apply when filing the UB-04 claim form. Only type of Bill has been used in UB 04 FORM...
• CPT code 65730 and 65759, 65710, 65750 CPT CODE DESCRIPTION OF SERVICE FEE 65710 KERATOPLASTY (CORN. TRANS), LAMELLAR 677.77 65730 KERATOPLASTY, PENETRATING (NON-AHAKIA) 754....
• CPT CODE 99070 WITH DI modifier CPT CODE 99070 - Supplies and materials (except spectacles), provided by the physician or other qualified health care professional over and ...
• Walker CPT code list HCPCS CODES: Group 1 Codes: A4636 REPLACEMENT, HANDGRIP, CANE, CRUTCH, OR WALKER, EACH A4637 REPLACEMENT, TIP, CANE, CRUTCH, WALKE...
• Usage of Modifier TC under ASC setup - Guideline Effective for dates of service on or after January 1, 2009 for allowed ASC claims, if modifier = TC, contractors must ensure that either: ...
• CPT CODE 99307, 99310 AND 99318 Procedure code and Description 99307 NURSING FAC CARE SUBSEQ $43.16 - $47.96 - 99308 NURSING FAC CARE SUBSEQ $66.72 - $74.13 - 99309 NUR...
• CPT code A0427 - Reason for denial Common payment errors for ambulance emergency transport HCPCS code A0427  One of the top contributors to First Coast Service Options’ (Fir...
• Detailed overview of Health information technology What Is Health IT?  The  term  “health  information  technology”  (health  IT)  refers  to  the  electronic systems health care professional...

Nursing Home Billing Guidelines & Codes - A Roadmap to Reimbursement

Maximize your nursing home reimbursement with ease: Expert guidance on the latest billing guidelines & codes.

Are you a healthcare provider experiencing difficulties in navigating the complex world of nursing home billing and coding? Nursing Homes have an immense role to play, whether for long-term or short-term care. Nursing homes can be categorized into ALF( Assisted Living Facilities), SNF (Skilled Nursing Facilities SNF), and ALC (Assisted Living Centers).

This comprehensive guide will break down the latest nursing home billing guidelines and decipher billing code codes, giving you an understanding of constantly changing CMS guidelines to ensure your facility receives the proper reimbursement for the vital care provided to your residents.

Nursing Home Billing Guidelines

Nursing homes, also known as skilled nursing facilities, provide around-the-clock medical care and assistance with daily living activities for older adults and those with chronic health conditions.

These facilities are essential to the healthcare system, as they allow individuals to receive the care they need in a safe and comfortable environment. However, with the care and services provided come billing and reimbursement responsibilities for the nursing home administrators.

To ensure proper reimbursement and compliance with regulations, nursing home administrators must understand and follow the various nursing home billing guidelines set forth by Medicare and Medicaid and private insurance companies.

The level of care provided by a nursing home facility is the primary determinant of how much reimbursement you can expect from insurance providers.

Knowing what type of care your residents need and ensuring that your facility meets these requirements can help ensure proper payment for services rendered. There are four types of care involved:

• Primary care is the cornerstone of healthcare, where general practitioners such as physicians, nurse practitioners, and physician assistants provide a wide range of medical services to individuals dealing with common illnesses and injuries. These providers act as the first point of contact for patients and play a vital role in the healthcare system.
• Secondary care is the next step in the healthcare journey. Primary care providers refer patients to specialists such as pathologists and oncologists for more in-depth treatment and management of specific conditions. These specialists provide expert care and play a critical role in diagnosing and treating complex conditions.
• Tertiary care is the highest level of specialty care, where advanced technologies and procedures are employed to tackle complex and severe cases. These specialized facilities, such as dialysis and neurosurgery centers, provide the most specialized care and play a vital role in saving lives and improving the quality of life for patients.
• Quaternary care is the cutting-edge of healthcare, where the most advanced and experimental treatments are offered to patients. These treatments are typically only available at select institutions and often involve a multidisciplinary approach to care. Quaternary care is critical in pushing the boundaries of what is possible in healthcare and advancing medical knowledge.

