Nursing Home CPT Codes 99304-99316: The 2026 Billing, Reimbursement, and Denial Guide

A physician rounds at the nursing facility on Tuesday, documents the visit, and picks the right code. Three weeks later the claim comes back downcoded. The code was correct. The place of service field wasn’t.

A payer looks at three things on a nursing facility claim: the medical decision making level or total time, the place of service code, and whether the patient’s Medicare Part A benefit was active that day.

Getting the nursing home CPT codes right covers one of them. Miss either of the other two and the claim reprices or denies anyway.

Two dates changed how this code family works. On January 1, 2023, history and exam stopped setting the code level. On January 1, 2026, nursing facility codes lost the facility and non-facility payment parity they had carried since the family was built.

Nursing Home CPT Codes 2026: Complete Reference Table

Most coding tables in circulation carry at least one wrong time threshold. Cross-check anything you’re about to load into a template or a charge capture screen.

Nursing Facility CPT Codes 99304-99316: MDM Level, Time Threshold, and Valid Place of Service

The place of service column carries more weight in 2026 than it did in 2025, and Section 10 explains why. Two of those codes, POS 54 and POS 56, appear in almost no published coding reference even though the Medicare Claims Processing Manual lists them alongside 31 and 32.

Quick code reference

99304: Straightforward or low complexity MDM, or 25 minutes or more total time.

99305: Moderate complexity MDM, or 35 minutes or more total time.

99306: High complexity MDM, or 45 minutes or more total time.

99307: Straightforward MDM, or 10 minutes or more total time.

99308: Low complexity MDM, or 15 minutes or more total time.

99309: Moderate complexity MDM, or 30 minutes or more total time.

99310: High complexity MDM, or 45 minutes or more total time.

99315: Discharge day management, 30 minutes or less on the date of the encounter.

99316: Discharge day management, more than 30 minutes on the date of the encounter.

One structural rule catches people. Every time figure in that table is a threshold the encounter has to meet or exceed, which is the opposite of how office visit codes work.

Are Nursing Home CPT Codes Billed to Part A or Part B?

The physician’s visit stays payable under Part B even during a covered Part A stay. CMS excludes physician professional services from SNF consolidated billing, and that exclusion is what keeps this code family billable at all. The CMS SNF Billing Reference spells out the requirement.

The facility’s billing office and the physician’s billing office run on different systems, different forms, and different payment methodologies for the same encounter date. When the two don’t talk, the physician’s claim gets routed to the SNF and comes back unpaid.

Part A coverage turns on three conditions. The patient needs a 3-day qualifying inpatient hospital stay, and observation or emergency department time doesn’t count toward it. Admission to the SNF has to happen within 30 days of hospital discharge. The patient also has to need daily skilled care that is reasonable and necessary.

Nursing Facility vs Skilled Nursing Facility: What Changes on the Claim

Billing teams make more errors on that distinction than on the code selection itself. Plenty of buildings house both populations under one roof and one census list.

Initial Nursing Facility Care Codes 99304, 99305, and 99306

Initial codes get billed once per admission, per physician, per specialty, no matter how long the stay runs. If the patient discharges and comes back for a new stay, the initial codes apply again.

One rule catches billers off guard. Medicare will not pay for an initial nursing facility visit and an office, outpatient, or emergency department E/M on the same date for the same patient.

CPT guidelines allow the other site to be reported separately with modifier 25, so the CPT rule and the Medicare payment rule part ways here. Follow the Medicare rule on a Medicare claim.

The same MDM framework runs office visits, so a coder who can level a 99215 office visit already knows how to level a 99306. The AAFP nursing home E/M coding guidance maps the two families side by side.

CPT 99304: Low MDM or 25 Minutes

CPT 99304 reports initial nursing facility care with straightforward or low medical decision making, or 25 minutes or more of total time on the date of the encounter. It covers the first comprehensive evaluation when the patient arrives at the facility.

Picture a patient admitted for a short course of IV antibiotics. No significant comorbidities, a clean care plan, and no high-risk treatment decisions. The physician reviews the nursing notes, confirms the antibiotic regimen, and documents the assessment.

The note has to name which problems the physician addressed, what data got reviewed, and why the risk stayed low. A line reading “patient admitted to SNF for skilled care” won’t support 99304 in a post-payment review, and the addendum you write six months later carries less weight than the note you wrote that day.

