Which CPT Codes are Used in Nursing Facility Billing?

We will cover CPT codes nursing facilities should recognize for areas including:

1. Evaluation and Management Services
2. Physical, Occupational and Speech Therapy
3. Wound Care and Complex Medical Supplies
4. Psychological and Psychiatric Testing
5. Radiology and Diagnostic Services
6. Medication Administration

Additionally, examples will demonstrate proper application of codes to reflect services delivered based on robust nursing documentation and billing requirements by major payers. Appropriate use of modifiers is also addressed.

This definitive CPT code resource aims to ensure nursing facilities receive optimal reimbursement capturing the full spectrum of resident services and care provided.

E&M CPT codes capture levels based on complexity:

Nursing Facility E&M Codes

• 99304-99306: Initial skilled nursing facility care codes covering comprehensive intake assessments when patients first enter the nursing facility from acute inpatient, outpatient, or community settings requiring skilled services. Usage determines level.
• 99307-99310: Subsequent skilled nursing facility care codes for follow-up visits and care oversight after the initial comprehensive assessment. Based on visit complexity.
• 99318: Other nursing facility services requiring medically necessary face-to-face visit on patient’s initial SNF admission day, which are otherwise not captured by initial assessment codes.

Proper code level selection depends on documentation and components including:

• Number and complexity of diagnosed conditions requiring management
• Review of patient health history and medical records
• Physical exam extent
• Medical decision making complexity in establishing care plan
• Time spent providing counseling and/or coordination of care

For example, a resident admitted after extensive hospitalization for a fall would likely require 99306 initial SNF care for a highly complex assessment whereas a patient transferred for short-term IV antibiotic treatment may only need basic 99304 initial code.

After the comprehensive initial assessment, subsequent skilled nursing facility E&M codes capture necessary follow-up visits and care:

• 99307: Used for low complexity visits that may not require hands-on exam
• 99308: Moderate complexity visits including interval history and brief exam
• 99309: High complexity visits with detailed interval history, comprehensive exam, and possible care plan adjustments
• 99310: Very high complexity visits reserved for unstable patients requiring intensive services

Subsequent visit code selection should accurately reflect work performed. This includes evaluating symptom progression, modifying care plans, updating medication orders, specialty care coordination, and managing multidimensional patient issues.

Correct application of nursing facility E&M codes requires integration between care provided and coding principles:

• Initial vs subsequent visit coding determined by elapsed time between assessments
• Careful review of resident case mix categories, which determine Medicare payment rates and coverage eligibility, to identify billable complexity
• Complete diagnoses list with impact on management documented
• Only face-to-face time between provider, patient, and caregivers counts toward selection
• Medical necessity and skilled need for each encounter clearly justified
• Detailed resident evaluation, updated progress notes, modified orders, new assessments, and care plan changes recorded to support code levels

With accurate documentation synchronizing clinical services and billing codes, nursing facilities ensure appropriate reimbursement for management, evaluation, and care coordination of residents.

CPT codes specifically capture these modalities:

Physical Therapy CPT Codes

• 97161: Physical therapy evaluation low complexity
• 97162: Physical therapy evaluation moderate complexity
• 97163: Physical therapy evaluation high complexity
• 97164: Physical therapy re-evaluation established patient
• 97165: Occupational therapy evaluation low complexity
• 97166: Occupational therapy evaluation moderate complexity
• 97167: Occupational therapy evaluation high complexity
• 97168: Occupational therapy re-evaluation established patient

Speech Therapy CPT Codes

• 92521: Speech therapy evaluation
• 92522: Speech therapy evaluation with modifiers
• 92523: Speech therapy treatment 15 minutes
• 92524: Speech therapy treatment each additional 15 minutes

The level of evaluation codes depends on elements like:

• Number of body parts involved requiring assessment
• Review of health records and history
• Functional testing performed
• Clinical decision making complexity
• Time spent

Treatment codes are then selected for therapy services based on the hands-on time spent actively engaged in exercises, gait training, manual therapy, modalities like electrical stimulation, and supervision of activities. Billing documentation must capture details supporting code level.

