Medical billing for nursing homes can be really challenging if you are not updated with the latest guidelines and requirements. Why? Mainly due to the complex documentation and the multi-level coding structures of the patient visits. Just the evaluation and management (E/M) visits are divided into three categories, i.e., initial visits, subsequent visits, and discharge services.
One of the most frequently used codes in nursing homes is CPT code 99304, which belongs to the initial visits category. It is also a significant source of revenue for practices. So, you must learn how to use it correctly.
Our experts at MediBillMD have created this detailed guide on code 99304. So, let’s start.
CPT Code 99304 – Description
CPT code 99304 is defined as:
Initial nursing facility care visit for the evaluation and management of a patient requiring a medically appropriate history and/or examination combined with straightforward or low-level medical decision-making.
An important point to note for billing 99304 claims is that for a valid use of this code, the procedure must meet all the key criteria mentioned in the definition, or the session duration must be at least 25 minutes, when using total time for code selection.
CPT code 99304 is specifically used for initial visits to a skilled nursing facility (SNF) or nursing facility (NF). The patient can be either new or established. It is also important to mention here that the initial visit must occur within 30 days of admission to the nursing facility. Otherwise, your claims will most probably be denied.
Scenarios Where CPT Code 99304 is Applicable
Still not clear? To make things simple, let’s look at some of the real-world scenarios in which this code can be used:
- Hospital to Nursing Home Transfer: Patient leaves the hospital but still needs medical care that’s too complex for home. The physician conducts a first visit checkup to determine if nursing home care is the right choice and establishes a treatment plan.
- Direct Admission for Long-term Care: A patient with multiple ongoing health problems (like diabetes, heart issues) comes to the nursing home for regular medical supervision. A physician’s first visit establishes the starting point and creates an overall care plan.
- After Surgery Recovery: Patient recovering from major surgery (hip replacement, heart surgery) needs nursing home care for rehabilitation. First visit focuses on checking the surgical site, managing pain, and coordinating physical therapy. However, before using 99304 in surgical scenarios, always refer to the global period guidelines of the performed surgery and make sure there is no contradiction.
Applicable Modifiers for CPT Code 99304
The following are some modifiers that can be appended to the CPT code 99304:
| 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. |
| AI | Principal Physician of Record | Used to identify the principal physician of record during an inpatient admission. |
| GT | Telehealth Services | Used when the physician performs the initial E/M visit via interactive audio/video telecommunication systems. |
CPT Code 99304 – Billing & Reimbursement Guidelines
The following are some essential billing guidelines for CPT code 99304:
Ensure Comprehensive Documentation
Like all other claims, insurance claims for CPT code 99304 must be supported by proper documentation. Comprehensive documentation helps in justifying medical necessity and ensures fair reimbursement for your services.
For 99304, your documentation must include:
- Patients condition
- The complexity of the medical issues that the physician addressed
- Details regarding any reviewed data, such as lab tests, hospital records, and the care plan
- Total time spent on the visit and the activities performed during the visit
Be Wary of the Limitations
Please note that CPT code 99304 is used for only an initial E/M visit. You cannot use it more than once for a patient. It applies when the patient is first admitted to a nursing home and cannot be used for subsequent visits.
Use Appropriate Place of Service Codes
As evident from the code description that we provided above, code 99304 can only be used in Skilled Nursing Facilities (POS 31) or Nursing Facilities (POS 32). Always ensure you use the correct Place of Service (POS) code in your claims.
POS 31 should be used when patients have Part A skilled nursing facility benefits. POS 32 applies to patients without Part A benefits or those in non-covered nursing facility stays.
Check the Medicare Reimbursement Rate
The reimbursement amount for CPT code 99304 varies for each MAC locality. The national average reimbursement amount for 99304 is $77.63 for both facility and non-facility settings.
You can check the exact reimbursement rate for your MAC locality via the PFS Lookup Tool.
Wrapping Up
We have come to the end of this guide. Let’s do a quick recap of the most important points.
CPT code 99304 is an E/M code that is used for initial visits in nursing facilities and skilled nursing facilities. The evaluation under 99304 typically lasts 25 minutes or more. For fair reimbursement, you must append the correct modifiers, such as 25, AI, and GT when necessary.
Hopefully, with the help of this guide, you can successfully file claims for 99304. However, if you are facing continuous denials or bottlenecks in your revenue cycle, consider employing expert nursing home billing services from specialized billing companies like MediBillMD.