CPT 99305: Moderate MDM or 35 Minutes

CPT 99305 reports initial nursing facility care with moderate medical decision making, or 35 minutes or more of total time. It fits the patient arriving with several active diagnoses that need care plan decisions.

A transfer after a heart failure exacerbation, with diabetes and chronic kidney disease in the mix. The physician adjusts diuretic dosing, sets up nephrology follow-up, and builds a fluid monitoring protocol.

99305 is the most undercoded initial code in the family. Physicians write “patient evaluated, care plan established” without naming the diagnoses they weighed or the risk level they landed on, and the coder has nothing to work with.

CPT 99306: High MDM or 45 Minutes, Plus the MDM Element Almost Nobody Documents

CPT 99306 reports initial nursing facility care with high medical decision making, or 45 minutes or more of total time. It covers admissions where the physician faces high-risk treatment decisions.

A stroke admission with residual deficits, several high-risk medications, and coordination running across neurology and rehab. Starting anticoagulation, managing an active infection, or rebuilding a complex pain regimen all land at this level.

The University of Rochester compliance guidelines publish that element alongside the full MDM grid. Of all the nursing home CPT codes, 99306 carries the widest gap between what physicians do and what they write down.

The principal physician of record has to append modifier AI to the initial nursing facility care code. Missing AI is a leading cause of CARC 16 on initial-care claims, and it gets worse when several specialties bill the same patient during one stay.

Subsequent Nursing Facility Care Codes 99307, 99308, 99309, and 99310

Subsequent codes are per-day services. Medicare won’t pay more than one nursing facility E/M per practitioner, per patient, per date of service, and the Recovery Audit Contractor program reviews that limit under an approved issue.

Federal regulation sets a separate visit schedule under 42 CFR Part 483: at least once every 30 days for the first 90 days after admission, then at least once every 60 days. Medical necessity still governs payment. The schedule governs compliance.

CPT 99307: Straightforward MDM or 10 Minutes

CPT 99307 reports subsequent nursing facility care with straightforward medical decision making, or 10 minutes or more of total time on the date of the encounter. Because 99308 starts at 15 minutes, time-based selection between the two turns on that 15-minute line.

A stable patient recovering from hip replacement, no new symptoms, routine labs ordered. The physician reviews nursing notes, confirms medication compliance, and moves on.

99307 is the most underbilled subsequent code. Physicians do more clinical work than the note captures, and the claim drops to the floor of the family by default.

CPT 99308: Low MDM or 15 Minutes

CPT 99308 reports subsequent nursing facility care with low medical decision making, or 15 minutes or more of total time. It fits stable chronic conditions that need assessment without high-risk decisions.

Adjusting medication for well-controlled hypertension, reviewing basic labs, or ordering a simple diagnostic test all sit at this level.

Commercial payer algorithms downcode 99308 when the note reads “patient stable, continue current management.” That exact phrasing is the trigger. Name what you managed and why the risk stayed low.

CPT 99309: Moderate MDM or 30 Minutes

CPT 99309 reports subsequent nursing facility care with moderate medical decision making, or 30 minutes or more of total time. It sits at the same MDM level as a moderate MDM office visit and the same level as subsequent hospital care under 99233.

A heart failure exacerbation needing daily fluid monitoring, diuretic adjustment, and renal function tracking. Behavioral changes in a dementia patient that force a care plan revision land here too.

Among the nursing home CPT codes, 99309 carries the most audit exposure because it carries the most volume. The note needs the diagnoses managed, the data reviewed, and the risk level that supports moderate MDM. A line reading “patient seen, doing well” doesn’t survive review.

CPT 99310: High MDM or 45 Minutes

CPT 99310 reports subsequent nursing facility care with high medical decision making, or 45 minutes or more of total time. It covers medically unstable patients where high-risk treatment decisions are on the table.

A new sepsis episode in a post-surgical patient. A new DVT that forces anticoagulation decisions. Coordinating an emergency transfer back to acute care.

The deciding question between 99309 and 99310 is whether the encounter involved high-risk treatment decisions or moderate-risk management. When the documentation supports either one, 99309 is the more defensible choice. OIG and RAC reviewers flag 99310 as the most overused code in the family.

Annual nursing facility assessments bill as subsequent care now, using 99307 through 99310, selected by MDM or time like any other subsequent visit. The next section covers what happened to the code that used to report them.

