Accurately billing for follow-up visits for a nursing home facility is an integral part of a provider’s revenue cycle. But unfortunately, the intricacies surrounding CPT code 99309 may lead to confusion and payment delays. These struggles range from documentation requirements to decision-making level, and time calculation.
This guide provides a clear roadmap to the documentation, modifier use, and billing rules necessary to ensure you receive timely reimbursement for the follow-up care you provide to residents in nursing facilities.
So, without further ado, let’s get started!
CPT Code 99309 – Description
CPT code 99309 covers a subsequent nursing facility (NF) encounter in which the physician performs evaluation and management (E/M) service on a single day. However, there are two key requirements. The provider must fulfil at least one of the following to report this code:
(1) It involves moderate complexity of medical decision-making.
(2) The physician spends at least 30 minutes seeing the patient.
That is, if the physician either meets the encounter time limit or decision-making level, you can report this code for established patients.
Scenarios Where CPT Code 99309 is Applicable
Let’s discuss a few real-world clinical scenarios to understand the application of CPT 99309:
Post-Operative Follow-Up
Picture a 70-year-old female patient admitted to a nursing home for rehabilitation following a hip fracture repair. She receives a follow-up visit from the healthcare practitioner. During the encounter, the physician reviews physical therapy progress notes, pain level, and incision site. The physician also orders a medication regimen adjustment.
The medical decision-making involved during the visit is moderate. It aims to manage a stable post-operative condition with multiple treatment options and data points.
Here, CPT code 99309 applies.
Chronic Diseases Management
Imagine a long-term male resident with a history of stable diabetes and congestive heart failure (CHF) scheduled for a routine follow-up visit.
The physician evaluates the patient for any new symptoms (e.g., shortness of breath), reviews lab results (e.g., electrolytes, A1c), and adjusts the dosages.
Since the physician only manages multiple stable chronic illnesses, moderate decision-making is involved.
The provider will report CPT code 99309 to bill for the encounter.
New, Simple Problem with Established Patient
A physician sees a female patient with a history of Alzheimer’s disease in a nursing home. She has developed a new, localized skin rash.
Thus, the provider performs a physical examination and considers potential causes (e.g., fungal infection). Based on the diagnosis, he orders a new topical cream and instructs the nursing staff on its application.
The visit involves a moderate level of decision-making. So, here, the provider can report CPT code 99309 to bill for the service.
Applicable Modifier for CPT Code 99309
Discussed below are the two key modifiers needed to bill for 99309 as a telehealth visit:
Modifier GT
There may be circumstances that demand you to conduct the follow-up NF visit via an interactive audio and video telecommunications system. This system enables physicians to establish real-time, two-way communication with the patient. When this happens, report CPT code 99309 with modifier GT.
Note that Medicare no longer accepts modifier GT on claims. Instead, billers are advised to use the place of service (POS) code 02. However, some private payers still approve its use.
Modifier GQ
Append modifier GQ to CPT code 99309 when the physician performs a subsequent NF visit via an asynchronous, store-and-forward communications system. Unlike a real-time encounter, the system collects and sends information to a provider to review at a later time.
CPT Code 99309 – Billing & Reimbursement Guidelines
The following are the main billing and reimbursement guidelines related to CPT 99309:
Documentation Requirements
Ensure detailed documentation to demonstrate the medical necessity of CPT code 99309. Therefore, your documentation should support the medical decision-making level (i.e., moderate) or the time spent.
You must document the total time spent on the visit if time is the key factor of the encounter. Include a summary of the activities the physician performed, such as care coordination and counseling.
In case decision-making played a significant role during the visit, your documentation must support a moderate complexity level. Mention assessment details, diagnosis, or treatment management options, and a review of a moderate amount of data.
You Can Bill 1 Telehealth Visit Every 30 Days
You can bill for a follow-up NF visit once in a calendar month (30 days) for the first 90 days after admission and once every 2 calendar months (60 days) thereafter. The same rule applies to telehealth encounters for services covered under CPT 99309.
Moreover, if the physician conducts the visit via telehealth, you must append the relevant modifier, GQ or GT. Details of their appropriate use are covered under the ‘Applicable Modifiers for CPT Code 99309’ section.
Understand Payer-Specific Policies
Frequency limitations and reimbursement guidelines related to CPT code 99309 may vary among payers. Therefore, you must strive to establish open lines of communication with the payer. It will help you verify coverage details, documentation requirements, and ensure compliance with payer-specific policies.
Summary
We have covered a lot of ground in this guide. However, before concluding, let’s revisit the key takeaways!
First, we explained the CPT code 99309 descriptor. It covers a follow-up NF visit with moderate decision-making or at least 30 minutes of physician time.
Next, we shared a few real-world clinical scenarios. These include new, simple problems with established patients, chronic disease management, and post-operative follow-up.
We also shared two key modifiers (GT & GQ) that will help you bill for CPT code 99309 in case the physician conducts the encounter using a telehealth system.
Finally, we discussed the key billing and reimbursement guidelines related to this CPT code.
All these details will help you master billing requirements related to CPT 99309. In case you struggle, consider partnering with MediBillMD for professional, cost-effective, and tailored nursing home billing services.
