How To Use CPT Code 99305

CPT 99305 is a code for initial nursing facility care involving evaluation and management with moderate medical decision making or at least 35 minutes of total time spent on the encounter. This article will cover topics such as the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT 99305.

1. What is CPT 99305?

CPT 99305 is a code used by medical professionals to bill for initial nursing facility care services. This code is specifically for the evaluation and management of a patient in a nursing facility setting, involving moderate medical decision making or at least 35 minutes of total time spent on the encounter. The total time includes both face-to-face and non-face-to-face activities on the encounter date.

2. 99305 CPT code description

The official description of CPT code 99305 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 moderate level of medical decision making. When using total time on the date of the encounter for code selection, 35 minutes must be met or exceeded.”

3. Procedure

The 99305 procedure involves the following steps:

1. Reviewing tests and preparing for the patient visit
2. Performing a medically appropriate history and/or examination
3. Evaluating the patient’s condition and determining the level of medical decision making required
4. Counseling and educating the patient or caregiver
5. Ordering tests and communicating with other healthcare providers
6. Documenting the encounter in the medical record
7. Interpreting and communicating test results
8. Coordinating care with other healthcare professionals or agencies

4. Qualifying circumstances

Patients eligible to receive CPT code 99305 services are those who require initial nursing facility care involving evaluation and management. The patient’s condition must necessitate moderate medical decision making or at least 35 minutes of total time spent on the encounter. This code is not applicable for follow-up visits or other types of care provided in a nursing facility setting.

5. When to use CPT code 99305

It is appropriate to bill the 99305 CPT code when a healthcare provider performs an initial nursing facility care visit involving evaluation and management, with moderate medical decision making or at least 35 minutes of total time spent on the encounter. This code should not be used for follow-up visits or other types of care provided in a nursing facility setting.

6. Documentation requirements

To support a claim for CPT 99305, the following information must be documented in the medical record:

• A medically appropriate history and/or examination
• The level of medical decision making involved
• Total time spent on the encounter, including both face-to-face and non-face-to-face activities
• Details of counseling and education provided to the patient or caregiver
• Orders for tests and communication with other healthcare providers
• Interpretation and communication of test results
• Coordination of care with other healthcare professionals or agencies

7. Billing guidelines

When billing for CPT code 99305, it is essential to ensure that the documentation supports the claim and that the code is used appropriately. The level of medical decision making or total time spent on the encounter must meet the requirements specified in the code description. Additionally, all services performed should be documented in the medical record, including the history and examination, counseling and education, and coordination of care.

8. Historical information

CPT 99305 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 99305

Five similar codes to CPT 99305 include:

• CPT 99304: Initial nursing facility care with a lower level of medical decision making or less total time spent on the encounter
• CPT 99306: Initial nursing facility care with a higher level of medical decision making or more total time spent on the encounter
• CPT 99307: Subsequent nursing facility care with a lower level of medical decision making or less total time spent on the encounter
• CPT 99308: Subsequent nursing facility care with a moderate level of medical decision making or more total time spent on the encounter
• CPT 99309: Subsequent nursing facility care with a higher level of medical decision making or more total time spent on the encounter

10. Examples

Here are 10 detailed examples of CPT code 99305 procedures:

1. A patient with newly diagnosed congestive heart failure is admitted to a nursing facility for monitoring and management. The provider spends 40 minutes on the initial evaluation and management, including a comprehensive history and examination, and moderate medical decision making.
2. A patient with a recent stroke is admitted to a nursing facility for rehabilitation. The provider spends 35 minutes on the initial evaluation and management, including a comprehensive history and examination, and moderate medical decision making.
3. A patient with advanced dementia is admitted to a nursing facility for long-term care. The provider spends 45 minutes on the initial evaluation and management, including a comprehensive history and examination, and moderate medical decision making.
4. A patient with a complicated wound infection is admitted to a nursing facility for intravenous antibiotic therapy and wound care. The provider spends 50 minutes on the initial evaluation and management, including a comprehensive history and examination, and moderate medical decision making.
5. A patient with a recent hip fracture is admitted to a nursing facility for postoperative care and rehabilitation. The provider spends 40 minutes on the initial evaluation and management, including a comprehensive history and examination, and moderate medical decision making.
6. A patient with uncontrolled diabetes is admitted to a nursing facility for medication management and education. The provider spends 35 minutes on the initial evaluation and management, including a comprehensive history and examination, and moderate medical decision making.
7. A patient with chronic obstructive pulmonary disease is admitted to a nursing facility for respiratory therapy and management. The provider spends 45 minutes on the initial evaluation and management, including a comprehensive history and examination, and moderate medical decision making.
8. A patient with a recent myocardial infarction is admitted to a nursing facility for cardiac rehabilitation. The provider spends 50 minutes on the initial evaluation and management, including a comprehensive history and examination, and moderate medical decision making.
9. A patient with end-stage renal disease is admitted to a nursing facility for dialysis and management. The provider spends 40 minutes on the initial evaluation and management, including a comprehensive history and examination, and moderate medical decision making.
10. A patient with a recent amputation is admitted to a nursing facility for prosthetic fitting and rehabilitation. The provider spends 35 minutes on the initial evaluation and management, including a comprehensive history and examination, and moderate medical decision making.