99308

Subsequent Nursing Facility Care, Moderate Complexity MDM, 30 Minutes

CPT code 99308 represents a subsequent nursing facility (NF) evaluation and management (E/M) service provided by a physician or other qualified healthcare professional. This service is intended for the ongoing care of patients residing in a skilled nursing facility (SNF), nursing facility (NF), or intermediate care facility (ICF/IID). To report 99308, the encounter must involve a medically appropriate history and/or a physical examination. The complexity of medical decision making (MDM) must be at least moderate. Alternatively, if the provider chooses to select the code based on the total time spent on the date of the encounter, a minimum of 30 minutes must be documented. The service includes the evaluation of the patient's current clinical status, the review of laboratory or diagnostic studies, and the adjustment of the treatment plan as necessary. Moderate complexity MDM typically involves the management of at least one chronic illness with a mild exacerbation, or two or more stable chronic illnesses, or an undiagnosed new problem with an uncertain prognosis. The data review component for moderate complexity often requires the analysis of multiple tests or obtaining a history from an independent historian, such as a family member or facility staff. The risk level is moderate, frequently involving prescription drug management or decisions regarding minor surgery with identified patient or procedure risk factors. This code is used for routine follow-up visits or for the assessment of new, non-emergent clinical issues that arise during the patient's stay.

Clinical Indications

  • Management of patients with multiple chronic comorbidities requiring regular physician oversight.
  • Follow-up for acute conditions such as urinary tract infections, pneumonia, or cellulitis initially treated in the facility.
  • Medication titration for chronic conditions like hypertension, heart failure, or diabetes mellitus.
  • Assessment of a patient showing a decline in functional or cognitive status.
  • Review of diagnostic test results that require a change in the established care plan.
  • Evaluation of behavioral symptoms or psychological needs in patients with dementia or psychiatric disorders.
  • Wound care assessment and management for pressure ulcers or surgical sites.
  • Routine regulatory visits as mandated by state or federal nursing facility guidelines.

Procedure Steps

  1. Review the patient’s nursing facility medical record, including nursing notes, medication administration records, and recent lab results.
  2. Perform a medically appropriate history, including an interval history of symptoms and changes since the last visit.
  3. Conduct a medically appropriate physical examination focused on the patient's current complaints and chronic conditions.
  4. Assess the patient’s response to current medications and treatments.
  5. Analyze diagnostic data such as imaging, lab tests, or consultations from specialists.
  6. Develop or update the management plan, including ordering new tests, adjusting medications, or initiating therapies.
  7. Communicate the updated plan of care to the nursing facility staff and, if appropriate, the patient’s family or legal representative.
  8. Document the encounter in the facility's medical record, ensuring the MDM complexity or total time (at least 30 minutes) is clearly stated.

Coding Guidelines

  • Selection of 99308 is based on either meeting the moderate MDM requirement or reaching the 30-minute time threshold.
  • Total time includes both face-to-face and non-face-to-face time spent by the provider on the date of the encounter.
  • If the MDM is low complexity or the time is less than 30 minutes (minimum 15), use code 99307.
  • If the MDM is high complexity or the time is at least 45 minutes, use code 99309.
  • Do not report 99308 on the same day as an initial nursing facility care service (99304-99306).
  • Medicare 'incident-to' rules do not apply in the nursing facility setting for these E/M codes; the provider performing the service must bill under their own NPI.
  • For patients transitionally seen in the hospital and nursing facility on the same day, only one E/M code (typically the initial NF visit or hospital discharge) may be billed depending on the circumstances.
  • A medically appropriate history and/or exam is required, but the extent of these is determined by the provider and not used for code level selection.

Associated ICD-10 Codes