Did you know that nursing homes provide care services to approximately 1.2 million individuals in the USA? This highlights the need for attentive, high-quality care. However, for physicians, this attention extends beyond the patient’s bedside to the complex process of medical billing.
How? Since each visit to a nursing facility represents a vital part of a patient’s care journey, you must accurately capture the time and complexity of these encounters to ensure proper reimbursement.
In this guide, we will discuss everything you need to know about billing CPT code 99306.
So, if you are a physician who often sees patients in a nursing home, we recommend you read this guide till the end!
CPT Code 99306 – Description
CPT code 99306 covers an initial evaluation and management (E/M) nursing facility (NF) visit. This encounter must either involve high complexity medical decision-making (MDM) or the physician should have spent at least 50 minutes of total time on the visit on a single date.
Scenarios Where CPT Code 99306 is Applicable
Here are some of the real-world clinical scenarios where this procedural code applies:
Complex Comorbidities (High Complexity MDM)
Picture a 78-year-old male patient who has been recently shifted from the hospital to an NF. He has a history of chronic kidney disease (CKD), congestive heart failure (CHF), and poorly controlled diabetes.
The physician conducts the patient’s initial E/M visit. The encounter focuses on stabilizing the patient’s fluid overload, managing new-onset atrial fibrillation, and adjusting a complex medication list with a high risk of drug-drug interactions due to renal impairment.
That’s not all! The physician also reviews extensive hospital records, including those prepared by nephrology and cardiology consultants, and orders new lab work and an EKG to assess the patient’s current status.
Since the MDM is high due to the complexity of managing multiple high-risk and unstable chronic conditions, CPT code 99306 applies.
Extensive Family Counseling (Time-Based)
Assume a 69-year-old female patient admitted to an NF following a severe stroke that resulted in right-sided hemiplegia and aphasia.
The physician spent 50 minutes on the initial E/M encounter. It involved a comprehensive physical examination, coordination with a speech language pathologist and physical therapist, and completion of the admission paperwork.
Moreover, the encounter also included a detailed discussion with the patient’s spouse and adult children about the patient’s long-term prognosis and goals of care. The physician also spent time reviewing the patient’s fragmented hospital records from multiple facilities to understand the full scope of her pre- and post-stroke condition.
The physician will report CPT code 99306 to bill for the service.
Acute Unstable Condition (High Complexity MDM)
Imagine a 72-year-old male patient with end-stage dementia and severe lower respiratory tract infection (aspiration pneumonia). He was admitted to an NF since he is a non-verbal patient and has a poor prognosis (low likelihood of full recovery).
Thus, the physician’s initial E/M visit requires a high level of MDM. That is, he must decide whether to start aggressive treatment and discuss the goals of care with the patient’s Power of Attorney.
What’s more? The physician reviews a recent chest X-ray and lab results and considers the patient’s fragile state when choosing a course of action.
Here, CPT code 99306 applies.
Applicable Modifiers for CPT Code 99306
Here’s a list of some of the applicable modifiers for accurately billing CPT 99306:
Modifier 25
What happens when the physician in an NF performs a minor procedure on the same day as a distant, separately identifiable E/M visit (CPT code 99306)? You append modifier 25 to highlight that the E/M visit was not a standard, bundled part of the procedure. Thus, the payer should be reimbursed separately.
Modifier 95 & GT
Did the physician perform the initial E/M visit (CPT code 99306) via a real-time, interactive audio and video telecommunications system? If yes, you must append the relevant modifier (95 or GT) to indicate a telehealth service.
Modifier 95 is a more widely used modifier. Contrarily, modifier GT is an older modifier that some payers still recognize.
Thus, we recommend that you check with the relevant payer before appending the modifier and submitting the claim.
CPT Code 99306 – Billing & Reimbursement Guidelines
Discussed below are the essential billing and reimbursement guidelines for CPT 99306:
Justify High-Complexity MDM
If you want to report CPT code 99306 against high-level MDM, then your documentation must meet at least two of the following criteria:
1. Risk
Your documentation clearly states that the patient has a high risk of complications and/or morbidity. This is typically an outcome of one of the following:
- The current patient conditions
- Diagnostic procedures
- Chosen management options
2. Problems
During the encounter, the physician addressed multiple chronic conditions, like diabetes, high blood pressure, and heart disease.
3. Data
The physician reviewed and analyzed an extensive amount and/or complexity of patient data. It can include the following:
- Acquiring a history from an independent historian (e.g., a family member) for a patient unable to provide a reliable history.
- Independently interpreting a test performed by another physician.
- Reviewing external notes from each unique source (e.g., from other specialty departments).
- Reviewing and ordering tests.
Report Total Time on the Date of Encounter
If you are using time as the basis for billing CPT code 99306, then the total time spent by the healthcare provider on the date of encounter must be at least 50 minutes. Discussed below are the key activities that count towards this time:
- Preparation to see the patient, e.g., review of medical records, lab tests, etc.
- Performing a detailed physical examination or evaluation.
- Ordering tests, medications, or other procedures based on the evaluation.
- Educating and counseling the patient, family, or caregiver.
- Referring and coordinating care with other practitioners.
- Documenting clinical information in the electronic health records (EHR) system.
Summary
Phew! We have covered a lot of ground in this comprehensive guide. But, before saying goodbye, let’s quickly recap the key takeaways.
First, we explained the CPT code 99306’s descriptor. It covers an initial E/M nursing home visit. However, the encounter must fulfill either of the two requirements: it should involve high complexity MDM, or the physician must have spent at least 50 minutes on the encounter.
Next, we shared a few real-world clinical scenarios. These include acute unstable conditions, extensive family counseling, and complex comorbidities.
We also looked into the applicable modifiers for CPT 99306, including 25, 95, and GT.
Finally, we discussed the key billing and reimbursement guidelines related to this CPT code.
Hopefully, all these details will help you ensure accurate billing for critical nursing home encounters. However, if you still struggle, feel free to outsource nursing home billing services to MediBillMD.
