home health nursing visit cpt code

A step-by-step approach that saves time coding E/M office visits can now be tailored to hospital and nursing home E/M visits as well.

KEITH W. MILLETTE, MD, FAAFP, RPh

Fam Pract Manag. 2023;30(1):8-12

Author disclosure: no relevant financial relationships.

Following the major revisions to coding evaluation and management (E/M) office visits in 2021, 1 a similar revamp has been made for coding E/M visits in other settings. Effective Jan. 1, 2023, the history and physical examination requirements have been eliminated for coding hospital and nursing home visits. 2 As with office visits, hospital and nursing home coding is now based solely on medical decision making (MDM) or total time (except for emergency department visits, which must be coded based on MDM, and hospital discharge visits, which must be coded based on time). This further streamlines E/M coding, creating one unified set of rules for office, nursing home, and hospital visits.

Hospital and nursing home E/M visits are divided into three groups: initial services (i.e., admissions), subsequent services, and discharge services. According to the American Medical Association (AMA), initial visits are “when the patient has not received any professional services from the physician or other qualified health care professional or another physician or other qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, during the inpatient, observation, or nursing facility admission and stay.” 2 After the patient has received care from that group once, all other visits are subsequent until the discharge service. When the patient transitions from inpatient to observation, or vice versa, that does not begin a new stay eligible for an initial services visit.

CPT codes 99234-99236 are for patients admitted to the hospital and discharged on the same date. For patients with multi-day stays, use 99221-99223 for initial services, 99231-99233 for subsequent visits, and 99238-99239 for discharge services.

Initial nursing home visits are coded with 99304-99306. CPT is deleting the code for nursing home annual exams (99318), which will instead be coded as subsequent nursing home visits (99307-99310).

Two sets of observation care codes (99217-99220 and 99224-99226) should no longer be used as of Jan. 1. Observation services have instead been merged into the corresponding initial service, subsequent service, and discharge codes.

These changes open the door to a simpler, quicker coding process. Many of the principles that already apply to E/M office visit coding now apply to hospital and nursing home E/M coding, but there are some differences in the details. This short guide can help physicians navigate the changes.

Coding for evaluation and management (E/M) visits in hospitals and nursing homes is now much like coding E/M office visits.

This unified set of coding rules allows physicians to quickly code nearly all visits using a template that starts with total time.

There are a few key differences to be aware of, such as total time spent past midnight on the date of service can be counted for hospital E/M visits, but not for office E/M visits.

MEDICAL DECISION MAKING

Determining the level of MDM for hospital and nursing home visits is now much like doing so for office visits. 3 The four MDM levels are straightforward, low, moderate, and high. They are determined by three factors: the number and complexity of problems addressed, the amount and complexity of data reviewed, and the patient's risk of complications, morbidity, or mortality.

If you feel confident coding office visits based on MDM, you can use that knowledge to code hospital and nursing home visits based on MDM as follows:

A level 1 initial or subsequent hospital visit requires the same MDM components as a level 3 office visit,

A level 2 initial or subsequent hospital visit requires the same MDM components as a level 4 office visit,

A level 3 initial or subsequent hospital visit requires the same MDM components as a level 5 office visit.

Several medical decisions that are more common in hospitals than office settings carry enough risk that, when paired with high-level problems, they call for the top visit level. These include the decision to escalate hospital care (e.g., transfer to the intensive care unit), the decision to deescalate care or discuss do-not-resuscitate orders due to poor prognosis, the decision to use IV narcotics or other drugs that require intensive monitoring, and decisions regarding emergency surgery for patients with or without risk factors or non-emergency surgery for patients with risk factors.

There are new time thresholds for each level of service for initial hospital visits, subsequent hospital visits, and nursing home visits to use when you are coding by total time. Instead of offering a time range like office visits (e.g., a 99214 office visit requires 30–39 minutes), nursing home and hospital care visits require that you meet or exceed specific times (e.g., a 99232 subsequent hospital visit requires 35 or more minutes).

