Without a doubt, accurate billing for a patient’s initial visit to a nursing home is critical for the practice’s financial health. However, with requirements centered on decision-making or specific visit duration, coding and documentation can be challenging and prone to errors.
Therefore, our billing specialists have curated this detailed guide to cut through the confusion. It shares knowledge on billing rules, documentation, and modifier usage related to CPT code 99305.
Thus, if you want to master all these details, read this guide till the end!
CPT Code 99305 – Description
CPT code 99305 covers an initial nursing facility visit that involves evaluation and management (E/M) care services for a new patient. The following are the two key requirements of this CPT code. The physician must fulfill at least one of these to become eligible for reimbursement against it.
- Spend at least 35 minutes of total time on the visit on a single day.
- Perform a moderate complexity of medical decision-making.
Nursing homes play an integral role in the U.S. healthcare landscape. Over 1.4 million people reside in more than 15,500 Medicare and Medicaid certified nursing facilities.
Scenarios Where CPT Code 99305 is Applicable
Here, let’s look into a few clinical scenarios where CPT 99305 applies:
Post-Hospitalization Admission to a Nursing Facility
Picture a 72-year-old male patient admitted to a nursing home from the hospital following a hip fracture and surgical repair.
Thus, the physician performs an initial E/M visit to review the hospital discharge summary, evaluate the condition of the post-operative wound, and establish a new care plan for pain management.
During this initial visit, the provider makes moderate-level decision-making related to workup and care coordination.
Here, CPT code 99305 applies.
Time-Based Initial Encounter
Imagine a 50-year-old male patient who is admitted to a nursing facility for long-term care. Thus, the healthcare practitioner performs an initial E/M visit and spends 40 minutes on a single date.
The reason? The patient has several chronic illnesses. The physician reviews the patient’s extensive medical history and performs a physical examination.
Moreover, the provider discusses treatment plan goals with the patient and caregiver during the encounter.
The visit qualifies for CPT code 99305 because the total time exceeds the 35-minute threshold.
Transfer from Another Nursing Facility
Consider a 60-year-old female patient transferred from one nursing home to another with a chronic respiratory condition.
Thus, the physician at the new nursing facility performs an initial E/M visit to review the patient’s medical record from the previous facility. He also conducts a detailed physical examination and develops a new, facility-specific care plan.
Since the patient was new to the physician at this nursing home, the visit involved moderate decision-making. Therefore, CPT code 99305 applies here.
Applicable Modifiers for CPT Code 99305
Discussed below are some of the modifiers that apply when billing for services covered under CPT 99305. These modifiers help ensure coding specificity:
Modifier 25
What happens when the E/M service covered CPT code 99305 was performed with another significant, separately identifiable E/M service on the same day by the same physician? You append modifier 25 to the other E/M service code.
Modifier GT
Append modifier GT to CPT code 99305 when the physician performs the initial E/M visit via interactive audio/video telecommunication systems. That is, the provider conducts an initial E/M visit as a telehealth service.
CPT Code 99305 – Billing & Reimbursement Guidelines
The following are the essential billing and reimbursement requirements related to CPT 99305:
Ensure Comprehensive Documentation
Detailed and accurate documentation ensures timely reimbursement. It also helps establish the medical necessity of the rendered service, which is an essential requirement across payers.
Here’s what your documentation for CPT code 99305 must include:
- For Medical Decision-Making Billing
State the patient’s condition, the complexity of the medical issues that the physician addressed, and details of the reviewed data, such as lab results and hospital records. Moreover, you should attach the care plan.
- For Time-Based Billing
Your documentation must mention the total time spent on the visit. You should also summarize the activities performed, including patient history review, physical examination, counseling, and care coordination.
Report CPT Code 99305 Once Per Patient
Note that, since CPT code 99305 describes an initial E/M visit, a physician cannot report it more than once for a single patient. It applies when the patient is first admitted to a nursing home, the physician conducts a detailed review of records, performs a physical examination, and prepares the treatment plan. That is when this code should be billed either as an in-person encounter or a telehealth visit.
For any other subsequent visits, report CPT code 99309.
Understand Payer-Specific Policies
Payer guidelines related to billing and reimbursement of CPT code 99305 may significantly vary. Since there is no one standard, you should check with the relevant payer and adhere to the specific policies to avoid denials and payment delays.
Summary
With that said, we have come to the end of this guide. But before saying adieu, let’s quickly revisit the key takeaways.
First, we explained the CPT code 99305 descriptor. It covers an initial nursing facility encounter with a new patient and covers E/M services. The visit must involve moderate decision-making or last for at least 35 minutes.
Next, we shared some real-world clinical scenarios. These include patient transfer from another nursing home, a time-based initial visit, and post-hospitalization admission to a nursing facility.
We also shared that modifier 25 and GT are applicable when billing CPT 99305 under specific circumstances.
Finally, we discussed the essential billing and reimbursement guidelines related to this code.
Hopefully, with these details, navigating nursing home care visits will become a breeze. However, if that does not happen, and outsourcing is the only solution, feel free to partner with MediBillMD for nursing home billing services.
