How To Use CPT Code 99304

CPT 99304 refers to the initial nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. This article will cover topics such as the description, procedure, qualifying circumstances, when to use the code, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT 99304 procedures.

1. What is CPT 99304?

CPT 99304 is a code used to describe the initial nursing facility care provided to a patient, which includes evaluation and management services. This code is applicable when the patient requires a medically appropriate history and/or examination and the medical decision making involved is straightforward or of low complexity. The code is used by healthcare providers to bill for these services and ensure accurate reimbursement.

2. 99304 CPT code description

The official description of CPT code 99304 is: “Initial nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 25 minutes must be met or exceeded.”

3. Procedure

The 99304 procedure involves the following steps:

1. Reviewing the patient’s medical history and/or conducting a medically appropriate examination.
2. Evaluating the patient’s condition and determining the level of medical decision making required.
3. Providing necessary care, counseling, and education to the patient or caregiver.
4. Coordinating care with other healthcare providers, if necessary.
5. Documenting the encounter, including the history, examination, and medical decision making involved.

4. Qualifying circumstances

Patients eligible to receive CPT code 99304 services are those who require initial nursing facility care, which includes evaluation and management services. The patient must require a medically appropriate history and/or examination, and the medical decision making involved should be straightforward or of low complexity. Additionally, the total time spent on the date of the encounter must be at least 25 minutes.

5. When to use CPT code 99304

It is appropriate to bill the 99304 CPT code when a healthcare provider performs an initial nursing facility care visit involving evaluation and management services for a patient. The visit must involve a medically appropriate history and/or examination and straightforward or low medical decision making, or the provider must spend at least 25 minutes of total time on the encounter on a single date.

6. Documentation requirements

To support a claim for CPT 99304, the following information must be documented:

• A medically appropriate history and/or examination performed by the provider.
• The level of medical decision making involved in the encounter.
• The total time spent on the date of the encounter, if using time for code selection.
• Details of the care, counseling, and education provided to the patient or caregiver.
• Coordination of care with other healthcare providers, if applicable.

7. Billing guidelines

When billing for CPT code 99304, healthcare providers should ensure that the documentation supports the services provided and meets the requirements for the code. Providers should also be aware of any payer-specific guidelines or policies related to billing for initial nursing facility care services.

8. Historical information

CPT 99304 was added to the Current Procedural Terminology system on January 1, 2006. Since then, there have been several updates to the code description, with the most recent change occurring on January 1, 2023.

9. Similar codes to CPT 99304

Five similar codes to CPT 99304 include:

• CPT 99305: This code is used for initial nursing facility care with a higher level of medical decision making or longer total time spent on the encounter.
• CPT 99306: This code is used for initial nursing facility care with the highest level of medical decision making or the longest total time spent on the encounter.
• CPT 99307: This code is used for subsequent nursing facility care with straightforward or low medical decision making or a shorter total time spent on the encounter.
• CPT 99308: This code is used for subsequent nursing facility care with a moderate level of medical decision making or a longer total time spent on the encounter.
• CPT 99309: This code is used for subsequent nursing facility care with a high level of medical decision making or the longest total time spent on the encounter.

10. Examples

Here are 10 detailed examples of CPT code 99304 procedures:

1. A patient is admitted to a nursing facility for rehabilitation following a hip replacement surgery. The provider performs an initial evaluation and management visit, spending 30 minutes on the encounter.
2. A patient with dementia is admitted to a nursing facility for long-term care. The provider conducts an initial evaluation and management visit, including a medically appropriate history and examination, and spends 25 minutes on the encounter.
3. A patient with congestive heart failure is admitted to a nursing facility for monitoring and management. The provider performs an initial evaluation and management visit, involving straightforward medical decision making, and spends 28 minutes on the encounter.
4. A patient with a history of falls is admitted to a nursing facility for safety monitoring and assistance with activities of daily living. The provider conducts an initial evaluation and management visit, including a medically appropriate examination, and spends 27 minutes on the encounter.
5. A patient with chronic obstructive pulmonary disease is admitted to a nursing facility for management of respiratory symptoms. The provider performs an initial evaluation and management visit, involving low medical decision making, and spends 26 minutes on the encounter.
6. A patient with a recent stroke is admitted to a nursing facility for rehabilitation and therapy. The provider conducts an initial evaluation and management visit, including a medically appropriate history and examination, and spends 29 minutes on the encounter.
7. A patient with diabetes is admitted to a nursing facility for management of blood sugar levels and wound care. The provider performs an initial evaluation and management visit, involving straightforward medical decision making, and spends 31 minutes on the encounter.
8. A patient with a history of urinary tract infections is admitted to a nursing facility for monitoring and management. The provider conducts an initial evaluation and management visit, including a medically appropriate examination, and spends 32 minutes on the encounter.
9. A patient with Parkinson’s disease is admitted to a nursing facility for assistance with mobility and activities of daily living. The provider performs an initial evaluation and management visit, involving low medical decision making, and spends 33 minutes on the encounter.
10. A patient with a recent hip fracture is admitted to a nursing facility for rehabilitation and therapy. The provider conducts an initial evaluation and management visit, including a medically appropriate history and examination, and spends 35 minutes on the encounter.