nursing home visit cpt codes

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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.

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Nursing Facility Services (Codes 99304 - 99318)

This transmittal revises the Claims Processing Manual, Pub. 100-04, Chapter 12, §30.6.13 with the new code changes by the American Medical Association Current Procedural Terminology (CPT) 2006 for reporting evaluation and management visits in the skilled nursing facility (SNF) or nursing facility (NF) settings (codes 99304 - 99306 for the initial visit; codes 99307 - 99310 for subsequent nursing facility visits and code 99318 for an annual assessment visit) and who may use these codes. This transmittal identifies the federally mandated visits per the Long Term Care regulations and also clarifies the "initial visit" definition, medically necessary visits, "incident to" services, prolonged services, split/shared evaluation and management services, gang visits,and discharge day management in the SNF and NF settings.

Download the Guidance Document

Issued by: Centers for Medicare & Medicaid Services (CMS)

Issue Date: January 06, 2006

DISCLAIMER: The contents of this database lack the force and effect of law, except as authorized by law (including Medicare Advantage Rate Announcements and Advance Notices) or as specifically incorporated into a contract. The Department may not cite, use, or rely on any guidance that is not posted on the guidance repository, except to establish historical facts.

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
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Friday, June 3, 2016

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List of CPT/HCPCS Codes

We maintain and annually update a List of Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) Codes (the Code List), which identifies all the items and services included within certain designated health services (DHS) categories or that may qualify for certain exceptions. We update the Code List to conform to the most recent publications of CPT and HCPCS codes and to account for changes in Medicare coverage and payment policies. Code List updates for years 2022 and earlier were published in the Federal Register as an addendum to the annual Physician Fee Schedule final rule. 

Beginning with the Code List effective January 1, 2023, updates are published solely on this webpage.  On or before December 2 nd of each year, we will publish the annual update to the Code List and provide a 30-day public comment period using www.regulations.gov . To be considered, comments must be received within the stated 30-day timeframe. We anticipate that most comments will be addressed by April 1 st ; however, a longer timeframe may be necessary to address complex comments or those that require coordination with external parties. If no comments are received, in lieu of a comment response, we will publish a note below the applicable Code List year stating so. 

2024 Annual Update to the Code List

Below you will find the Calendar Year (CY) 2024 Code List published November 29, 2023 and a description of the revisions for CY 2024, our response to comments on that Code List, and the updated CY 2024 Code List, which is effective January 1, 2024 unless otherwise indicated on the Code List.

• UPDATED list of codes effective January 1, 2024, published March 1, 2024 (all codes effective January 1, 2024 unless otherwise indicated on the Code List) (ZIP)
• List of codes effective January 1, 2024, published November 29, 2023 (ZIP)
• Annual Update to the List of CPT/HCPCS Codes Effective January 1, 2024 (PDF)

We received one comment related to the additions, deletions, and corrections to the codes on the Code List effective January 1, 2024. Our response to this comment is below. We also received one comment related to Medicare coverage for platelet-rich plasma treatments. We consider this comment to be outside the scope of the annual update. CMS does not respond to out of scope comments on the annual updates to the Code List. 

Comment : One commenter noted that, although most Hepatitis B vaccine codes are identified on the Code List as CPT/HCPCS codes to which the exception for preventive screening tests and vaccines at § 411.355(h) applies, the Hepatitis B vaccine associated with CPT code 90739 was not listed. The commenter requested that CPT code 90739 be added to the list of vaccine codes to which the exception for preventive screening tests and vaccines at §411.355(h) applies, effective retroactively to January 1, 2024.

Response : We agree with the commenter that the exception for preventive screening tests and vaccines at § 411.355(h) should apply to CPT code 90739 and are revising the Code List accordingly. The applicability of the exception for preventive screening tests and vaccines to CPT code 90739 is prospective only and effective on the date indicated on the UPDATED list of codes. 

In considering this comment, we also identified two CPT codes (90653 and 90658, both flu vaccines) that were inadvertently left off of the list of codes to which the exception for preventive screening tests and vaccines at § 411.355(h) should apply. Accordingly, we are adding these CPT codes to the list of codes to which the exception at § 411.355(h) applies, effective on the date indicated on the UPDATED list of codes.

