Complete Guide to CPT Code 99308: Nursing Facility Subsequent Care

If you’ve noticed more denied claims for follow-up visits in your nursing facility, it’s not always because your team didn’t provide care. Incorrect coding often causes these denials. Medicare auditors are increasing their reviews of evaluation and management (E/M) services, and they now deny over 20% more claims each year in skilled nursing facilities (SNFs) due to insufficient documentation

Using the correct code, like CPT 99308, ensures your facility gets reimbursed for the care you provide. With over 1.5 million residents in U.S. nursing homes, many covered by Medicare, accurate coding is essential for financial health, patient care, and compliance.

This guide explains CPT 99308, related codes, documentation tips, and common mistakes, helping your team stay compliant and get paid correctly

What is CPT 99308?

CPT 99308 is a medical billing code used for follow-up visits in nursing facilities. It applies when a patient’s condition is stable or mildly complex, and the visit requires about 15 minutes at the bedside. This code is for established patients, those who have already been seen before, and involves low-complexity medical decision-making. It is used only in nursing facilities, including skilled nursing facilities, long-term acute care hospitals, and assisted living facilities with medical oversight. It is not used for home visits, outpatient clinics, or inpatient hospital care.

In simple terms, 99308 is for patients who need more attention than a brief check-up but don’t require extensive care.

Related CPT Codes for  Nursing Facility Services

Nursing facility codes are divided into initial visits, follow-up visits, and discharge services. For initial visits.

Initial Nursing Facility Care (new patient)

• 99304: Low complexity
• 99305: Moderate complexity
• 99306: High complexity

Subsequent Nursing Facility Care (established patient)

• 99307: Low complexity (5-10 minutes)
• 99308: Low complexity (15 minutes) 
• 99309: Moderate complexity (25 minutes)
• 99310: High complexity (35 minutes)

Discharge Services

• 99315: Initial discharge day
• 99316: Subsequent discharge day

From this, we can see 99308 is a middle-tier subsequent care code, typically used when the patient needs more time than the most basic follow-up but less than a moderate-complexity visit.

Understanding CPT 99308

To understand CPT code 99308, it helps to break down the key components:

1. Subsequent Nursing Facility Care

This code is intended for established patients, meaning the provider has already seen and documented a comprehensive assessment for the patient in a previous visit. Subsequent differentiates this from initial evaluations, which typically involve more extensive assessment and planning.

2. Time Component

99308 CPT code requires approximately 15 minutes of face-to-face time with the patient at the bedside and on the facility floor. It’s important to note that time is a general guideline, not a strict requirement. Some payers allow coding based on medical decision-making complexity rather than exact time.

3. Medical Decision Making (MDM)

For 99308, MDM is low complexity, which means:

• Minimal number of diagnoses or management options
• Limited amount and complexity of data reviewed
• Minimal risk of morbidity  associated with the patient’s problem(s)

Providers should document the medical decision-making process, including any changes to medications, interventions, or follow-up care.

4. Setting

CPT 99308 is used exclusively in nursing facilities, which include:

• Skilled Nursing Facilities (SNFs)
• Long-Term Acute Care Hospitals (LTACHs)
• Assisted Living Facilities with medical oversight

CPT 99308 vs. Other Nursing Facility Codes

Choosing the accurate code for a follow-up visit can be tricky, so it helps to compare 99308 with the adjacent nursing facility codes to see how complexity, time, and care needs differ.

CPT 99308 sits in the middle of this range, providing follow-up care for stable patients that requires slightly more time and attention than the most basic 99307 visit, but less complexity than 99309 or 99310

Documentation Requirements for CPT 99308

Proper documentation is essential to justify coding and avoid claim denials. For 99308, the following elements should be documented:

1. Patient Identification
   Clearly record the patient’s name, date of birth, and facility location to confirm the visit is for the correct individual.

2. Reason for the Visit
   Note the chief complaint or reason for follow-up. Include any recent changes in the patient’s condition or new concerns since the last visit.

3. History of Present Illness (HPI)
   Provide a brief but specific description of the patient’s current health status, including symptoms, complaints, or progress since the previous visit.

4. Assessment
   Record relevant vital signs, physical findings, and ongoing medical problems. Document your clinical observations and how they relate to the patient’s current care.

5. Medical Decision Making (MDM)
   Detail the issues addressed during the visit, any changes to medications or treatment plans, and any diagnostic tests ordered. Show the reasoning behind decisions to demonstrate clinical judgment.

6. Plan of Care
   Describe follow-up instructions, recommendations for nursing staff, referrals, or consultations. Clearly state the next steps you will take for the patient’s care.

7. Time Spent
   While not always required, noting the approximate face-to-face time spent with the patient and total time on patient care activities can support coding if your insurer allows time-based billing.

Proper and thorough documentation not only supports accurate billing for CPT 99308 but also ensures continuity of care, compliance, and better outcomes for your patients.

When to Use CPT 99308

This code is commonly used for chronic disease management, such as routine follow-ups for diabetes or hypertension, post-hospital follow-up visits to monitor recovery, routine monitoring after minor surgeries or wounds, and low-risk medication adjustments for established patients. Essentially, 99308 is appropriate whenever a stable patient requires a follow-up visit that is longer and slightly more detailed than a brief check but does not involve complex decision-making.

Common Errors and How to Avoid Them

Each visit should be paired with the appropriate diagnosis code, such as E11.65 for diabetes or I10 for hypertension. CPT 99308 is billed once per patient per day, even if multiple providers see the patient. Modifiers like 25 or 59 may be needed if procedures are performed on the same day or if distinct services are provided.

Common errors include using initial visit codes for follow-up visits, selecting the wrong complexity level, failing to document time or medical decision-making adequately, billing multiple follow-up visits for the same patient on the same day, and using outpatient codes instead of nursing facility codes.

Why CPT 99308 Matters

Using CPT 99308 accurately ensures your facility receives fair reimbursement for the care you provide, supports high-quality patient care, maintains regulatory compliance, and strengthens facility metrics and population health tracking. Proper documentation demonstrates clinical reasoning, supports continuity of care, and keeps your facility ready for audit.

Conclusion

CPT 99308 is a key code for follow-up care in nursing facilities. Using it correctly ensures that your facility is reimbursed fairly, supports high-quality patient care, and maintains compliance with Medicare and other payers. 

Thorough documentation, including patient information, reason for visit, assessment, medical decision-making, and plan of care, not only reduces claim denials but also reflects clinical judgment and continuity of care. By training staff on proper coding and documentation, your facility can protect revenue, improve audit readiness, and deliver better outcomes for patients.