Introduction Nursing facility services

A nursing facility is not a hospital but does have inpatient beds and a professional health care staff that provides health care to persons who do not require the level of service provided in an acute care facility.

A skilled nursing facility (SNF) is one that has a professional staff that often includes physicians and nurses. The patients of a skilled nursing facility require less care than that given in an acute care hospital, but more care than that provided in a nursing home. Skilled nursing facilities are also called skilled nursing units, skilled nursing care, or extended care facilities. Professional and practical nursing services are available 24 hours a day. Rehabilitation services, such as occupational therapy, physical therapy, and speech therapy, are
available on a daily basis. A skilled nursing facility was previously called an extended care facility. Patients may stay for several weeks in a skilled nursing facility before returning home or being transferred to an intermediate care facility for long-term care. Skilled nursing facilities provide care for individuals of all ages, even though the majority of services are provided to geriatric patients.

An intermediate care facility provides regular, basic health services to individuals who do not need the degree of care or treatment provided in a hospital or a skilled nursing facility. Residents, because of their mental or physical conditions, require assistance with their activities of daily living, such as bathing, dressing, eating, and
ambulating. Intermediate care facilities generally provide long-term care, usually over several years. Professional and practical nursing services are available on a 24-hour basis. Activities, social services, and dietary and other therapies are available on a daily basis. The majority of residents of intermediate care facilities are geriatric individuals or individuals of any age with developmental disabilities.

The long-term care facility describes health and personal services provided to ill, aged, disabled, or mentally handicapped individuals for an extended period of time. Other types of facilities are better described as skilled or intermediate care facilities.
Four subheadings of nursing facility services are available: Initial Nursing Facility Care, Subsequent Nursing Facility Care, Nursing Facility Discharge Services, and Other Nursing Facility Services.

Initial nursing facility care (CPT code 99304 and 99306)

Initial Nursing Facility Care codes (99304-99306) do not distinguish between new and established patients.

Initial nursing facility service codes describe the first encounter with a patient by a physician or qualified clinician in nursing facilities and skilled nursing facilities, or for services in a psychiatric residential treatment center and immediate care facility for patients with intellectual disabilities. Initial nursing facility codes may be reported once per admission, per physician or qualified clinician, per stay. Initial nursing facility codes do not differentiate between new or established patients. Under the initial nursing facility care category, there are three levels represented by CPT code 99304, 99305, and 99306.

All services require a medically appropriate history and/or examination. Code selection is based on the level of medical decision making (MDM) or total time personally spent by the physician and/or other qualified health care professional(s) on the date of the encounter. Factors to be considered in MDM include the number and complexity of problems addressed during the encounter, amount and complexity of data requiring review and analysis, and the risk of complications and/or morbidity or mortality associated with patient management. CPT code 99304 is reported for a visit that entails straightforward or low MDM. If time is used for code selection, a total time of 25 minutes must be met or exceeded on the day of the encounter.

CPT code  99305 is reported for a visit requiring a moderate level of MDM or meeting or exceeding 35 minutes of total time. CPT code 99306 is reported for a high level of MDM or meeting or exceeding 45 minutes of total time. For high MDM, an additional component is recognized for initial nursing facility codes for the number and complexity of problems addressed: multiple morbidities requiring intensive management, for the patient who is at risk of worsening status or hospital admission and requiring frequent evaluations with possible changes to medications and/or treatment.

Subsequent nursing facility care (CPT code 99307-99310)

Subsequent Nursing Facility Care codes (CPT code 99307-99310) do not distinguish between a new and an established patient.

Subsequent nursing facility care service codes describe visits that occur after the first encounter of the patient’s nursing facility admission by the supervising qualified clinician. Codes are reported per day and do not differentiate between new or established patients. All services require a medically appropriate history and/or examination. Code selection is based on the level of medical decision making (MDM) or total time personally spent by the physician and/or other qualified health care professional(s) on the date of the encounter. Factors to be considered in MDM include the number and complexity of problems addressed during the encounter, amount and complexity of data requiring review and analysis, and the risk of complications and/or morbidity or mortality associated with patient management.

CPT code 99307 is reported for a visit that entails straightforward MDM. If time is used for code selection, a total time of 10 minutes must be met or exceeded on the day of the encounter. CPT code 99308 is reported for a visit requiring a low level of MDM or meeting or exceeding 15 minutes of total time; 99309 for a moderate level of MDM or meeting or exceeding 30 minutes of total time; and 99310 for a high level of MDM or meeting or exceeding 45 minutes of total time.

Nursing facility discharge services (CPT code 99315-99316)

Nursing facility discharge services are time-based codes that describe the amount of time spent by the clinician during all final steps involved in the discharge of a patient from the nursing facility, including the last patient exam, discussing the nursing facility stay, instructions for ongoing care as it relates to all pertinent caregivers, and preparing the medical discharge records, prescriptions, and/or referrals as applicable. A face-to-face service with the patient or family/caregiver is required and may occur on a date that is prior to the date that the patient leaves the facility.

Time reported should be for the total duration of time spent by the provider on the date of the encounter, even when the time spent on that date is not continuous. For a nursing facility discharge duration of 30 minutes or less, report CPT code 99315; for a duration of greater than 30 minutes, report CPT code 99316. These codes are reported following initial and subsequent nursing facility care codes 99304-99306 and 99307-99310.