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

Find out more about CPT code 99308, a code for nursing facility services, its guidelines, and documentation requirements.

Use Code

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

Frequently asked questions

As often as medically necessary; commonly used weekly or biweekly.

CPT code 99308 is used for a subsequent nursing facility visit that involves an expanded problem focused interval history, detailed examination, and medical decision making of moderate complexity. In contrast, 99307 is for a similar visit but includes a problem-focused interval history and examination, with straightforward decision making, making it less comprehensive than 99308.

No, unless billing based on time rather than MDM.