Insurance Plans Coverage Criteria

Medicare Part A and Part B plans have distinct acceptance criteria for nursing home services. Under Part A, a patient in a nursing facility is covered for 20 days. Beyond the 21st day, Medicare will provide partial coverage for services, and co-insurance will apply.

It is important to note that coverage criteria are limited to the extent of available benefits. Once the patient's benefits have been exhausted, the nursing facility staff will submit claims to the resident for additional coverage.

Medicare part B coverage kicks in for long-term care facilities once the patient has been disqualified for part A Coverage. Some of the most often reimbursed services in long-term care are physical, occupational, and speech therapy services.

Billing Period for Nursing Home

Claims for Nursing home billing are sent monthly. Nursing homes usually bill patients by using CMS-1450 (which is also called UB-04 ). Claims can also be sent if the patient is:

• Dropped from skill care
• Benefits are exhausted

For providers to bill accurately, they should remember that proper documentation is made.

Billing Cycle

The billing cycle for nursing home services requires a series of steps that ensure accurate and timely billing to patients or their insurance providers.

• First, the MAC (Medicare Administrative Contractor) will return a continuing stay bill if the prior bill has not yet been processed. In this case, it is important to hold onto the returned bill until the Remittance Advice (RA) for the prior bill has been received.
• Next, it is important to note that certain days, such as the day of discharge or death or the day when a patient begins a Leave of Absence (LOA), are not counted as utilization days for billing purposes. Additionally, if a patient discharges and returns before the following midnight, it is not considered a discharge for billing purposes.
• Another important aspect of the billing cycle is the HIPPS rate code that appears on the claim. This code must match the assessment transmitted and accepted by the state where the facility operates.
• Once all the information is collected and verified, the bill is submitted to the patient or insurance provider. The payment is then processed, and the facility receives a Remittance Advice (RA) indicating the payment amount and any adjustments made to the bill.
• Finally, the billing cycle is completed when the facility receives payment for the services provided, and the billing records are updated accordingly. It is important to note that the billing cycle may vary depending on the facility's policies, procedures, and the type of services provided.

Following the proper nursing home billing guidelines, a path can be set for proper reimbursement from the insurance side. This should also be kept in mind that guides are constantly changing, so it’s better to follow up with CMS to remain updated.

What are the codes used in Nursing Home Billing

In nursing home billing, several codes are used to describe the services provided to patients accurately.

ICD-10 codes: These codes are used to indicate the diagnosis of the patient and are used for billing medical procedures and services.

HCPCS codes: These codes are used to indicate the specific services or supplies provided to the patient and are used for billing Medicare and Medicaid.

CPT codes: These codes are used to indicate the specific procedures or services provided to the patient and are used for billing private insurance.

Revenue codes: These codes indicate the type of service provided and are used for billing Medicare and Medicaid.

CPT Codes used in Nursing Home Billing

In nursing home billing, Current Procedural Terminology (CPT) codes are used to indicate the specific procedures or services provided to patients. These codes are used for billing private insurance and are developed and maintained by the American Medical Association (AMA).

Examples of CPT codes that are primarily used in nursing home billing include:

• Evaluation and management codes (99304-99306) - to bill for physician visits, including initial evaluations and consultations.
• Nursing Home Discharge Management codes ( 99315 & 99316 ) – to be billed when for nursing facility discharge day management
• Follow-Up Codes(99307-99310) – Used to be billed for subsequent nursing facility care visits
• Procedure codes (10040-69990) - are used to bill for procedures such as wound care, injections, and diagnostic tests.
• Physical therapy codes (97001-97755 ) - These codes are used to bill for physical therapy services provided by a therapist or assistant.
• Occupational therapy codes (97001-97755) - used to bill for occupational therapy services provided by a therapist or assistant.
• Speech-language pathology codes (92526-92625) - used to bill for speech-language pathology services provided by a therapist or assistant.

It's important to note that the codes used will depend on the specific services provided, so it's essential to refer to the AMA's CPT codes for the most up-to-date information. Additionally, it's important to check with the facility's billing department and the private insurance company to ensure that the codes used are valid for reimbursement.

Modifiers Used Along CPT Codes

Modifiers are used in conjunction with CPT codes to indicate that a service or procedure has been modified in some way.