When coding initial hospital visits by total time, you can count all the time you spend caring for the patient on admission even if some of it extends after midnight on the calendar day of the admission. According to the AMA, “a continuous service that spans the transition of two calendar dates is a single service and is reported on one calendar date. If the service is continuous before and through midnight, all the time may be applied to the reported date of service.” 3 This differs from office visits, for which you may count only the time on the date of the visit. Otherwise, the definition of total time for hospital and nursing home E/M visits is similar to that of office visits. It includes the time you personally spend on E/M for that patient before, during, and after the face-to-face services. It does not include staff time, time spent on separately reportable procedures, travel time, or teaching time.

A SIMPLER WAY TO CODE

Like the 2021 changes to office visit E/M coding, the 2023 changes should make coding hospital and nursing home E/M visits simpler and quicker.

The universal coding template suggests coding by time first if that will appropriately credit you for the work you did. It's the most straightforward and easy method. But if you believe MDM will credit you for a higher level of work, then step 2 is to determine what level of problems (low, moderate, or high) you addressed and whether you managed (prescribed, adjusted, or decided to keep the same) a prescription medication. Answering those two questions allows you to code most visits quickly using MDM. For the few visits that remain, you will need to proceed to steps 3 or 4, which may require you to tally data points and are therefore more time-consuming.

The template was adapted from a prior FPM article on office E/M coding 4 by adding nursing home and hospital visit times and relabeling office-visit level 3, 4, and 5 problems as low-, moderate-, and high-level problems.

UNIVERSAL CODING TEMPLATE

Step 3: MDM with simple data

Moderate-level problem PLUS one of the following:

• Interpret one study (e.g., “I personally looked at the x-ray, and it shows …”),
• Discuss patient management or a study with an external physician (one who is not in the same group practice as you or is in a different specialty or subspecialty),
• Modify workup or treatment because of social determinants of health.

EQUALS moderate-level visit, even without medication management (see codes in Step 2).

Step 4: MDM counting data points

Moderate-level problem PLUS at least three points from data counting (below),

EQUALS moderate-level visit (see codes in Step 2).

High-level problem PLUS at least two of these three:

• Interpret one study (e.g., "I personally looked at the x-ray, and it shows..."),
• Discuss patient management or a study with an external physician,
• At least three points from data counting (below),

EQUALS high-level visit (see codes in Step 2).

Data counting:

• Review/order unique test/study: 1 point for each,
• Review external notes: 1 point for each unique source,
• Assessment requiring use of an independent historian (family member or other person who can provide a reliable history for a patient who is unable to): 1 point max.

Documentation to support your coding should also be easier going forward. While documenting a medically appropriate history and physical exam is still certainly important for good patient care, it's no longer required for coding; therefore, you should be able to determine the code level from only a few lines of documentation. The quiz below provides some examples to pair with the coding template for practice.

Hopefully, using this step-by-step approach to the 2023 E/M coding changes will allow you to code many types of visits more quickly and accurately so you can spend more time with your patients and less time on the computer.

Millette KW. Countdown to the E/M coding changes. Fam Pract Manag . 2020;27(5):29-36.

CPT evaluation and management (E/M) code and guideline changes. American Medical Association. Accessed Nov. 2, 2022. https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf

Table 2 - CPT E/M office revisions level of medical decision making (MDM). American Medical Association. Accessed Nov. 2, 2022. https://www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf

Millette KW. A step-by-step time-saving approach to coding office visits. Fam Pract Manag . 2021;28(4):21-26.

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Home Health Coding: Changes to Commonly Used Codes in Home Health 

Home Health Coding 101

What is home health coding.

Home Health coding in the PDGM world is much more specific than what we’ve ever seen in the industry. The coder must have specific documentation from the physicians and clinicians to ensure proper primary diagnosis coding and that all secondary diagnoses are coded to the highest specificity. It’s also important to have all of the comorbidities the patient may have so that those may be coded. This could potentially result in a comorbidity adjustment (which could increase reimbursement).

What does a home health coder do?

A home health coder reviews the entire patient chart including medical records, clinician and physician documentation, visit notes and the OASIS in order to code to the highest specificity. Coding in the PDGM world requires much more specific physician documentation than ever before to ensure that the primary diagnosis is not only correct, but will be acceptable under PDGM. Find out more on who owns the documentation and how home health coders look at a “paper patient” to accurately review a chart.

What is the ICD-10 code for home health services?

There is not a code for this. ICD-10 is diagnostic coding, not services.