Nursing Facility Discharge Day Management: CPT 99315 and 99316

The discharge day work these codes cover includes the following.

• Final examination of the patient
• Discussion of the stay with the patient or family
• Discharge instructions given to all relevant caregivers
• Preparation of discharge records, prescriptions, and referral forms
• Coordination of post-discharge care

The face-to-face encounter can happen on a date before the patient physically leaves the facility. Time spent on that date doesn’t have to be continuous. Most billing teams assume the code has to match the physical discharge date, and it doesn’t.

A physician or qualified health care professional may also report a discharge day management code when pronouncing the death of a patient. That single rule represents revenue most nursing facility practices never capture.

No pair in this family goes unbilled more often than 99315 and 99316. Facilities miss them because no trigger exists in the EHR to generate a coding encounter on discharge day. The work gets done and never turns into a charge.

Configure the discharge order to open a pending billing encounter for the discharging physician to close. That one workflow change recovers the charge without asking anyone to remember anything.

SNF discharge codes and hospital discharge codes are separate families. Billing 99238 or 99239 for a nursing facility discharge triggers a place of service mismatch and an automatic denial.

CPT 99318 Was Deleted: What to Bill for Annual Nursing Facility Assessments

99318 hides in EHR superbills and charge capture templates, billing system code libraries, standing orders that name the code by number, and printed encounter forms. Each one needs updating before the next billing cycle. The HHS nursing facility services guidance confirms the deletion date.

Claims submitted with 99318 after January 1, 2023, that paid through a system gap may be subject to repayment on review. An internal audit of every 99318 claim since that date belongs in any nursing facility compliance review.

Search results still describe 99318 as an active code, because pages published before 2023 keep ranking and keep getting quoted. Verify code status against a current source before you trust any coding article, this one included.

Deleted codes sitting in a template are the quietest failure point in nursing home CPT codes, because nothing flags them until the remittance comes back.

Nursing Home CPT Code Time Thresholds That Get Quoted Wrong

Look these codes up twice and you’ll find two different time thresholds for the same code. Some of the numbers in circulation don’t trace back to any primary source at all. Below is where each one came from.

99306 is 45 minutes, not 50 or 70. The AMA 2023 E/M descriptors and guidelines set the threshold at 45 minutes. The 50-minute figure traces to a derived value-set display rather than the CPT descriptor. The 70-minute figure has no traceable primary source. Verify against your licensed CPT 2026 codebook before you build it into a template.

99310 is 45 minutes, not 35. A 35-minute subsequent visit is a 99309. Sources quoting 99310 at 35 minutes push coders into the most audited code in the family.

99309 is 30 minutes, not 25. The 25-minute figure is the pre-2021 typical time, carried forward on pages that never updated after the 2023 revision.

99308 is 15 minutes or more, not 20. That threshold hasn’t moved since January 2023.

99307 is a 10-minute threshold, not a 10 to 14 minute range. The AMA descriptor reads that 10 minutes must be met or exceeded, the same construction used for every other code in the family. Published tables print 99307 as a closed range because 99308 begins at 15 minutes, which is where time-based selection moves up. The practical boundary is real. The descriptor still has no ceiling in it.

History and exam no longer set the code level. Any source describing these codes with “detailed history,” “comprehensive examination,” or “expanded problem-focused” is running the pre-2021 framework. Physicians still document history and exam for patient care. Those elements stopped determining the code on January 1, 2023.

One framing error causes more mistakes across the nursing home CPT codes than any single wrong number. Nursing facility codes work as meet-or-exceed thresholds. Office visit codes work as ranges. Treating a nursing facility threshold like a range is how a 35-minute visit becomes a 99310.

Prolonged Nursing Facility Services: HCPCS G0317 and CPT 99418

You’ll see CPT 99417 named as the code Medicare replaced with G0317. That comparison is a code-family mix-up. 99417 is the office and outpatient prolonged code, and it was never applicable in a nursing facility. The nursing facility CPT counterpart is 99418.

Prolonged Nursing Facility Services: CPT 99418 and Medicare G0317 Time Thresholds

Medicare counts qualifying time across one day before the encounter, the date of the encounter, and the three calendar days after. Every activity inside that window needs its own date and duration documented. A total minute count with no itemization won’t survive review. The counting rules sit in the Medicare Claims Processing Manual, Chapter 12, Section 30.6.15.