Here are some examples of modifiers that how modifiers are used in nursing home billing:

Modifier 25: This modifier indicates that a significant, separately identifiable Evaluation and Management (E/M) service was provided on the same day as a procedure or service.

Modifier 59: This modifier indicates that a procedure or service was distinct or independent from other services performed on the same day.

Modifier 51: This modifier indicates that multiple procedures were performed during a single session.

Modifier -52: This modifier is used to indicate that a procedure or service was partially reduced or eliminated at the physician's discretion.

Modifier -53: This modifier is used to indicate that a procedure or service was discontinued due to extenuating circumstances.

Modifier -74: This modifier is used to indicate that a procedure or service was performed in a teaching setting by a resident under the direct supervision of an attending physician.

It is important to note that the use of modifiers may vary depending on the payer, so it's essential to check with the facility's billing department and the private insurance company to ensure that the codes and modifiers used are valid for reimbursement. Additionally, the facility may have some restrictions on certain modifiers, so it's essential to check with the facility's billing department for guidance.

Words by Author

Navigating the constantly evolving landscape of nursing home billing can be challenging for healthcare providers. However, providers can maximize reimbursement for their services by adhering to the CMS nursing home billing guidelines and utilizing the appropriate coding schema.

Outsourcing nursing home billing services to a reputable and affordable company, such as HMS USA LLC in NY, can alleviate the burden and complexity of this task, allowing providers to focus on providing quality care to their patients.

ABOUT AUTHOR

Tammy Carol

As a blog writer with years of experience in the healthcare industry, I have got what it takes to write well researched content that adds value for the audience. I am a curious individual by nature, driven by passion and I translate that into my writings. I aspire to be among the leading content writers in the world.

Thanks for subscribing to our newsletter.

You should receive a confirmation email soon.

Email Already Exists

Email sent successfully

We have received your information, our representative will contact you shortly.

We have received your information, and you will receive a call from a medical team shortly to confirm your appointment.

Our contact numbers are given below for quick assistance.

(516) 725-7237

Medical Coding Question: How To Code For Nursing Home Visits

Medical Coding Questions : CPT Nursing Facility Services. This one is Alicia’s.

Diane asked, “Nursing home resident monthly visit note. If you’re seeing a resident for their required visit… and the keyword there is ‘required’… the MD says, “No complaints, nothing acute.” How can you code this? I think you have all sorts of diagnoses, all sorts of medication and just say, “Will continue current meds. Will follow routinely.” The company expects me to bill them but where’s the medical necessity except for the fact that is a required visit by Medicaid/Medicare.

Medical Coding Question: How To Code For Nursing Home Visits 

Well, when you’re doing a skilled facility, it’s required for the doctor to come in and evaluate routinely the patient. So he gets paid for that and the code range for that is in nursing facility services. It’s an E&M code. They’re 99304 through 99318. And the key is ‘provides continuous healthcare service to patients who are not actually ill’. But they do get paid for coming in and visiting and examining that patient. So you have some choices that I picked out. “Stable, recovering or improving” which, for this example, would be the perfect code, 99307 because the patient’s stable. They’re not making any changes. They’re recovering or they’re improving. And then you have other choices: not responding or minor complications, significant complications or new problems, significant new problem: require immediate physician attention.

So there are codes for that and they are expected. That’s why they’re wanting you to bill for that. Another medical coding question answered!

Related Medical Coding Question Posts:

• Free CPC Practice Exam 50 Questions
• CPC Review Blitz Videos
• CPC Practice Exam
• Online Medical Billing and Coding
• ICD 10 Training

7 thoughts on “Medical Coding Question: How To Code For Nursing Home Visits”

We are just now coding for our facility. What codes would we use for initial psych eval on admit? Would it be 90791-90792 or would it be 99304-99306? I’m completely confused on this issue.

How do I code telepsychiatry for nursing home patients? Do I use the in office codes since the physician never leaves the Psychiatry office or do I use nursing home codes that are used when the physician goes to the nursing home facility? Thanks!