2023 Annual Update to the Code List

Below you will find the Code List that is effective January 1, 2023 and a description of the revisions effective for Calendar Year 2023. 

• List of codes effective January 1, 2023, published December 1, 2022
• Annual Update to the List of CPT/HCPCS Codes Effective January 1, 2023, published December 1, 2022 (PDF)

The comment period ended December 30, 2022. We did not receive any comments related to the additions, deletions, and corrections to the codes on the Code List effective January 1, 2023. We received one (1) comment related to the supervision level required for specific services. We consider this comment to be outside the scope of the annual update. CMS does not respond to out of scope comments on the annual updates to the Code List. 

DHS Categories

The DHS categories defined by the Code List are:

• clinical laboratory services;
• physical therapy services, occupational therapy services, outpatient speech-language pathology services;
• radiology and certain other imaging services; and
• radiation therapy services and supplies.

The Code List also identifies those items and services that may qualify for either of the following two exceptions to the physician self-referral prohibitions: 

• EPO and other dialysis-related drugs (42 CFR § 411.355(g)).
• Preventive screening tests and vaccines (42 CFR § 411.355(h)).

NOTE: The following DHS categories are defined at 42 CFR §411.351 without reference to the Code List:

• durable medical equipment and supplies;
• parenteral and enteral nutrients, equipment and supplies;
• prosthetics, orthotics, and prosthetic devices and supplies;
• home health services;
• outpatient prescription drugs; and
• inpatient and outpatient hospital services.

Related Links

• List of codes effective January 1, 2022, published November 19, 2021
• List of codes effective January 1, 2021, issued December 1, 2020
• List of codes effective January 1, 2020, published December 2, 2019
• List of codes effective January 1, 2019, published November 23, 2018
• List of codes effective January 1, 2018, published November 3, 2017 [ZIP, 59KB]
• List of codes effective January 1, 2017, published November 16, 2016 [ZIP, 54KB]
• List of codes effective January 1, 2016, published October 30, 2015 [ZIP, 58KB]
• List of codes effective January 1, 2015, published November 13, 2014 (79 FR 67972) [ZIP, 54KB]
• List of codes effective January 1, 2014, published December 10, 2013 (78 FR 74791) [ZIP, 54KB]
• List of codes effective January 1, 2013, published November 16, 2012 (77 FR 69334) [ZIP, 54KB]

2023 Brings Important Coding, Medicare Payment Updates

Hospital, nursing home e/m visit coding to see big changes.

Dec. 20, 2022, 3:20 p.m. News Staff — Two years ago, the AAFP was busy developing resources to help members prepare for major revisions to office visit evaluation and management coding and documentation guidelines scheduled to take effect Jan. 1, 2021. The changes, intended to reduce physicians’ administrative burden and allow them more time for direct patient care, followed extensive advocacy by the AAFP and other medical groups.

This year, the AAFP began educating members about similar changes coming in 2023 to coding for E/M services provided in hospitals, nursing homes and other settings (e.g., patients’ homes), beginning with a session at the 2022 Family Medicine Experience.   Members are encouraged to keep an eye out for additional information and resources to be released on this topic.

Changes to E/M Codes and Guidance

As of Jan. 1, code level selection for facility-based E/M services will largely mirror that now used for office/outpatient E/M services. The history and physical examination will no longer contribute to the level for these visits; rather, physicians will select codes for these services based on either the total time they spent caring for the patient on the date of the encounter or their level of medical decision-making. (The exceptions will be emergency department visits, which must be MDM-based because the codes do not have a time component, and hospital-discharge and nursing facility-discharge visits, which can only be coded based on time.)

Furthermore, only a few adjustments are needed to repurpose the MDM table used to select office-based E/M codes for use in coding hospital and nursing home E/M services. They are

• adding “1 stable acute illness” and “1 acute, uncomplicated illness or injury requiring hospital inpatient or observation level of care” to the low-level MDM elements in the problems addressed category;
• adding decisions regarding “escalation of hospital-level of care” and “parenteral controlled substances” to the high-level MDM elements in the risk category; and
• adding “multiple morbidities requiring intensive management” to the risk category, although this applies only to initial nursing facility visits.