Three restrictions on G0317 appear in almost no published guide.

• G0317 cannot be reported with nursing facility discharge day management, 99315 or 99316
• G0317 cannot be reported on the same date as 99358, 99359, or 99418
• Time spent in another setting can count toward prolonged nursing facility services when the prolonged requirements are met

That third rule is a revenue opportunity rather than a restriction, and practices almost never capture it. Prolonged services sit outside the core nursing home CPT codes, and the reporting rules split between CPT and Medicare.

POS 31 vs POS 32: The Place of Service Decision That Changed in January 2026

A claim can carry the right code and still reprice or deny, because the place of service field decides which payment rate applies. For nursing facility visits, that field changed meaning on January 1, 2026, for the first time since the code family was built.

When POS 31 Applies and When to Switch to POS 32

A patient admitted under Part A moves to custodial care once the 100-day benefit period runs out. The place of service has to move with them, from POS 31 to POS 32. Practices that set the place of service once at admission generate a claim-level error from the day benefits exhaust forward.

In a building housing both Part A and long-term residents, defaulting to one code for the whole census is the version of this mistake we see most. Verify Part A status per patient, per visit. The CMS Place of Service Code Set carries the official definitions, and our guide to 2026 place of service codes covers the facility and non-facility rate engine across every setting.

POS 11 belongs to the physician office. A provider who travels to the facility still bills POS 31 or POS 32, because the code describes where the patient received the service. The full POS 11 billing rules guide covers the ownership test behind that. Residents in assisted living fall outside this family and use POS 13 assisted living billing with the home or residence codes.

POS 54 and POS 56: The Two Nursing Facility Codes Almost Nobody Uses

CPT defines nursing facility to include psychiatric residential treatment centers and intermediate care facilities. Physicians rounding in those settings reach for an office or inpatient code because they don’t realize this code family already covers them.

The CY 2026 Fee Schedule Change That Broke Payment Parity

The nursing facility code family carried identical facility and non-facility practice expense RVUs for years, so the place of service choice didn’t change the payment amount. The CY 2026 Physician Fee Schedule Final Rule cut the indirect practice expense allocation for services valued in facility settings, and that parity is gone.

Published analyses estimate roughly a 6% reduction for CPT 99309 billed at POS 31 and roughly a 10% increase at POS 32. CMS confirmed the methodology change in CMS-1832-F. The percentage estimates come from industry analysis rather than from CMS, so treat them as directional.

The place of service field now carries as much revenue weight as the nursing home CPT codes themselves.

CMS issued a system edit in July 2025 under CR 13767 that flags POS 32 submitted during an active Part A stay. It followed an OIG finding from March 2025 that Medicare had overpaid for physician services at SNFs where providers used POS 32 and POS 31 applied. A wrong place of service is an audit trigger now.

SNF Consolidated Billing: What the Facility Bills and What You Bill

Consolidated billing comes out of the Balanced Budget Act of 1997. It has been in place for more than 25 years, and it still explains why nursing facility claims come back unpaid to the wrong party. The Federal Register SNF consolidated billing rule carries the statutory citation.

CMS excludes these services from consolidated billing, which keeps them separately payable during a covered Part A stay.

• Physician and qualified non-physician practitioner professional services
• Dialysis-related services, including transportation to dialysis and erythropoietin administration
• Ambulance transport at the beginning or end of the SNF stay
• Chemotherapy drugs and chemotherapy administration
• Customized prosthetic devices prescribed by a physician
• Radioisotope services
• Marriage and family therapist and mental health counselor services, effective January 1, 2024
• Category I major hospital outpatient services, including CT, MRI, cardiac catheterization, radiation therapy, angiography, and outpatient surgery

Radiology and pathology groups get caught on the professional and technical split. The professional component of a read is excluded and bills to Part B. The technical component isn’t excluded and routes through the SNF. Billing both to Medicare sends the technical line back as a bundling denial, which is the CO-97 denial resolution pattern most nursing facility practices see first.

Specimen collection follows the same logic. A SNF resident’s draw uses G0471 rather than the routine venipuncture code, and our G0471 SNF specimen collection guide covers the distinction.

Consolidated billing decides which nursing home CPT codes you bill directly and which services route through the facility. The rules switch off when Part A coverage is disqualified. Exhausted benefits, no qualifying 3-day hospital stay, or an unmet level-of-care requirement each pull the claim out of consolidated billing.