Unfortunately, this request is outside the scope of help we can provide on the blog. We recommend submitting it for consideration at our Topic Requests page: https://www.cco.us/topic-request/

When a patient is admitted into a nursing home under POS 31 (short term care) and transferred over to POS 32 (long term care) does there need to be a CPT code 99315 to discharge from POS 31 and admit to POS 32; or do we just change the POS when billing?

That’s a great question but we don’t answer specific coding questions on the blog. If you like, you can submit a Topic Request and we’ll consider presenting it as a webinar. You can also attend webinars and ask the question during the Q&A sessions. https://www.cco.us/topic-request/

If pt. has a medicare advantage plan the services were rendered at the pt’s home. Which nursing codes can I bill the payer? The payer just denied the claim because they follow medicare guidelines and they require medicare codes for the nursing services, which ones can I use? The payer denied codes 99601 and 99602.

Sorry, but “How Do I Code/Bill” questions are not answered on the blog. That benefit is reserved for CCO Club members. We do hope you’ll consider joining the CCO Club so you can take advantage of that benefit along with many others.

Leave a Comment Cancel reply

• Medical Billing
• Credentialing
• Behavioral Health
• Genetic Testing
• Pharmacogenetic (PGx) Testing
• COVID-19 Testing
• Allergy Testing
• Skilled Nursing Facilities
• Biologics and Specialty Drugs
• Telestroke and Teleneurology
• Remote Patient Monitoring
• Speech Therapy
• Home Infusion Therapy
• Substance Abuse
• Sleep Study Labs
• Physical Therapy (PT)
• Occupational Therapy
• Denial Management
• HL7 Integration

Which CPT Codes are Used in Nursing Facility Billing?

CPT Codes for Nursing Facilities: The Complete Guide to Billing and Documentation for Skilled Nursing Services

However, nursing facilities often struggle to optimize reimbursement through accurate and complete billing capture of the wide variety of skilled services delivered day to day. Proper use of Current Procedural Terminology (CPT) codes provides the mechanism to substantiate delivery of nursing care, therapies, treatments, evaluations, medication administration and more based on medical necessity and payer coverage policies. But pinpointing the appropriate CPT codes can prove challenging given the diversity of patient needs and interventions provided.

Insufficient documentation and coding gaps lead to lost revenue for nursing facilities attempting to receive rightful payment for their skilled services at already slim margins. This makes billing and coding an essential competency for nursing facility administrators seeking to place their organizations on solid financial footing to support advancing quality of care.

This comprehensive guide examines the array of CPT codes applicable in skilled nursing settings based on resident needs, modalities performed, and payer billing guidelines.

We will cover CPT codes nursing facilities should recognize for areas including:

• Evaluation and Management Services
• Physical, Occupational and Speech Therapy
• Wound Care and Complex Medical Supplies
• Psychological and Psychiatric Testing
• Radiology and Diagnostic Services
• Medication Administration

Additionally, examples will demonstrate proper application of codes to reflect services delivered based on robust nursing documentation and billing requirements by major payers. Appropriate use of modifiers is also addressed.

This definitive CPT code resource aims to ensure nursing facilities receive optimal reimbursement capturing the full spectrum of resident services and care provided.

CPT Codes for Nursing Facility Evaluation and Management (E&M) Services

Evaluation and management services encompass visits, assessments, care planning and coordination for nursing home residents.

E&M CPT codes capture levels based on complexity:

Nursing Facility E&M Codes

• 99304 – 99306 : Initial skilled nursing facility care codes covering comprehensive intake assessments when patients first enter the nursing facility from acute inpatient, outpatient, or community settings requiring skilled services. Usage determines level.
• 99307 – 99310 : Subsequent skilled nursing facility care codes for follow-up visits and care oversight after the initial comprehensive assessment. Based on visit complexity.
• 99318 : Other nursing facility services requiring medically necessary face-to-face visit on patient’s initial SNF admission day, which are otherwise not captured by initial assessment codes.

Proper code level selection depends on documentation and components including:

• Number and complexity of diagnosed conditions requiring management
• Review of patient health history and medical records
• Physical exam extent
• Medical decision making complexity in establishing care plan
• Time spent providing counseling and/or coordination of care

For example, a resident admitted after extensive hospitalization for a fall would likely require 99306 initial SNF care for a highly complex assessment whereas a patient transferred for short-term IV antibiotic treatment may only need basic 99304 initial code.

