CPT code 99308: Subsequent nursing facility care visit, low level

What is the 99308 CPT code?

CPT code 99308 is a subsequent nursing facility care code that's used for the evaluation and management of a patient in a nursing facility that requires a low-level medical decision-making. It's typically during routine skilled nursing care follow-ups and includes a reassessment, brief exam, and update of the care plan for individuals recovering from conditions or are stable.

Documentation requirements

To support the use of CPT code 99308, accurate documentation is crucial. Therefore, the patient's medical records must include the following:

• Date, facility, and time spent (if applicable)
• Chief complaint and problem pertinent system review
• Brief interval history and expanded problem-focused examination
• Documentation supporting a low level of complexity
• Updates to medications, orders, and care plan

Billing guidelines

For accurate reimbursement, the healthcare professional should follow these guidelines:

• Report one per patient per day
• Use for subsequent visits after the initial nursing facility admission
• Medical necessity must be established for the condition of the patient during the time of visit
• Choose the level of service based on key components or total time spent
• Use modifiers if necessary
• Check with the specific payer for their specific billing guidelines and requirements