SNF Facility Claims: Type of Bill, Revenue Codes, and the UB-04

There is no place of service code on a UB-04. When a payer rejects an institutional claim for a missing place of service, the problem sits in claim-type routing at the clearinghouse. Nursing home CPT codes never appear on a UB-04 at all, and the CMS-1500 claim form errors guide covers the professional side of that split.

Core UB-04 Codes on a Medicare Part A Skilled Nursing Facility Claim

Situational codes handle the rest. Condition code 57 reports a readmission within 30 days, condition code 40 reports a same-day transfer, condition code 21 flags a no-payment claim, and condition code 20 flags demand billing.

Occurrence span 74 covers a leave of absence, 76 covers patient-liable days, and 77 covers SNF-liable days. Value code 09 gets set to one dollar on a benefits-exhaust claim.

Therapy CPT Codes in the Nursing Facility Setting

A missing GP, GO, or GN on a Part B therapy line returns CARC 16. It is the most common therapy denial in this setting, and it is a one-character fix. Unit counting follows the 8-minute rule for therapy once the claim moves to Part B.

CPT 97535, self-care and home management training, is reportable by both physical and occupational therapy. The discipline modifier is the only thing separating them on the claim.

Telehealth for Nursing Facility Visits: The 2026 Frequency Limit Removal

That 14-day cap dates to the CY 2011 Physician Fee Schedule final rule at 75 FR 73318. It stood for 15 years. Practices that dropped telehealth follow-ups because of it can restart them.

Three claim mechanics change when the visit moves to telehealth.

• Append modifier 95 for synchronous audio-video, or modifier 93 for synchronous audio-only
• Use POS 02 or POS 10 rather than POS 31 or POS 32, because the nursing facility codes describe where the service would have happened in person
• Skip modifier GN, which belongs to outpatient speech therapy and returns a wrong-category denial here

The underlying E/M rules don’t change. Our 2026 telehealth CPT codes guide covers the full modifier and place of service matrix by payer.

PDPM, Primary Diagnosis, and the ICD-10 Codes That Drive SNF Payment

The FY 2026 SNF PPS Final Rule fact sheet made 34 technical revisions to the PDPM ICD-10 mappings. Thirty-three codes moved from Medical Management to Return to Provider, including type 1 diabetes mellitus, hypoglycemia, and obesity. One code moved from Acute Neurologic to Medical Management.

Published summaries repeat the number 34 without giving that split or naming the conditions. Return to Provider is CMS saying a more specific or clinically appropriate primary diagnosis exists for a covered Part A stay. The claim generates no payment until someone supplies one.

Facilities using a broad code as a catch-all primary will watch those claims stop. These diagnoses show up most often on SNF claims.

• Infections and acute care: N39.0 urinary tract infection, J18.9 pneumonia, A41.9 sepsis, G93.41 metabolic encephalopathy
• Orthopedic aftercare: Z47.1 aftercare following joint replacement, Z47.89 other orthopedic aftercare, S72.001D and S72.002D subsequent femur neck fracture encounters
• Chronic conditions: I50.9 heart failure, J44.9 COPD, E11.9 type 2 diabetes mellitus, G20 Parkinson disease

Specificity decides whether those codes hold up. Heart failure documented without an acuity term drops to I50.9 when the chart supports something sharper, and our CHF ICD-10 specificity guide walks the I50 family. Swallowing problems follow the same pattern, where dysphagia ICD-10 coding moves to a post-stroke I69 code once a cause is on the chart.

The PDPM diagnosis drives facility payment while the nursing home CPT codes drive the physician’s Part B claim. A specific primary diagnosis that the daily skilled care notes don’t support will clear coding review and fail audit review. On the physician side, a mismatch between diagnosis and procedure returns CARC 11.

The Nursing Facility Billing Rules That Trigger Most Denials

Six rules govern how the nursing home CPT codes get paid. Most published coding references skip all of them.

Rule 1: one E/M per practitioner per day. Nursing facility E/M codes are per-day services. Medicare will not pay more than one per practitioner, per patient, per date of service. The CMS Recovery Audit approved issue 0061 targets excessive units of nursing facility services as an active review topic.

Rule 2: no same-day collision. Medicare will not pay for an initial nursing facility visit and an office, outpatient, or emergency department E/M on the same date for the same patient. CPT permits reporting the other site with modifier 25, so confirm which rule your payer follows before you bill both.

