Which CPT Codes are Used in Nursing Facility Billing?

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12 months ago

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 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 Services
Physical, Occupational and Speech Therapy
Wound Care and Complex Medical Supplies
Psychological and Psychiatric Testing
Radiology and Diagnostic Services
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.

CPT Codes for Nursing Facility Evaluation and Management (E&M) Services

Evaluation 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 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.

Ongoing Subsequent Visit E&M CPT Codes

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.

Proper Nursing Home E&M Billing and Documentation

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 for Skilled Nursing Facility Rehabilitation Services

Rehabilitating patients back to optimal functionality requires physical, occupational and speech therapy.

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 for Wound Care Supplies and Procedures

Chronic wounds require extensive nursing facility resources for cleansing, dressing changes, and monitoring to prevent deterioration.

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.

Psychological and Psychiatric CPT Codes for Nursing Homes

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.

Radiology and Diagnostic CPT Codes for Nursing Home Residents

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.

Medication Administration CPT Codes

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.

Summary

Applying 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.