Ongoing Subsequent Visit E&M CPT Codes

After the comprehensive initial assessment, subsequent skilled nursing facility E&M codes capture necessary follow-up visits and care:

• 99307 : Used for low complexity visits that may not require hands-on exam
• 99308 : Moderate complexity visits including interval history and brief exam
• 99309 : High complexity visits with detailed interval history, comprehensive exam, and possible care plan adjustments
• 99310 : Very high complexity visits reserved for unstable patients requiring intensive services

Subsequent visit code selection should accurately reflect work performed. This includes evaluating symptom progression, modifying care plans, updating medication orders, specialty care coordination, and managing multidimensional patient issues.

Proper Nursing Home E&M Billing and Documentation

Correct application of nursing facility E&M codes requires integration between care provided and coding principles:

• Initial vs subsequent visit coding determined by elapsed time between assessments
• Careful review of resident case mix categories, which determine Medicare payment rates and coverage eligibility, to identify billable complexity
• Complete diagnoses list with impact on management documented
• Only face-to-face time between provider, patient, and caregivers counts toward selection
• Medical necessity and skilled need for each encounter clearly justified
• Detailed resident evaluation, updated progress notes, modified orders, new assessments, and care plan changes recorded to support code levels

With accurate documentation synchronizing clinical services and billing codes, nursing facilities ensure appropriate reimbursement for management, evaluation, and care coordination of residents.

CPT Codes for Skilled Nursing Facility Rehabilitation Services

Rehabilitating patients back to optimal functionality requires physical , occupational and speech therapy .

CPT codes specifically capture these modalities:

Physical Therapy CPT Codes

• 97161 : Physical therapy evaluation low complexity
• 97162 : Physical therapy evaluation moderate complexity
• 97163 : Physical therapy evaluation high complexity
• 97164 : Physical therapy re-evaluation established patient
• 97165 : Occupational therapy evaluation low complexity
• 97166 : Occupational therapy evaluation moderate complexity
• 97167 : Occupational therapy evaluation high complexity
• 97168 : Occupational therapy re-evaluation established patient

Speech Therapy CPT Codes

• 92521 : Speech therapy evaluation
• 92522 : Speech therapy evaluation with modifiers
• 92523 : Speech therapy treatment 15 minutes
• 92524 : Speech therapy treatment each additional 15 minutes

The level of evaluation codes depends on elements like:

• Number of body parts involved requiring assessment
• Review of health records and history
• Functional testing performed
• Clinical decision making complexity

Treatment codes are then selected for therapy services based on the hands-on time spent actively engaged in exercises, gait training, manual therapy, modalities like electrical stimulation, and supervision of activities. Billing documentation must capture details supporting code level.

Using PT, OT, Speech Therapy Modifiers

Specific modifiers describe therapy circumstances to convey further context:

• GP : Services delivered under an outpatient physical therapy plan of care
• GO : Services delivered under an outpatient occupational therapy plan of care
• GN : Services delivered under an outpatient speech-language pathology plan of care

Modifiers that may also apply in certain cases:

• 59 : Distinct procedural service when multiple therapies provided in one day
• AS : Physician assistance for only part of a therapy service
• AT : Acute treatment with goal to reinstate prior level of function

The modifiers provide supplemental information to illustrate therapy delivery circumstances impacting billing requirements.

CPT Codes for Wound Care Supplies and Procedures

Chronic wounds require extensive nursing facility resources for cleansing, dressing changes, and monitoring to prevent deterioration.

CPT codes capture involved services:

Wound Care CPT Codes

• 97597 : Debridement of wound surface
• 97598 : Removal of devitalized tissue from wound(s)
• 97602 : Wound(s) care including cleaning, local care, and dressing
• 97605 : Negative pressure wound therapy

Wound Care Supply CPT Codes

• AXXXX : Codes for surgical dressings like hydrogels, foam, impregnated gauze, etc.

