[{"@context":"https:\/\/schema.org\/","@type":"BlogPosting","@id":"https:\/\/medwave.io\/2024\/01\/which-cpt-codes-are-used-in-nursing-facility-billing\/#BlogPosting","mainEntityOfPage":"https:\/\/medwave.io\/2024\/01\/which-cpt-codes-are-used-in-nursing-facility-billing\/","headline":"Which CPT Codes are Used in Nursing Facility Billing?","name":"Which CPT Codes are Used in Nursing Facility Billing?","description":"CPT Codes for Nursing Facilities: The Complete Guide to Billing and Documentation for Skilled Nursing Services Nursing facilities fulfill a critical role in the post-acute care continuum by providing rehabilitation and custodial care services to patients not yet ready to transition home after hospitalization. The range of skilled nursing services offered enables recovery and stabilization […]","datePublished":"2024-01-04","dateModified":"2024-10-13","author":{"@type":"Person","@id":"https:\/\/medwave.io\/author\/admin-2\/#Person","name":"admin","url":"https:\/\/medwave.io\/author\/admin-2\/","identifier":2,"image":{"@type":"ImageObject","@id":"https:\/\/secure.gravatar.com\/avatar\/c316763f6818380164c3414fc4575167bcffddaaedbc31902e4e2c7a44540392?s=96&r=g","url":"https:\/\/secure.gravatar.com\/avatar\/c316763f6818380164c3414fc4575167bcffddaaedbc31902e4e2c7a44540392?s=96&r=g","height":96,"width":96}},"publisher":{"@type":"Organization","name":"Medwave Billing & Credentialing","logo":{"@type":"ImageObject","@id":"https:\/\/medwave.io\/wp-content\/uploads\/2017\/12\/medwave-pittsburgh-medical-billing-400x400.png","url":"https:\/\/medwave.io\/wp-content\/uploads\/2017\/12\/medwave-pittsburgh-medical-billing-400x400.png","width":200,"height":200}},"image":{"@type":"ImageObject","@id":"https:\/\/medwave.io\/wp-content\/uploads\/2023\/02\/white-female-medical-billing-outsourced.jpg","url":"https:\/\/medwave.io\/wp-content\/uploads\/2023\/02\/white-female-medical-billing-outsourced.jpg","height":300,"width":620},"url":"https:\/\/medwave.io\/2024\/01\/which-cpt-codes-are-used-in-nursing-facility-billing\/","about":["Articles","E&M Services","Nursing Billing","Nursing Facility Billing","Nursing Facility Evaluation","Nursing Facility Management","Old Folks Home Billing","Psychiatric Billing","Radiology Billing","Skilled Nursing","Skilled Nursing Billing","Skilled Nursing Facility"],"wordCount":1665,"keywords":["92521","92522","92523","92524","96116","96121","96125","96127","96372","97597","97598","97602","97605","99304","99306","99307","99308","99309","99310","99318","Nursing Facility Evaluation","Nursing Facility Management","Psychiatric Billing","PT Billing","Radiology Billing","Skilled Nursing Billing","Speech Billing"],"articleBody":"CPT Codes for Nursing Facilities: The Complete Guide to Billing and Documentation for Skilled Nursing ServicesNursing facilities fulfill a critical role in the post-acute care continuum by providing rehabilitation and custodial care services to patients not yet ready to transition home after hospitalization. The range of skilled nursing services offered enables recovery and stabilization for populations such as post-surgical patients, those with newly diagnosed illnesses requiring education and management, individuals recovering from fall-related injuries requiring physical therapy, and patients with chronic conditions necessitating periodic acute flare intervention.However, nursing facilities often struggle to optimize reimbursement through accurate and complete billing capture of the wide variety of skilled services delivered day to day. Proper use of Current Procedural Terminology (CPT) codes provides the mechanism to substantiate delivery of nursing care, therapies, treatments, evaluations, medication administration and more based on medical necessity and payer coverage policies. But pinpointing the appropriate CPT codes can prove challenging given the diversity of patient needs and interventions provided.Insufficient documentation and coding gaps lead to lost revenue for nursing facilities attempting to receive rightful payment for their skilled services at already slim margins. This makes billing and coding an essential competency for nursing facility administrators seeking to place their organizations on solid financial footing to support advancing quality of care.We dissect the array of CPT codes applicable in skilled nursing settings based on resident needs, modalities performed, and payer billing guidelines.We will cover CPT codes nursing facilities should recognize for areas including:Evaluation and Management ServicesPhysical, Occupational and Speech Therapy Wound