An internist we work with rounds at three nursing facilities on Tuesdays and Thursdays. She sees between 14 and 22 patients a day, writes her notes in each facility's chart, and keeps a folded census sheet in her coat pocket with check marks next to the names she saw. On Friday she hands the sheet to the billing office. When we compared six months of those sheets to the facilities' own census records, about one visit in eight had a note in the facility chart and no charge in the billing system. Nothing was denied. The claims were never sent.
That is the shape of the problem in nursing facility visit coding. The codes themselves are not hard, and since January 1, 2023 they follow the same medical decision making (MDM) and time framework as office visits. The revenue problem is upstream: visits performed in a building the practice does not control, documented in a record the practice does not own, and captured from memory. The second problem is smaller but real: rounding physicians tend to code every subsequent visit at the same level because it is faster.
This article covers the 99304 to 99316 codes as they have worked since the 2023 changes, the MDM and time thresholds for each, the federal rules about who may perform which visit, the places rounding physicians go wrong, and the census reconciliation that closes the charge capture gap.
Key takeaways
- Since January 1, 2023, nursing facility visits are leveled by MDM or total time on the date of service, 99318 (the annual assessment) is gone, and the initial codes 99304 to 99306 are reported once per admission per physician or group.
- Subsequent visits 99307 to 99310 carry time thresholds of 10, 20, 30 and 45 minutes; the initial codes carry 25, 35 and 50 minutes; discharge is 99315 (30 minutes or less) or 99316 (more than 30 minutes).
- In a skilled nursing facility (place of service 31), federal rules require a physician to perform the initial comprehensive visit; nurse practitioners and physician assistants may alternate the required subsequent visits.
- Assisted living and group home visits are not nursing facility codes; since 2023 they are reported with the home or residence codes 99341 to 99350.
- The largest revenue loss is visits never billed, and the fix is a monthly reconciliation of each facility's census against your charges.
The codes after the 2023 changes
The 2023 CPT revision brought nursing facility services in line with the 2021 office visit framework. History and exam are no longer scored; they are performed as medically appropriate. The level is chosen either by MDM, using the same three elements as the office (number and complexity of problems, data reviewed and analyzed, risk of complications or management), or by total practitioner time on the date of the encounter, including time reviewing the facility chart, examining the patient, talking with nursing staff and family, documenting and coordinating care. Time spent by clinical staff and travel between facilities do not count.
| Code | Type | MDM level | Time threshold (meet or exceed) |
|---|---|---|---|
| 99304 | Initial | Straightforward or low | 25 minutes |
| 99305 | Initial | Moderate | 35 minutes |
| 99306 | Initial | High | 50 minutes |
| 99307 | Subsequent | Straightforward | 10 minutes |
| 99308 | Subsequent | Low | 20 minutes |
| 99309 | Subsequent | Moderate | 30 minutes |
| 99310 | Subsequent | High | 45 minutes |
| 99315 | Discharge | Not applicable | 30 minutes or less |
| 99316 | Discharge | Not applicable | More than 30 minutes |
Two prolonged service codes sit on top. For Medicare, G0317 is reported for each additional 15 minutes once total time reaches 95 minutes for 99306 or 85 minutes for 99310. For payers that follow CPT, 99418 serves the same purpose with CPT's own thresholds. Both require documented total time; MDM alone does not get you there.
The deletion of 99318 matters for rounding physicians who used it for the annual assessment. That visit is now a subsequent visit coded by MDM or time like any other. The "initial" codes are also narrower than people assume: they are for the first visit by the physician or group during the stay, once per admission, and a patient readmitted after a hospitalization gets a new initial visit only if the facility admits them as a new stay.
Who may perform which visit
The federal nursing home regulations at 42 CFR 483.30 sit alongside the coding rules. In a skilled nursing facility (SNF, place of service 31, where the patient is in a Medicare Part A stay), the initial comprehensive visit must be performed by a physician, and it cannot be delegated to an NP or PA. After that, the resident must be seen at least once every 30 days for the first 90 days and at least every 60 days thereafter, and those required visits may alternate between the physician and an NP or PA who is not employed by the facility. In a nursing facility that is not a SNF stay (place of service 32), an NP or PA may perform the initial visit if state law allows and the facility permits it.
Medically necessary visits beyond the required schedule are billable when documented, and they are where the clinical value lives: a fall, a new fever, a medication change after a hospital transfer. What is not billable is a visit whose only purpose is to sign facility paperwork or to satisfy the calendar with no clinical content. "Monthly visit, no complaints, continue current plan" is a 99307 at best and an audit target at worst.
