Billing physician visits in nursing facilities is not as simple as billing emergency room services or consultations. Nursing home billing is divided into multi-level codes that have very complex documentation requirements and application rules.
CPT code 99306 is one of the most used codes in nursing home visits. So, naturally, it is a big source of revenue. Therefore, you must learn how to use it correctly.
That’s the purpose of this guide. In this guide, we have tried our best to explain code 99306 in simple terms and how you can use it correctly. So, let’s start.
CPT Code 99306 – Description
CPT code 99306 is defined as:
“Initial nursing facility care, per day, for the evaluation and management (E/M) of a patient, which requires a medically appropriate history and/or examination and a high level of medical decision-making. When using total time on the date of the encounter for code selection, 50 minutes must be met or exceeded.”
Let’s expand on this. 99306 is basically part of the initial nursing facility care code family. It is the highest level code of this family. The code family has two more codes, i.e.:
- 99304 (straightforward or low complexity, 25 minutes)
- 99305 (moderate complexity, 35 minutes)
You might be wondering how to select the right code from these. Actually, what determines the code level is either the complexity of medical decision-making (MDM) or the total time the physician spends on the date of the encounter.
That’s why an important point to note here is that for 99306 to be valid, the nursing facility care visit must last at least 50 minutes. Also, CPT code 99306 is reported once per admission, per physician or per provider group, not once per calendar visit. If there are any subsequent visits, you should bill them with the CPT codes that are specific to subsequent visits, like 93307, 93308, 93309, and 99310.
Appropriate Use Cases for CPT Code 99306
We hope that the description clarified all the concepts. However, to understand how CPT code 99306 works in practice, here are a couple of scenarios in which it can be used:
Complex Multi-System Comorbidities
Suppose a patient has a long history of kidney disease. He also has had congestive heart failure and is currently dealing with poorly controlled diabetes. He is transferred from the hospital to a nursing facility for continued recovery. During the initial encounter, the physician works to stabilize fluid overload, manages new-onset atrial fibrillation, and adjusts a complex medication regimen that carries a high risk of drug interactions because of the patient’s reduced kidney function.
The physician also reviews extensive hospital records from the nephrology and cardiology teams and orders new lab work along with an EKG to establish a current baseline. Because the encounter involves managing several unstable, high-risk chronic conditions at once, the MDM reaches a high-complexity threshold, and CPT code 99306 applies.
Post-Stroke Care
Let’s consider another scenario. Suppose a patient recently had a stroke. He is in the recovery stage now, but has hemiplegia and aphasia. After the immediate treatment, he is transferred to a skilled nursing facility for rehabilitation and any medical management. Soon after, a physician visits the patient. This is the first visit by the physician.
During the physician’s initial 55-minute nursing-facility visit, the physician performs a medically appropriate examination, evaluates the patient’s neurologic deficits, mobility, communication, swallowing and aspiration risk, medication regimen, and secondary stroke-prevention plan, and coordinates the treatment plan with the physical therapist and speech-language pathologist.
Now, since this scenario includes high-level MDM and fulfills all the other requirements, the billing department can use CPT code 99306 to bill the initial physician visit.
Modifiers to Append with CPT Code 99306
CPT code 99306 does not need many modifiers. But the following are some modifiers that can be used with this code when necessary:
| Modifier | Description | Usage Guidelines |
|---|---|---|
| 25 | Significant, Separately Identifiable E/M Service | Indicates that the initial nursing facility assessment represents a distinct E/M service separate from any concurrent procedures. It is used when there is a significant separate service provided in addition to the initial nursing visit. |
| AI | Principal Physician of Record | Used to identify the principal physician of record during an inpatient admission. |
| GT | Telehealth Services | This is used when the initial visit by the physician is not physical but performed via interactive audio/video telecommunication systems. Note: Many insurance carriers now accept modifier 95 in its place. |
Reimbursement Guidelines for CPT Code 99306
Now that we have cleared the basics, here are some essential guidelines that you must follow for every CPT code 99306 claim:
Meet the High-Complexity MDM or Time Threshold
We have already mentioned in the description that initial nursing care CPT codes are selected based on the medical decision-making difficulty or the time. For 99306 to be valid, the MDM should be of high complexity. To meet this criterion, at least two of the following must be fulfilled:
- Risk: The patient’s condition, the diagnostic workup, or the chosen management options must carry a high risk of complications or morbidity.
- Problems Addressed: The encounter must involve multiple chronic conditions, at least one of which must be severe or poorly controlled.
- Data Reviewed and Analyzed: The physician must independently interpret tests, obtain history from an independent historian, or review extensive records from multiple external sources.
Avoid Same-Day Billing
Medicare does not allow split or shared E/M visits in the nursing facility setting, and prolonged service codes 99354 through 99357 cannot be billed alongside nursing facility service codes.
Also, confirm the correct place of service (POS) code is used on the claim.
Final Words
We have reached the end of this guide, but before we conclude, here is a quick summary of the important points that we discussed above:
- CPT code 99306 is an E/M code.
- You should use this when a physician conducts an initial high-complexity visit in a nursing or skilled nursing facility.
- The visit under this code usually takes 50 minutes or more.
We hope that this guide will help you use code 99306 correctly. However, medical billing is not an easy task, and many in-house billing teams face frequent denials. If you are dealing with a similar situation, then consider acquiring expert nursing home billing services from specialized billing companies like NeuraBill.