Rule 3: the exception to Rule 2. Time spent in another setting can count toward prolonged nursing facility services when the prolonged requirements are met. Practices almost never capture it.

Rule 4: who performs the initial visit. In a skilled nursing facility, the admitting physician performs the initial comprehensive visit. In a nursing facility, a qualified non-physician practitioner who is not employed by the facility may perform it where state law permits. Qualified NPPs may perform all subsequent visits in both settings.

Rule 5: the 30-day assessment window. The initial comprehensive assessment has to be completed within 30 days of admission. It covers the assessment itself, developing a plan of care, and writing or verifying admitting orders.

Rule 6: split and shared visits. Effective January 1, 2024, the substantive portion of a split or shared visit means more than half the total time, or a substantive part of the medical decision making. Published guidance on how this applies in the facility setting hasn’t settled, so confirm with your Medicare Administrative Contractor before you build it into a workflow.

Recoupments under Rule 1 surface months later, buried inside an aging report where nobody connects them to a coding pattern. MedSole RCM’s AR follow-up for Medicare claims works stuck Medicare claims by aging bucket and payer behavior until each one is paid, appealed, or confirmed unrecoverable.

Nursing Facility Claim Denials and the CARC Codes Behind Them

Most nursing facility denials start somewhere other than the code itself. The place of service field, a missing modifier, or a thin note carries the failure, and the nursing home CPT codes on the claim were correct all along.

Nursing Facility Billing Errors and the CARC Denial Code Each One Returns

CARC 5 and CARC 50 account for most preventable nursing facility denials, and a pre-submission check catches both. CARC 5 is a field check. CARC 50 is a documentation standard, and the CO-50 medical necessity denial guide covers the addendum and appeal workflow. Missing-field rejections follow the CO-16 missing information denial path instead.

2026 and 2027 Regulatory Changes Affecting Nursing Facility Billing

CMS issued the FY 2027 SNF PPS Final Rule, CMS-1843-F, on July 29, 2026. It finalizes a 2.4% payment update, built on a 3.3% market basket reduced by a 0.9% productivity adjustment, for an estimated $882.74 million increase in aggregate payments. FY 2027 begins October 1, 2026.

The same rule finalizes a Quality Reporting Program change CMS declined to adopt a year earlier. The data submission timeframe drops from 4.5 months to roughly 45 days beginning with the FY 2029 SNF QRP.

CMS also now requires SNFs to submit MDS data for all residents receiving covered skilled care, regardless of payer. Value-Based Purchasing adjustments account for an estimated $203.60 million reduction in FY 2027.

The FY 2026 rule, CMS-1827-F, still governs the current fiscal year.

• Issued July 31, 2025, published August 4, 2025, effective October 1, 2025
• 3.2% payment update, a $1.16 billion increase over FY 2025
• An estimated $208.36 million reduction from the SNF Value-Based Purchasing Program
• 34 PDPM ICD-10 mapping revisions
• Four Social Determinants of Health data elements removed from the SNF QRP, covering living situation, food, and utilities

On the physician side, the CY 2026 Physician Fee Schedule, CMS-1832-F, took effect January 1, 2026. It carried the facility practice expense change covered in Section 10 and the permanent removal of telehealth frequency limits for subsequent nursing facility visits.

Consolidated billing enforcement runs on a quarterly cycle of its own.

• MM14427, transmittal R13684CP, effective July 1, 2026
• MM14561, transmittal R13881CP, released August 21, 2026, effective October 1, 2026, with implementation October 5, 2026
• Category IV-B and Category V HCPCS removed from the Part A file beginning January 2026

One proposed change deserves a watch rather than an action. CMS proposed in July 2026 to delete CPT 92507, the speech therapy treatment code, effective January 1, 2027, and replace it with 10 time-based codes across five disorder categories. That rule is proposed and not final. Keep 92507 in the charge master until CMS finalizes it.

Four rules changed how the nursing home CPT codes and the claims around them get paid between October 2025 and October 2026. Enrollment status gates all of it, because a claim from a provider whose revalidation lapsed denies regardless of coding. MedSole RCM handles provider enrollment and credentialing at $99 per payer across 900-plus payer networks in all 50 states, with no minimum volume and no long-term contract. Our Medicare provider enrollment 2026 guide covers the revalidation cycle.