Coding Changes as of October 2021: Most Commonly Used Home Health Codes

Video From Jessica, Director of Coding and OASIS Review:

Jessica’s List of the Most Commonly Used Codes in Home Health that are Changing:

Coding can be complex, especially with an expansive list and complicated sequence requirements. If you need a little bit of help or full management, we have you covered. Click HERE to receive a no obligation, fully transparent coding services quote.

Learn more about outsourcing home health coding

Home health coding certification, what certification do home health coders need to have, home health coders should be icd-10 certified which can be obtained by earning the hcs-d certification or the bchh-c certification., how is home health coding different from inpatient care, even though inpatient coding and home health coding use the same coding set, they are different in many ways. procedure codes are not used in home health; however, they are used in inpatient coding. typically there are not many acute care codes used in home health because, for the most part, that acute condition is resolved while inpatient; whereas, inpatient coders would capture those acute conditions as they are actively being treated while inpatient., what is episodic and non-episodic care related to home health coding.

Episodic claims will be submitted in monthly intervals and each episode will require coding with each resumption of care. Claims that are billed non-episodically will require less from a coder as those claims will only be assessed upon admission.

Why should a biller know home health coding?

A biller should be somewhat familiar with coding to ensure that claims are not sent through with improper codes and in turn get rejected – Certain codes are deemed obsolete and the billing and coding staff would need to be aware of which diagnostic codes are impacted.

Using an obsolete code can delay reimbursement and in some cases prevent a claim from passing validation checkpoints in the clearinghouse if used on a claim after the date deemed obsolete.

Want to talk to someone about your coding or billing needs? Contact a member of our team to learn more .

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We maintain and annually update a List of Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) Codes (the Code List), which identifies all the items and services included within certain designated health services (DHS) categories or that may qualify for certain exceptions. We update the Code List to conform to the most recent publications of CPT and HCPCS codes and to account for changes in Medicare coverage and payment policies. Code List updates for years 2022 and earlier were published in the Federal Register as an addendum to the annual Physician Fee Schedule final rule. 

Beginning with the Code List effective January 1, 2023, updates are published solely on this webpage.  On or before December 2 nd of each year, we will publish the annual update to the Code List and provide a 30-day public comment period using www.regulations.gov . To be considered, comments must be received within the stated 30-day timeframe. We anticipate that most comments will be addressed by April 1 st ; however, a longer timeframe may be necessary to address complex comments or those that require coordination with external parties. If no comments are received, in lieu of a comment response, we will publish a note below the applicable Code List year stating so. 

2024 Annual Update to the Code List

Below you will find the Calendar Year (CY) 2024 Code List published November 29, 2023 and a description of the revisions for CY 2024, our response to comments on that Code List, and the updated CY 2024 Code List, which is effective January 1, 2024 unless otherwise indicated on the Code List.

• UPDATED list of codes effective January 1, 2024, published March 1, 2024 (all codes effective January 1, 2024 unless otherwise indicated on the Code List) (ZIP)
• List of codes effective January 1, 2024, published November 29, 2023 (ZIP)
• Annual Update to the List of CPT/HCPCS Codes Effective January 1, 2024 (PDF)

We received one comment related to the additions, deletions, and corrections to the codes on the Code List effective January 1, 2024. Our response to this comment is below. We also received one comment related to Medicare coverage for platelet-rich plasma treatments. We consider this comment to be outside the scope of the annual update. CMS does not respond to out of scope comments on the annual updates to the Code List. 

Comment : One commenter noted that, although most Hepatitis B vaccine codes are identified on the Code List as CPT/HCPCS codes to which the exception for preventive screening tests and vaccines at § 411.355(h) applies, the Hepatitis B vaccine associated with CPT code 90739 was not listed. The commenter requested that CPT code 90739 be added to the list of vaccine codes to which the exception for preventive screening tests and vaccines at §411.355(h) applies, effective retroactively to January 1, 2024.

Response : We agree with the commenter that the exception for preventive screening tests and vaccines at § 411.355(h) should apply to CPT code 90739 and are revising the Code List accordingly. The applicability of the exception for preventive screening tests and vaccines to CPT code 90739 is prospective only and effective on the date indicated on the UPDATED list of codes. 

In considering this comment, we also identified two CPT codes (90653 and 90658, both flu vaccines) that were inadvertently left off of the list of codes to which the exception for preventive screening tests and vaccines at § 411.355(h) should apply. Accordingly, we are adding these CPT codes to the list of codes to which the exception at § 411.355(h) applies, effective on the date indicated on the UPDATED list of codes.