The setting also decides the code family. A patient in an assisted living facility, a group home or a custodial care setting is not in a nursing facility, and since 2023 those visits are reported with the home or residence codes 99341 to 99350 (the domiciliary codes 99324 to 99340 were deleted). Rounding physicians who cover a campus with a SNF wing and an assisted living wing need two code families and two places of service on the same day.
A worked example of a rounding day
Take the internist's Tuesday at one facility. The census shows 18 of her patients. She admits two: a 79-year-old after hip fracture surgery with delirium, anticoagulation and a new insulin regimen (high MDM, 55 minutes including a call to the surgeon: 99306), and an 84-year-old for short-term rehabilitation after pneumonia with stable comorbidities (moderate MDM: 99305). She discharges one patient home with a 20-minute discharge (99315). Of the remaining 15, four have acute issues that change management (a urinary tract infection with a new antibiotic, a fall with imaging ordered, uncontrolled blood pressure with a dose change, a new depressive episode with a medication start): moderate MDM, 99309 each. Nine are stable chronic disease follow-ups with medication review and labs: low MDM, 99308 each. Two are stable with nothing to do beyond confirming the plan: 99307 each.
The billing sheet that reached the office listed 15 names. Missing were one 99309, one 99308 and the 99315, because the discharge happened in the hallway on the way out. Across three facilities and two rounding days a week, that one-in-eight gap is dozens of visits a month, and the notes exist in the facility chart to support every one of them. The physician also coded all nine chronic follow-ups as 99307 out of habit, when the documentation of medication management and labs supports 99308. Neither problem is a denial, so neither shows up on a denial report.
Closing the charge capture gap
The fix has three parts. First, get the census from the facility, not from the physician's pocket. Every facility can print or export a daily list of residents by attending physician, and most will email it to the practice on rounding day. Second, capture charges at the bedside with a mobile charge capture tool or, at minimum, a pre-printed rounding sheet generated from that census with the code choices beside each name, so the physician marks a level rather than remembering a name. Third, reconcile monthly: match every resident on the census with an attending visit due against the charges posted, and list the exceptions for the physician to confirm or dictate a late note.
Two metrics tell you whether it is working: the ratio of facility notes to posted charges (it should be one to one) and charge lag, the days between the visit and the charge entering the system. Rounding practices we see often run 10 to 20 days of lag because charges wait for the Friday sheet, which pushes cash out and puts dates of service near timely filing limits for the facilities' Medicare Advantage residents. A weekly capture routine cuts that to under five days. If your billing team is not producing these two numbers, ask why; this is the kind of leak our RCM audits quantify first for practices that round, and it is usually the largest single finding.
Where the claims fail
When nursing facility claims do deny, the causes are predictable. The place of service does not match the patient's status (POS 31 during a Part A stay, POS 32 otherwise), and the facility's business office is the only reliable source for the Part A dates. Two practitioners from the same group bill the same patient on the same day, and Medicare pays one visit; the group has to combine the work into one claim. A specialist and the attending both bill the same day, which is fine when the diagnoses differ and the notes show different problems. And Medicare Advantage plans deny visits for residents whose plan changed at the start of the year, which the census will not tell you but an eligibility check will. Our billing team runs eligibility on the whole census at the start of each month for exactly that reason.
Questions we hear
Can the NP do the admission visit in a nursing home?
In a SNF during a Part A stay, no; federal rules reserve the initial comprehensive visit for the physician. In a nursing facility that is not a SNF stay, yes, if your state allows it and the NP is not employed by the facility. Either way, the NP's subsequent visits are billable under the NP's own NPI at the NP rate.
Does time spent reviewing the facility chart before seeing the patient count?
Yes, if it is on the date of the encounter and personally performed by the billing practitioner. Chart review, discussions with nursing staff, family calls, documentation and care coordination that day all count toward total time. Travel between facilities and work done on a different day do not.
Can we bill a visit when the physician only signs orders and reviews the chart without seeing the patient?
No. Every code in this family requires a face-to-face encounter. Care plan oversight for nursing facility patients has its own codes (G0181 and G0182 are for home health and hospice; nursing facility oversight is 99379 and 99380 for payers that cover them, and Medicare generally does not), so check the payer before assuming that time is billable.
What to do this week
- Ask each facility for a daily census by attending physician and have it emailed to the practice on rounding days.
- Compare last month's census against posted charges and list every resident with a note but no charge.
- Give rounding physicians a one-page card with the MDM and time thresholds for 99304 to 99316 and the reminder that 99318 no longer exists.
- Confirm place of service on every nursing facility claim against the facility's Part A dates.
- Run eligibility on the full census at the start of the month and flag residents whose coverage changed.
- Measure charge lag for facility visits and set a target of five days or less.
