CPT Code 99306: Initial nursing facility care, high complexity

CPT code 99306 documentation requirements

To accurately bill the evaluation and management code, thorough documentation is essential, and the medical records must have the following elements:

• Full initial admission note including H&P
• Comprehensive history
• Comprehensive examination
• Comprehensive assessment and management
• High complexity MDM (3+ problems, extensive data review, high risk)

Documentation must reflect a comprehensive initial patient encounter by the admitting healthcare provider with the established or new patient.

CPT code 99306 billing guidelines

For maintaining compliance with regulations and proper reimbursement, healthcare providers must follow the guidelines below:

• Bill once per admission/ per encounter per provider group.
• Can be used for new or established patients.
• Must meet current-year CPT/AMA MDM guidelines for high complexity.
• POS code 31 (SNF) or 32 (NF) must be used.

Other relevant CPT codes

• 99304–99305 – Lower complexity initial SNF visits
• 99307–99310 – Subsequent visits
• 99315–99316 – SNF discharge day management