Under the 2026 CMS Physician Fee Schedule Final Rule, nursing home CPT codes are undergoing major payment changes.
CPT Code 99309 is one of the most commonly used for this specialty. There is a substantial difference in reimbursement for a nursing home visit, CPT Code 99309. The most commonly used nursing home visit CPT code is as follows: When billing under POS 31 (Skilled Nursing Facility), the provider will receive approximately 6% less reimbursement than when billing under POS 32 (Nursing Facility), which will have 10% more reimbursement for the same CPT code.
2026 updates to skilled nursing facility CPT codes include changes in dual conversion factors and practice expense methodology, which affect provider reimbursement. This guide includes comprehensive information regarding 2026 skilled nursing CPT codes with important changes to reimbursement and, therefore, billing compliance requirements.
Nursing Home CPT Codes Description:
Nursing home CPT codes represent the evaluation and management services that are performed related to the care of residents of skilled nursing facilities. When billing for nursing home visits, CPT nursing home visit codes are used because the regulatory environment for long-term care facilities is different from that of an office visit.
Medical necessity is a key component of a compliant CPT code for billing nursing home visits. Each service level billed must be appropriately supported by clinical documentation of the medical necessity needed to justify the service.
Nursing Home CPT Codes Quick Reference
| CPT Code | Service Type | Time | Complexity | Use Case |
| 99304 | Initial Care | 25 min | Low | Post-op recovery |
| 99305 | Initial Care | 35 min | Moderate | Multiple chronic conditions |
| 99306 | Initial Care | 50 min | High | Unstable admission |
| 99307 | Subsequent Care | 10 min | Straightforward | Stable monitoring |
| 99308 | Subsequent Care | 15 min | Low | Minor adjustments |
| 99309 | Subsequent Care | 30 min | Moderate | Care plan changes |
| 99310 | Subsequent Care | 45 min | High | Acute deterioration |
| 99315 | Discharge | ≤30 min | N/A | Routine discharge |
| 99316 | Discharge | >30 min | N/A | Complex discharge |
| 99318 | Annual | Variable | Comprehensive | Yearly evaluation |
Initial Nursing Facility Care Codes (99304-99306)
Initial nursing home visit CPT codes apply regardless of whether the patient is new or established with the billing provider. The initial visit must occur within 30 days of admission. Proper selection of the CPT code for nursing home visits requires matching documentation to complexity.
CPT Code 99304: Initial Nursing Facility Care, Low Complexity
CPT 99304 applies to initial nursing facility evaluations requiring straightforward medical decision-making. There should be enough documentation to support about 25 minutes of total time. Low complexity scenarios could include a patient who had surgery but is recovering well or receiving IV antibiotics for a short period of time and has no serious medical problems.
CPT Code 99305: Initial Nursing Facility Care, Moderate Complexity
CPT 99305 applies to initial assessments with moderate-complexity medical decision-making. There should be enough documentation to support about 35 minutes of total time. Typical scenarios include patients with congestive heart failure and diabetes mellitus requiring medication adjustments or patients transferred from acute care with multiple chronic conditions.
CPT Code 99306: Initial Nursing Facility Care, High Complexity
CPT 99306 applies to initial evaluations involving high-complexity medical decision-making. There should be enough documentation to support about 50 minutes of total time. High complexity scenarios could include patients with sepsis (a severe infection), new or recently occurring stroke, or end-stage renal disease who require complex medication management as well as very close monitoring.
Subsequent Nursing Facility Care Codes (99307-99310)
Subsequent nursing home CPT codes capture follow-up visits after initial assessment. These skilled nursing CPT codes represent the most frequently billed services in nursing facility settings. Each CPT for nursing home visit must reflect actual work performed during the encounter.
CPT Code 99307: Subsequent Nursing Facility Care, Straightforward Complexity
CPT 99307 applies to follow-up visits requiring straightforward medical decision-making. The medical decision-making requires documentation from the encounter totaling about ten (10) minutes. Applications include stable patients requiring routine monitoring without care plan modifications.
CPT Code 99308: Subsequent Nursing Facility Care, Low Complexity
CPT 99308 applies to subsequent visits with low-complexity medical decision-making. Documentation must support a total time of approximately fifteen (15) minutes for the visit. Patients with well-controlled hypertension or diabetes mellitus on a long-standing and stable regimen may qualify for this type of visit.
CPT Code 99309: Subsequent Nursing Facility Care, Moderate Complexity
CPT 99309 applies to follow-up visits requiring moderate-complexity medical decision-making. Documentation must support a total time of approximately thirty (30) minutes for the visit. Examples include patients with chronic kidney disease who need medication changes, dementia patients who exhibit behavioral changes, and heart failure patients who require diuretics to be titrated. CPT 99309 represents the most commonly billed nursing home visit CPT codes.
Code 99310: Subsequent Nursing Facility Care, High Complexity
CPT 99310 applies to subsequent visits involving high-complexity medical decision-making for medically unstable patients. For patients in nursing facilities with medical instability, documentation of approximately 45 minutes of total time must be included in the follow-up visit notes. Common diagnoses for patients with high-complexity follow-up care include acute respiratory failure, unknown source of sepsis, and atrial fibrillation with hemodynamic instability.
Discharge Day Management and Annual Assessment
These nursing home visit CPT codes capture physician work preparing patients for transition from nursing facilities. Time determines which CPT code for nursing home visit applies for discharge management.
CPT Code 99315: Nursing Facility Discharge Management, 30 Minutes or Less
CPT 99315 is for discharge day management that takes 30 minutes or less of the physician’s time. Documentation must include a summary of care rendered during the visit, plans for follow-up, and education for the caregiver on how to care for the patient once home from the nursing facility. The most common usage of CPT 99315 is related to routine discharges of patients from skilled nursing facilities to their homes or assisted living facilities.