Other Considerations:

• Measure wound characteristics like length, width, depth and drainage amount to determine complexity
• Quantify surface area debrided and devitalized tissue removed in cm2
• Capture number of wounds addressed and time spent providing care
• Note supplies applied and dressing change frequency
• Ongoing wound evaluation, monitoring, instructions

Robust documentation of wound status, procedures performed, supplies utilized, and clinician time validates appropriate wound care CPT code levels selected.

Psychological and Psychiatric CPT Codes for Nursing Homes

Mental and behavioral health needs of residents require psychiatry and psychology services in skilled nursing settings:

Psychiatric CPT Codes

• 90832 – 90838 : Psychotherapy and evaluation codes based on time spent treating diagnosed mental health conditions

Psychological CPT Codes

• 96116 : Neurobehavioral status exam by psychologist or physician first 60 minutes
• 96121 : Neuropsychological testing by psychologist first hour
• 96125 : Standardized cognitive performance testing per hour of psychologist time
• 96127 : Brief emotional/behavioral assessment by physician

Using these codes accurately requires detailing:

• Diagnosed psychiatric illnesses and related symptoms requiring therapy management
• Start and end times for psychotherapy sessions
• Specific psychological tests administered and findings
• Interpretation of cognitive/emotional/behavioral test results
• Ongoing tracking of behavioral disturbances, mood, thought processes requiring psychologist expertise

By selecting psychiatric and psychological CPT codes aligned with assessments performed, treatment approaches used, time invested, and diagnoses addressed, nursing facilities capture provision of mental and behavioral health services.

Radiology and Diagnostic CPT Codes for Nursing Home Residents

Skilled nursing facilities provide many ancillary services like x-rays, labs tests, and other diagnostic procedures:

Radiology CPT Codes

• 71010 – 71035 : Chest x-ray codes by number of views
• 72020 – 72072 : X-ray codes for extremities
• 72100 – 72133 : X-ray codes for spine and pelvis
• 73030 : X-ray shoulder complete minimal 2 views
• 73560 : X-ray knee 2 or 3 views

Pathology CPT Codes

• 80048 : Basic metabolic panel
• 80053 : Comprehensive metabolic panel
• 80061 : Lipid panel
• 82947 : Glucose blood test
• 84443 : Thyroid stimulating hormone (TSH) test

Remember key principles:

• Attach radiology procedure report to substantiate exams performed and number of views captured
• Include lab requisition copies noting tests ordered
• Document medical necessity and how results inform resident diagnosis/treatment

Linking CPT codes to supporting service documents prevents payer rejection for insufficient evidence. This ensures reimbursement for x-rays, bloodwork, urinalysis and other facility-provided diagnostics.

Medication Administration CPT Codes

The extensive medication regimens required by nursing home residents demand accurate capture of administration services:

Injection CPT Codes

• 96372 : Subcutaneous or intramuscular injection, includes up to 5 medicinal agents

IV Medication CPT Codes

• 96365 : IV infusion for therapy, diagnosis or prevention; initial up to 1 hour
• 96366 : IV infusion each additional hour

Enteral/Parenteral Nutrition CPT Codes

• 99508 : Enteral/parenteral nutrition services, administrative services by physician

Key billing insights:

• Quantify number of medication agents given when using injection administration code 96372
• Only capture incremental time beyond first hour for IV infusion code 96366
• Ensure nutrition formula is documented as medically necessary

With robust notes detailing medication names, dosages, routes and oversight required, nursing facilities receive payment for management of extensive pharmaceutical regimens improving resident health.

Applying the optimal CPT codes in skilled nursing facilities requires understanding a broad array of services provided, precise documentation of resident evaluations, quantifying treatment times, listing diagnoses addressed, and payer billing policies. But specific codes do exist to capture rehabilitation therapies, complex medical equipment and supply usage, clinician E&M services, diagnostic testing, medication administration and more.

Becoming familiar with the CPT codes outlined here positions nursing facilities to maximize reimbursement potential through accurate billing capture. Partnering with a specialized post-acute care medical billing service offers an additional resource ensuring coding and documentation synchronize to convey the full scope of high-quality care delivered to improve the health of residents.