Story Highlights

Other CPT changes that stand to affect how these services are reported include

• hospital inpatient and observation codes have been collapsed into a single family of codes: 99221-99223 and 99231-99233;
• the lowest level emergency department code (99281) has been redefined to describe visits that may not require the presence of a physician or other qualified health care professional;
• the specific code for the nursing home annual exam has been deleted; this service will now be coded as a subsequent nursing home visit (99307-99310); and
• the “Domiciliary, Rest Home (e.g., Boarding Home), or Custodial Care Services” and “Home Services” E/M visit families have merged into a single code family titled “Home or Residence Services.”

For more details about the changes, members can review an FPM article published online ahead of print on Dec. 5; the article will appear in the January/February print journal issue.

On a related note, CPT has revised its hospital E/M guidelines to allow more than one service to be reported when a patient is admitted to inpatient or observation status during a visit at another service site, such as a physician’s office. According to the guidelines, physicians should append modifier 25 to the initial service and report the hospital-based service, as well. CMS, however, is continuing its policy of allowing only a single service to be reported to Medicare in such instances. It is unclear at this time whether non-Medicare payers will follow CPT’s lead.

Another CPT-related change involves how prolonged services — whether provided in an office or inpatient setting — should be reported. CPT has deleted the codes for reporting prolonged E/M services with direct patient contact in an office (99354-99355) or inpatient (99356-99357) setting. Physicians have been able to use code 99417, in conjunction with 99205 or 99215, to report prolonged services in the office setting since the 2021 changes were implemented; as of Jan. 1, that will be the only option for doing so. A new code, 99218, will be used to report prolonged hospital or nursing facility services.

Although CPT guidance allows physicians to report 99417 or 99418, along with a primary E/M code for the highest level of service in the appropriate setting, when they surpass the minimum time of the highest level of service by 15 minutes, Medicare requires clinicians to surpass the maximum time of the highest E/M level by 15 minutes before reporting prolonged services codes. CMS has developed specific Healthcare Common Procedure Coding System codes, broken down by practice setting, for reporting such services.

A second FPM article slated for the January/February issue but published early online shares more information about these additional coding updates. The article also outlines new and revised codes and related guidance for remote therapeutic monitoring, vaccine products and administration, and suture and staple removal.

Medicare Payment Updates

CMS has announced it will implement separate coding and payment for chronic pain management services beginning Jan. 1 and define the group of health care professionals eligible to provide this care to include nonphysician practitioners such as physician assistants and nurse practitioners. The agency has created new HCPCS codes to report chronic pain management and treatment that encompass holistic chronic pain care services, including assessment and monitoring; administration of a validated pain rating scale or tool; and development, implementation, revision, and/or maintenance of a person-centered care plan that includes strengths, goals, clinical needs, desired outcomes, and overall treatment management.

CMS considerably expanded the list of services that can be provided via telehealth during the COVID-19 public health emergency, and a number of those will remain on either a temporary or permanent basis in 2023. Telehealth services that will continue to be available temporarily (that is, through the end of 2023 or 151 days after the PHE ends, whichever is later) include several emotional/behavioral assessment, psychological, and neuropsychological testing and evaluation services, as well as audio-only services. Some prolonged services and chronic care management telehealth services will continue permanently.

Medicare Alternative Payment Program Changes

Finally, although Medicare’s Quality Payment Program and the Medicare Shared Savings Program won’t radically change in 2023, family physicians may want to familiarize themselves with some upcoming modifications.

In QPP’s Merit-based Incentive Payment System, for example, MIPS Value Pathways will be a new reporting option. Of 12 MVPs available for clinicians to report, two will focus on primary care: promoting wellness and optimizing chronic disease management.

In addition, the 2023 MIPS performance threshold will remain at 75 points, with eligible clinicians receiving payment increases or reductions of up to 9% on their Medicare Part B claims. There is no exceptional performance threshold in 2023.

Changes to the MSSP include the provision of Advance Investment Payments to new program entrants with no performance-based risk experience. The payments will consist of a one-time payment of $250,000 and eight quarterly payments based on the number of beneficiaries assigned to the accountable care organization. CMS will recoup the payments from any shared savings the ACO earns during its current agreement period.

CMS also will allow ACOs inexperienced with performance-based risk to remain in the Basic track level A for all five years of the agreement period. The Enhanced track will be optional for all participants.

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