CPT Code 99316: Nursing Facility Discharge Management, More Than 30 Minutes
CPT 99316 is for discharge day management that requires more than 30 minutes of the physician’s time. The documentation should include evidence of the complexities surrounding coordinating discharges that require more than the basic required elements, including but not limited to significant coordination of multiple providers, thorough medication reconciliations, and extensive family education and counseling.
CPT Code 99318: Annual Nursing Facility Assessment
CPT 99318 applies to comprehensive annual evaluations requiring detailed medical history review, complete physical examination, and care plan updates. This planned annual service differs from problem-based subsequent visits and may substitute for one federally mandated visit when requirements are met.
Documentation must demonstrate a systematic review of all chronic conditions, preventive health measures, and advance directives. This CPT code nursing home visit serves as the comprehensive yearly evaluation required by federal regulations.
Rehabilitation Services CPT Codes
Therapy services in a Skilled Nursing Facility are captured using specific CPT codes for each type of therapy (PT, OT, and ST). The CPT codes representing all Skilled Nursing services have been updated to reflect newer standards for therapy documentation for facility use, including skilled nursing CPT codes for 2026. To maintain compliance and optimize reimbursement, many providers depend on specialized rehab billing services to ensure accurate coding, documentation, and claim submission.
CPT 97161: Physical Therapy Evaluation, Low Complexity
CPT code 97161 reflects the initial evaluation for physical therapy with straightforward clinical presentation and minimal need for treatment planning.
CPT 97162: Physical Therapy Evaluation, Moderate Complexity
CPT code 97162 is used for physical therapy evaluations with a less stable clinical presentation and moderate need for ongoing assessment and treatment planning.
CPT 97163: Physical Therapy Evaluation, High Complexity
CPT 97163 is used for complex physical therapy evaluations with a high level of assessment required and extensive treatment planning for those patients with an unstable clinical presentation.
CPT 97164: Physical Therapy Re-evaluation
CPT 97164 is the code used to reflect the re-evaluation of an established patient who requires a modified plan of care.
CPT 97165: Occupational Therapy Evaluation, Low Complexity
CPT 97165 is the code used for the initial evaluation for occupational therapy with a straightforward functional assessment.
CPT 97166: Occupational Therapy Evaluation, Moderate Complexity
CPT 97166 is used for occupational therapy evaluations that require moderate functional assessments and activity analysis.
CPT 97167: Occupational Therapy Evaluation, High Complexity
CPT 97167 is used for complex occupational therapy evaluations that require extensive functional assessments and extensive intervention planning.
CPT 97168: Occupational Therapy Re-evaluation
CPT 97168 is used for the re-evaluation of an established patient with modified functional goals.
CPT 92521: Speech Therapy Evaluation
CPT 92521 is the code used for the evaluation of speech, language, voice, or communication.
CPT Code 92523: Speech Therapy Treatment, 15 Minutes
CPT 92523 applies to treatment sessions lasting 15 minutes addressing communication or swallowing disorders.
CPT Code 92524: Speech Therapy Treatment, Additional 15 Minutes
CPT 92524 captures each additional 15-minute increment beyond the first unit.
Therapy Services Time Requirements Table
| Service Type | CPT Code Range | Time Unit | Billing Notes |
| PT Evaluation | 97161-97164 | Per session | Based on complexity, not time |
| OT Evaluation | 97165-97168 | Per session | Based on complexity, not time |
| Speech Evaluation | 92521 | Per session | Comprehensive assessment |
| Speech Treatment | 92523-92524 | 15-minute units | Timed increments |
Wound Care, Psychiatric, and Ancillary Services
Wound care requires extensive documentation for nursing homes using CPT code references. Accurate documentation and proper coding are essential for compliance and reimbursement, which is why many facilities rely on specialized wound care billing services to ensure claims are submitted correctly. Make sure that the correct modifiers are attached to wound care bills for nursing home visit billing purposes.
Debridement is performed based on the outcome of cleansing the area after washing out the dead tissue. This process allows white blood cells (WBCs) a better chance of coming into contact with bacteria that might be present, improving the healing environment without first drying the area.
CPT 97597 – Debridement of Wound Surfaces
CPT code 97597 represents either selective or non-selective debridement of the wound surface, with the requirement that the area debrided be documented in square centimeters (cm2).
CPT 97598 – Removal of Devitalized Tissue
A CPT code of 97598 represents removing devitalized tissue from a wound, and documentation must describe the length and width of the wound and how much tissue was excised.
CPT 97602 – Wound Care (Cleaning, Dressing Application, and Local Care)
What is billed pursuant to CPT code 97602 represents a non-debridement wound, including cleansing, local care, and/or dressing applied to the wound.
CPT 97605 – Application of Negative Pressure Wound Therapy (NPWT)
CPT code 97605 is used to capture the NPWT systems used in promoting wound healing.
Conclusion
Proper billing of nursing home using the appropriate nursing home CPT codes will lead to reimbursement based on medical need, as well as meeting federal standards. When billing for nursing home CPT codes the healthcare provider must have complete support documentation for medical necessity before selecting the CPT Code Nursing Home Visit. In addition to medical necessity, the healthcare provider must keep detailed documented time for each CPT Code for nursing home visits/services provided.
Nexus io specializes in Nursing Home Billing Services, providing a full-service revenue cycle management program to help optimize your reimbursement. The coding team at Nexus io is in tune with the 2026 changes to skilled nursing facility CPT codes. All CPT codes for nursing home visits will be verified against established criteria to ensure proper CPT Code Nursing Home Visit selection and appropriate modifier assignment.