Care and Complex Medical SuppliesPsychological and Psychiatric TestingRadiology and Diagnostic ServicesMedication AdministrationAdditionally, 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.CPT Codes for Nursing Facility Evaluation and Management (E&M) ServicesEvaluation and management services encompass visits, assessments, care planning and coordination for nursing home residents.E&M CPT codes capture levels based on complexity:Nursing Facility E&M Codes99304–99306: 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 managementReview of patient health history and medical recordsPhysical exam extentMedical decision making complexity in establishing care planTime spent providing counseling and\/or coordination of careFor 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.Ongoing Subsequent Visit E&M CPT CodesAfter 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 exam99308: Moderate complexity visits including interval history and brief exam99309: High complexity visits with detailed interval history, comprehensive exam, and possible care plan adjustments99310: Very high complexity visits reserved for unstable patients requiring intensive servicesSubsequent 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.Proper Nursing Home E&M Billing and DocumentationCorrect 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 assessmentsCareful review of resident case mix categories, which determine Medicare payment rates and coverage eligibility, to identify billable complexityComplete diagnoses list with impact on management documentedOnly face-to-face time between provider, patient, and caregivers counts toward selectionMedical necessity and skilled need for each encounter clearly justifiedDetailed resident evaluation, updated progress notes, modified orders, new assessments, and care plan changes recorded to support code levelsWith accurate documentation synchronizing clinical services and billing codes, nursing facilities ensure appropriate reimbursement for management, evaluation, and care coordination of residents.CPT Codes for Skilled Nursing Facility Rehabilitation ServicesRehabilitating patients back to optimal functionality requires physical, occupational and speech therapy.CPT codes specifically capture these modalities:Physical Therapy CPT Codes97161: Physical therapy evaluation low complexity97162: Physical therapy evaluation moderate complexity97163: Physical therapy evaluation high complexity97164: Physical therapy re-evaluation established patient97165: Occupational therapy evaluation low complexity97166: Occupational therapy evaluation moderate complexity97167: Occupational therapy evaluation high complexity97168: Occupational therapy re-evaluation established patientSpeech Therapy CPT Codes92521: Speech therapy evaluation92522: Speech therapy evaluation with modifiers92523: Speech therapy treatment 15 minutes92524: Speech therapy treatment each additional 15 minutesThe level of evaluation codes depends on elements like:Number of body parts involved requiring assessmentReview of health records and historyFunctional testing performedClinical decision making complexityTime spentTreatment 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 ModifiersSpecific modifiers describe therapy circumstances to convey further context:GP: Services delivered under an outpatient physical therapy plan of careGO: Services delivered under an outpatient occupational therapy plan of careGN: Services delivered under an outpatient speech-language pathology plan of careModifiers that may also apply in certain cases:59: Distinct procedural service when multiple therapies provided in one dayAS: Physician assistance for only part of a therapy serviceAT: Acute treatment with goal to reinstate prior level of functionThe modifiers provide supplemental information to illustrate therapy delivery circumstances impacting billing requirements.CPT Codes for Wound Care Supplies and ProceduresChronic wounds require extensive nursing facility resources for cleansing, dressing changes, and monitoring to prevent deterioration.CPT codes capture involved services:Wound Care CPT Codes97597: Debridement of wound surface97598: Removal of devitalized tissue from wound(s)97602: Wound(s) care including cleaning, local care, and dressing97605: Negative pressure wound therapyWound Care Supply CPT CodesAXXXX: Codes for surgical dressings like hydrogels, foam, impregnated gauze, etc.Other Considerations:Measure wound characteristics like length, width, depth and drainage amount to determine complexityQuantify surface area debrided and