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Nursing facility E/M services
Last Modified: 4/11/2024
Location: FL, PR, USVI
Business: Part A, Part B
Nursing facilities include skilled nursing facilities, psychiatric residential treatment centers, and immediate care facilities for individuals with intellectual disabilities.
Beginning with dates of service on and after January 1, 2023, nursing facility E/M services, are selected based on time or the level of medical decision making (MDM).
When selecting time, it includes total time spent on the day of the encounter
Time is defined in the service descriptors used for selecting appropriate level of service. This is whether counseling/coordination of care dominates service. When using time, it does require a face-to-face encounter with physician or other qualified healthcare professional (QHP) and the patient or family/caregiver to occur. Time spent by clinical staff is not included in the total time.
An initial service is one that occurs when the patient has not received any professional services from the physician or other qualified healthcare professional (QHP) of the same specialty who belongs to the same group practice during the stay.
A subsequent service is one that occurs when the patient has received any professional services from the physician or QHP of the same specialty who belongs to the same group practice during the stay.
As of January 1, 2023, practitioners will select visit level based on the level of MDM or the amount of time spent by the physician or non-physician practitioner. For all E/M visits, history and physical exam must be performed in accordance with code descriptors, but history and exam no longer impact visit level selection. When practitioner time is used to select visit level, the full time must be completed; the general CPT rule regarding the midpoint for certain timed services does not apply.
Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of an E/M visit code. It would not be medically necessary or appropriate to bill a higher level of E/M service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported.
Initial nursing facility codes 99304, 99305 and 99306 may be used once per admission, per physician or qualified healthcare professional, regardless of the length of stay.
Subsequent nursing facility code 99307, 99308, 99309 and 99310 are used per day
Beginning January 1, 2023, the CPT code, other nursing facility service (99318), has been deleted and is no longer used to report an annual nursing facility assessment visit on the required schedule of visits on an annual basis.
Nursing facility discharge services should be reported using:
• 99315 - Nursing facility discharge day management; 30 minutes or less total time on the date of encounter
• 99316 - Nursing facility discharge day management; more than 30 minutes total time on the date of encounter
Beginning January 1, 2023, prolonged NF services are reported using Medicare-specific coding G0317. G0317 can only be reported using 99306 and 99310 and can be reported when the total time is exceeded by 15 or more minutes. G0317 does include time one day before the visit plus date of the visit plus 3 days after.
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.
