CPT Code 99309: Subsequent Nursing Facility Visit, Moderate Complexity

What is the CPT code 99309?

CPT code 99309 designates subsequent nursing facility care services of moderate complexity of medical decision-making (MDM) for the evaluation and management of established patients in long-term care settings. This code represents a specific billing unit for subsequent nursing facility visits that fall between routine follow-up care and complex encounters requiring more detailed assessment and comprehensive management than lower-level visits but not reaching the intensity of the highest-complexity visits.

Code 99309 is applied when healthcare providers engage in the ongoing management of patients with intricate health complexities that necessitate more than routine attention but do not require extensive decision-making. These encounters typically involve addressing moderate complexity health conditions, emphasizing the ongoing and comprehensive attention provided to patients in various stages of nursing facility care.

Healthcare providers utilize this code when managing patients with conditions requiring close monitoring and adjustment of treatment plans, such as:

• Multiple stable chronic conditions requiring ongoing medication management
• Recovering from post-acute conditions needing regular assessment
• Patients with advancing health issues that have not yet reached high complexity
• Management of moderate-severity new problems in the facility setting

CPT code 99309 documentation requirements

Proper documentation is essential for appropriate coding and subsequent reimbursement for nursing facility care services. The documentation must demonstrate that the level of service provided during visits meets the criteria for a moderate-complexity MDM.

Documentation for CPT code 99309 must include:

• Detailed interval history: Document a detailed review of the patient's condition since the last visit, including chief complaint, an extended history of present illness (HPI), and a review of systems (ROS) pertinent to the presenting problems. This should capture status changes, treatment responses, and new concerns.
• Detailed physical examination: This is a detailed examination focusing on the affected body areas and other relevant systems. It typically involves an extended examination of the affected body area(s), organ system(s), and other symptomatic or related organ systems.
• Medical decision-making of moderate complexity: Documentation must demonstrate moderate complexity through:
  • Multiple diagnoses or management options
  • Moderate amount of data to review (lab results, diagnostic studies, etc.)
  • Moderate risk of complications, morbidity, or mortality
• Time: If the visit is primarily driven by counseling or coordination of care, time must be documented, specifying the total face-to-face time spent with the patient and noting that more than 50% was devoted to counseling/coordination activities.

CPT code 99309 billing guidelines

Understanding the billing guidelines for CPT code 99309 ensures proper reimbursement and compliance with nursing facility service regulations.

Frequency and coverage limitations

Medicare and most payers limit the number of subsequent nursing facility visits that can be reported for a single patient. Medicare typically covers one subsequent nursing facility care visit (99307-99310) per patient per day, requiring appropriate documentation to justify the level of service provided.

When multiple providers from different specialties see the same patient on the same date, each may bill an appropriate subsequent care code if providing distinct services. However, providers from the same specialty group must bill only one visit collectively.

Common billing challenges

Several challenges can affect proper billing for subsequent nursing facility care:

• Distinguishing between low, moderate, and high complexity visits
• Justifying medical necessity for the level of service
• Proper documentation of time when used as the controlling factor
• Coordination with other providers for billing on the same date
• Transmission of patient record information between facilities and physicians

To avoid claim denials, providers should ensure robust documentation practices that establish the medical necessity of each moderate-complexity visit and review the documentation before assigning the 99309 code.