99309

Subsequent Nursing Facility Care, Moderate Medical Decision Making (30-44 Minutes)

CPT 99309 is a procedural code used for the subsequent nursing facility care of a patient, which involves a medically appropriate history and/or physical examination and moderate level of medical decision making (MDM). When selecting this code based on time, the provider must spend between 30 and 44 minutes of total time on the date of the encounter. This service is typically performed in a skilled nursing facility (SNF), intermediate care facility (ICF), or long-term care (LTC) setting. The physician or qualified healthcare professional manages patients who are experiencing new problems, worsening chronic conditions, or complex multi-system issues that require frequent monitoring and nuanced adjustments to the care plan. Moderate MDM in the nursing facility context usually involves addressing one or more chronic illnesses with exacerbation, progression, or side effects of treatment; two or more stable chronic illnesses; or a new acute problem with uncertain prognosis. The data component of MDM for this level involves a moderate amount of review and analysis, such as interpreting unique tests or reviewing prior external notes. The risk of morbidity is moderate, often involving prescription drug management or decisions regarding minor surgery with identified risk factors. The encounter includes a review of the patient's record, interaction with the nursing staff, physical assessment, and the updating of the facility’s comprehensive care plan.

Clinical Indications

  • Management of a patient with multiple chronic conditions requiring medication adjustment
  • Evaluation of an acute exacerbation of a chronic condition, such as COPD or CHF, within the nursing facility
  • Follow-up for a patient with a new acute onset illness requiring moderate diagnostic workup, such as pneumonia or cellulitis
  • Oversight of post-acute recovery following hospital discharge with moderate complexity
  • Management of complex wound care involving changes in status or infection
  • Evaluation of behavioral or psychological symptoms of dementia requiring pharmacological intervention

Procedure Steps

  1. Review of the facility's medical records, including nursing notes, therapist reports, and medication administration records (MAR) since the last visit
  2. Conducting a medically appropriate history from the patient, facility staff, and/or family members as available
  3. Performance of a medically appropriate physical examination focused on the patient's current complaints and chronic condition status
  4. Review and analysis of diagnostic results, including laboratory data, imaging, or specialist consultations
  5. Assessment of the patient's progress toward the goals established in the interdisciplinary comprehensive care plan
  6. Modification of the medical treatment plan, which may include new medication orders, therapy referrals, or dietary changes
  7. Communication and coordination of the care plan with the nursing staff and other members of the care team
  8. Detailed documentation of the findings, medical decision making, and the revised plan in the facility's electronic or paper medical record

Coding Guidelines

  • Report 99309 for subsequent nursing facility visits requiring Moderate MDM or 30-44 minutes of total time
  • Time spent on the date of the encounter includes both face-to-face and non-face-to-face time spent by the physician or QHP
  • Do not use 99309 for the initial nursing facility visit; use codes 99304-99306 for initial care
  • For visits exceeding 44 minutes, consider CPT 99310 (High MDM/45-59 minutes) or prolonged service codes if applicable
  • Ensure documentation supports the 'Moderate' MDM level if time is not the primary factor for code selection
  • 99309 may be billed by physicians, Nurse Practitioners (NPs), or Physician Assistants (PAs) according to state scope of practice
  • Cannot be reported on the same day as a nursing facility discharge (99315, 99316) by the same provider

Associated ICD-10 Codes