devitalized tissue removed in cm2Capture number of wounds addressed and time spent providing careNote supplies applied and dressing change frequencyOngoing wound evaluation, monitoring, instructionsRobust documentation of wound status, procedures performed, supplies utilized, and clinician time validates appropriate wound care CPT code levels selected.Psychological and Psychiatric CPT Codes for Nursing HomesMental and behavioral health needs of residents require psychiatry and psychology services in skilled nursing settings:Psychiatric CPT Codes90832–90838: Psychotherapy and evaluation codes based on time spent treating diagnosed mental health conditionsPsychological CPT Codes96116: Neurobehavioral status exam by psychologist or physician first 60 minutes96121: Neuropsychological testing by psychologist first hour96125: Standardized cognitive performance testing per hour of psychologist time96127: Brief emotional\/behavioral assessment by physicianUsing these codes accurately requires detailing:Diagnosed psychiatric illnesses and related symptoms requiring therapy managementStart and end times for psychotherapy sessionsSpecific psychological tests administered and findingsInterpretation of cognitive\/emotional\/behavioral test resultsOngoing tracking of behavioral disturbances, mood, thought processes requiring psychologist expertiseBy 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.Radiology and Diagnostic CPT Codes for Nursing Home ResidentsSkilled nursing facilities provide many ancillary services like x-rays, labs tests, and other diagnostic procedures:Radiology CPT Codes71010–71035: Chest x-ray codes by number of views72020–72072: X-ray codes for extremities72100–72133: X-ray codes for spine and pelvis73030: X-ray shoulder complete minimal 2 views73560: X-ray knee 2 or 3 viewsPathology CPT Codes80048: Basic metabolic panel80053: Comprehensive metabolic panel80061: Lipid panel82947: Glucose blood test84443: Thyroid stimulating hormone (TSH) testRemember key principles:Attach radiology procedure report to substantiate exams performed and number of views capturedInclude lab requisition copies noting tests orderedDocument medical necessity and how results inform resident diagnosis\/treatmentLinking 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.Medication Administration CPT CodesThe extensive medication regimens required by nursing home residents demand accurate capture of administration services:Injection CPT Codes96372: Subcutaneous or intramuscular injection, includes up to 5 medicinal agentsIV Medication CPT Codes96365: IV infusion for therapy, diagnosis or prevention; initial up to 1 hour96366: IV infusion each additional hourEnteral\/Parenteral Nutrition CPT Codes99508: Enteral\/parenteral nutrition services, administrative services by physicianKey billing insights:Quantify number of medication agents given when using injection administration code 96372Only capture incremental time beyond first hour for IV infusion code 96366Ensure nutrition formula is documented as medically necessaryWith robust notes detailing medication names, dosages, routes and oversight required, nursing facilities receive payment for management of extensive pharmaceutical regimens improving resident health.SummaryApplying the optimal CPT codes in skilled nursing facilities requires understanding a broad array of services provided, precise documentation of resident evaluations, quantifying treatment times, listing diagnoses addressed, and payer billing policies. But specific codes do exist to capture rehabilitation therapies, complex medical equipment and supply usage, clinician E&M services, diagnostic testing, medication administration and more.Becoming familiar with the CPT codes outlined here positions nursing facilities to maximize reimbursement potential through accurate billing capture. Partnering with a specialized post-acute care medical billing service offers an additional resource ensuring coding and documentation synchronize to convey the full scope of high-quality care delivered to improve the health of residents."},{"@context":"https:\/\/schema.org\/","@type":"BreadcrumbList","itemListElement":[{"@type":"ListItem","position":1,"name":"2024","item":"https:\/\/medwave.io\/2024\/#breadcrumbitem"},{"@type":"ListItem","position":2,"name":"01","item":"https:\/\/medwave.io\/2024\/\/01\/#breadcrumbitem"},{"@type":"ListItem","position":3,"name":"Which CPT Codes are Used in Nursing Facility Billing?","item":"https:\/\/medwave.io\/2024\/01\/which-cpt-codes-are-used-in-nursing-facility-billing\/#breadcrumbitem"}]}]