Nursing Home CPT Codes: Frequently Asked Questions

What are the CPT codes for skilled nursing care?

The CPT codes for skilled nursing care are 99304, 99305, and 99306 for initial nursing facility care; 99307, 99308, 99309, and 99310 for subsequent nursing facility care billed per day; and 99315 and 99316 for discharge day management. Level is selected by medical decision making or total time on the date of the encounter.

What is the coding for a SNF?

Skilled nursing facility coding uses CPT 99304-99316 for physician services on the CMS-1500, place of service 31 or 32 depending on Part A status, and type of bill 21X with HIPPS rate codes on the facility’s UB-04. CPT 99318 was deleted January 1, 2023 and is no longer valid on any claim.

What is the difference between CPT codes 99305 and 99306?

CPT 99305 reports initial nursing facility care with moderate medical decision making, or 35 minutes or more of total time. CPT 99306 reports high medical decision making, or 45 minutes or more. The difference is the MDM level and the time threshold, not the length of the note.

What is CPT code 99309 used for?

CPT 99309 reports subsequent nursing facility care with moderate medical decision making, or 30 minutes or more of total time on the date of the encounter. It covers active clinical situations such as a heart failure exacerbation or a new problem requiring workup. It is the most frequently billed subsequent nursing facility code.

What type of bill code is used for a SNF?

Skilled nursing facility Part A inpatient claims use type of bill 21X. The fourth digit reports claim frequency: 211 for admit-through-discharge, 212 or 213 for interim claims, and 214 for a final claim. Part B services furnished by a SNF use 22X, and hospital swing bed services use 18X.

What are the most common ICD-10 codes used in skilled nursing facilities?

Common skilled nursing facility ICD-10 codes include N39.0 urinary tract infection, J18.9 pneumonia, A41.9 sepsis, G93.41 metabolic encephalopathy, Z47.1 aftercare following joint replacement, I50.9 heart failure, J44.9 COPD, E11.9 type 2 diabetes mellitus, and G20 Parkinson disease.

How many SNF days will Medicare pay for?

Medicare Part A covers up to 100 days of skilled nursing facility care per benefit period. The first 20 days are covered in full. Days 21 through 100 require daily coinsurance. A new benefit period begins after 60 consecutive days without inpatient hospital or skilled nursing care.

What is the difference between a nursing facility and a skilled nursing facility?

A skilled nursing facility provides short-term post-acute care under Medicare Part A. A nursing facility provides long-term custodial care. Both settings use the same CPT codes, 99304-99316. The difference appears in the place of service code and the payment rate, not in code selection.

How much do nursing home billing services cost?

Percentage-of-collections pricing for medical billing typically runs 4% to 10%, and specialty outpatient firms sit at the higher end. MedSole RCM provides outsourced medical billing at 2.99% of collections and provider enrollment and credentialing at $99 per payer, serving all 50 states across 75 specialties with a 99% clean claim rate. Standalone denial management and AR follow-up run 4.49% of what gets recovered, or come included at no separate charge inside full-service billing. The MedSole RCM billing team works inside your existing EHR, with no setup fee and no long-term contract.

Sources

• CMS, Skilled Nursing Facility Billing Reference, MLN006846
• CMS, FY 2026 SNF Prospective Payment System Final Rule, CMS-1827-F, issued July 31, 2025
• CMS, FY 2027 SNF Prospective Payment System Final Rule, CMS-1843-F, issued July 29, 2026
• CMS, CY 2026 Medicare Physician Fee Schedule Final Rule, CMS-1832-F
• CMS, Place of Service Code Set
• CMS, Recovery Audit Program approved issue 0061, Excessive Units of Nursing Facility Services
• CMS, Medicare Claims Processing Manual, Chapter 12, Sections 30.6.13 and 30.6.15
• Federal Register, Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities, August 4, 2025
• American Medical Association, CPT Evaluation and Management Code and Guideline Changes, 2023
• HHS Guidance Portal, Nursing Facility Services, Codes 99304 to 99318
• University of Rochester Office of Integrity and Compliance, 2023 Nursing Facility E&M Guidelines
• AAFP, The 2023 Hospital and Nursing Home E/M Visit Coding Changes, FPM, January 2023

CPT codes are copyright American Medical Association. Coding rules change through the year. Verify every code, modifier, and effective date against your licensed CPT 2026 codebook and your Medicare Administrative Contractor before claim submission.