Summary & Overview
CPT 99310: Subsequent Nursing Facility Care, High Complexity
CPT code 99310 represents subsequent nursing facility care for patients requiring a detailed interval history, detailed examination, and high complexity medical decision making. This code is widely used in geriatric medicine to capture the complexity of ongoing care for residents in nursing facilities. Nationally, it is recognized by major payers including Aetna, Blue Cross Blue Shield, Cigna Health, Medicare, and UnitedHealthcare, making it a critical component of reimbursement and compliance for providers delivering high-level evaluation and management services.
This publication provides a comprehensive overview of 99310, including payer coverage, clinical context, and related billing codes. Readers will gain insights into benchmarks for utilization, policy updates affecting nursing facility care, and the clinical requirements necessary for accurate coding. The analysis also highlights associated modifiers and taxonomies relevant to geriatric, family, and internal medicine physicians. Understanding 99310 is vital for ensuring proper documentation and reimbursement for complex patient care in nursing facilities.
CPT Code Overview
CPT code 99310 is used for subsequent nursing facility care, per day, for the evaluation and management of a patient. This code requires at least two of three key components: a detailed interval history, a detailed examination, and medical decision making of high complexity. The service type is Geriatrics, and the typical site of service is a Nursing Facility (Place of Service 32). This code is essential for documenting and billing complex follow-up care provided to patients residing in nursing facilities.
Clinical & Coding Specifications
Clinical Context
A typical patient scenario for CPT code 99310 involves an elderly individual residing in a nursing facility (Place of Service 32). The patient may have multiple chronic conditions such as essential hypertension (I10), type 2 diabetes mellitus without complications (E11.9), and mobility issues like difficulty in walking (R26.2). The patient may also have a history of falling (Z91.81) and be bed-confined (Z74.01). During a subsequent nursing facility care visit, the provider conducts a detailed interval history and examination, and engages in medical decision making of high complexity. This visit is part of ongoing management, often by a geriatric medicine, family medicine, or internal medicine physician, to address acute changes, review medications, and coordinate care for complex medical needs.
Coding Specifications
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Modifiers:
- Modifier
25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service. Used when an E/M service is distinct from another procedure performed on the same day. - Modifier
59: Distinct Procedural Service. Used to indicate that a procedure or service is separate and not normally reported together with other services.
- Modifier