Using PT, OT, Speech Therapy Modifiers

Specific modifiers describe therapy circumstances to convey further context:

• GP: Services delivered under an outpatient physical therapy plan of care
• GO: Services delivered under an outpatient occupational therapy plan of care
• GN: Services delivered under an outpatient speech-language pathology plan of care

Modifiers that may also apply in certain cases:

• 59: Distinct procedural service when multiple therapies provided in one day
• AS: Physician assistance for only part of a therapy service
• AT: Acute treatment with goal to reinstate prior level of function

The modifiers provide supplemental information to illustrate therapy delivery circumstances impacting billing requirements.

CPT codes capture involved services:

Wound Care CPT Codes

• 97597: Debridement of wound surface
• 97598: Removal of devitalized tissue from wound(s)
• 97602: Wound(s) care including cleaning, local care, and dressing
• 97605: Negative pressure wound therapy

Wound Care Supply CPT Codes

• AXXXX: Codes for surgical dressings like hydrogels, foam, impregnated gauze, etc.

Other Considerations:

• Measure wound characteristics like length, width, depth and drainage amount to determine complexity
• Quantify surface area debrided and devitalized tissue removed in cm2
• Capture number of wounds addressed and time spent providing care
• Note supplies applied and dressing change frequency
• Ongoing wound evaluation, monitoring, instructions

Robust documentation of wound status, procedures performed, supplies utilized, and clinician time validates appropriate wound care CPT code levels selected.

Mental and behavioral health needs of residents require psychiatry and psychology services in skilled nursing settings:

Psychiatric CPT Codes

• 90832-90838: Psychotherapy and evaluation codes based on time spent treating diagnosed mental health conditions

Psychological CPT Codes

• 96116: Neurobehavioral status exam by psychologist or physician first 60 minutes
• 96121: Neuropsychological testing by psychologist first hour
• 96125: Standardized cognitive performance testing per hour of psychologist time
• 96127: Brief emotional/behavioral assessment by physician

Using these codes accurately requires detailing:

• Diagnosed psychiatric illnesses and related symptoms requiring therapy management
• Start and end times for psychotherapy sessions
• Specific psychological tests administered and findings
• Interpretation of cognitive/emotional/behavioral test results
• Ongoing tracking of behavioral disturbances, mood, thought processes requiring psychologist expertise

By selecting psychiatric and psychological CPT codes aligned with assessments performed, treatment approaches used, time invested, and diagnoses addressed, nursing facilities capture provision of mental and behavioral health services.

Skilled nursing facilities provide many ancillary services like x-rays, labs tests, and other diagnostic procedures:

Radiology CPT Codes

• 71010-71035: Chest x-ray codes by number of views
• 72020-72072: X-ray codes for extremities
• 72100-72133: X-ray codes for spine and pelvis
• 73030: X-ray shoulder complete minimal 2 views
• 73560: X-ray knee 2 or 3 views

Pathology CPT Codes

• 80048: Basic metabolic panel
• 80053: Comprehensive metabolic panel
• 80061: Lipid panel
• 82947: Glucose blood test
• 84443: Thyroid stimulating hormone (TSH) test

Remember key principles:

• Attach radiology procedure report to substantiate exams performed and number of views captured
• Include lab requisition copies noting tests ordered
• Document medical necessity and how results inform resident diagnosis/treatment

Linking CPT codes to supporting service documents prevents payer rejection for insufficient evidence. This ensures reimbursement for x-rays, bloodwork, urinalysis and other facility-provided diagnostics.

The extensive medication regimens required by nursing home residents demand accurate capture of administration services:

Injection CPT Codes

• 96372: Subcutaneous or intramuscular injection, includes up to 5 medicinal agents

IV Medication CPT Codes

• 96365: IV infusion for therapy, diagnosis or prevention; initial up to 1 hour
• 96366: IV infusion each additional hour

Enteral/Parenteral Nutrition CPT Codes

• 99508: Enteral/parenteral nutrition services, administrative services by physician

Key billing insights:

• Quantify number of medication agents given when using injection administration code 96372
• Only capture incremental time beyond first hour for IV infusion code 96366
• Ensure nutrition formula is documented as medically necessary

With robust notes detailing medication names, dosages, routes and oversight required, nursing facilities receive payment for management of extensive pharmaceutical regimens improving resident health.