2023 Annual Update to the Code List

Below you will find the Code List that is effective January 1, 2023 and a description of the revisions effective for Calendar Year 2023. 

• List of codes effective January 1, 2023, published December 1, 2022
• Annual Update to the List of CPT/HCPCS Codes Effective January 1, 2023, published December 1, 2022 (PDF)

The comment period ended December 30, 2022. We did not receive any comments related to the additions, deletions, and corrections to the codes on the Code List effective January 1, 2023. We received one (1) comment related to the supervision level required for specific services. We consider this comment to be outside the scope of the annual update. CMS does not respond to out of scope comments on the annual updates to the Code List. 

DHS Categories

The DHS categories defined by the Code List are:

• clinical laboratory services;
• physical therapy services, occupational therapy services, outpatient speech-language pathology services;
• radiology and certain other imaging services; and
• radiation therapy services and supplies.

The Code List also identifies those items and services that may qualify for either of the following two exceptions to the physician self-referral prohibitions: 

• EPO and other dialysis-related drugs (42 CFR § 411.355(g)).
• Preventive screening tests and vaccines (42 CFR § 411.355(h)).

NOTE: The following DHS categories are defined at 42 CFR §411.351 without reference to the Code List:

• durable medical equipment and supplies;
• parenteral and enteral nutrients, equipment and supplies;
• prosthetics, orthotics, and prosthetic devices and supplies;
• home health services;
• outpatient prescription drugs; and
• inpatient and outpatient hospital services.

Related Links

• List of codes effective January 1, 2022, published November 19, 2021
• List of codes effective January 1, 2021, issued December 1, 2020
• List of codes effective January 1, 2020, published December 2, 2019
• List of codes effective January 1, 2019, published November 23, 2018
• List of codes effective January 1, 2018, published November 3, 2017 [ZIP, 59KB]
• List of codes effective January 1, 2017, published November 16, 2016 [ZIP, 54KB]
• List of codes effective January 1, 2016, published October 30, 2015 [ZIP, 58KB]
• List of codes effective January 1, 2015, published November 13, 2014 (79 FR 67972) [ZIP, 54KB]
• List of codes effective January 1, 2014, published December 10, 2013 (78 FR 74791) [ZIP, 54KB]
• List of codes effective January 1, 2013, published November 16, 2012 (77 FR 69334) [ZIP, 54KB]

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Common Foot Problems in Older Adults: Causes and Treatment

As people age, preserving foot health becomes increasingly important in maintaining mobility and overall health.

Common Foot Problems in Older Adults

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Leonardo Da Vinci famously said, “The human foot is a masterpiece of engineering and a work of art.” He was amazed that such a seemingly small part of the human body could carry it for an entire lifetime.

This rings particularly true for our aging population. Factors – such as better health care, innovative strides in medicine and healthier lifestyle habits – have led to an increased life expectancy, especially when people incorporate walking and exercise into their daily routine. The result: a whole lot more wear and tear on these “masterpieces of engineering.”

Estimates show that by the time a person reaches age 65, approximately 90% of the population will have suffered a foot and ankle condition at some point. The foot is a complicated body part – home to 26 bones, 33 joints and a complex matrix of ligaments, tendons and muscles.

Due to the physiological complications that come with aging - such as decreased muscle mass, poor circulation and longer healing times - foot problems and injuries in older people can have complications on their overall health and mobility. Your feet really are your base of support.

7 Most Common Foot Problems 

The most common feet and ankle problems include:

• Plantar fasciitis
• Achilles tendonitis
• Fat pad atrophy

1. Plantar fasciitis

One of the most common conditions across all generations is plantar fasciitis , also known as “heel spur syndrome.” Affecting nearly 2 million Americans each year, plantar fasciitis is caused by an inflammation and degeneration of the plantar fascia, the tendon band located on the bottom of the foot. The plantar fascia is responsible for maintaining the structure and stability of the arch.

Long periods of standing, flat feet, high arches and obesity are risk factors for plantar fasciitis.

Patients with plantar fasciitis will often present with sharp or stabbing pain in the heel area with the first step in the morning. The pain typically lasts for a brief period, then decreases in pain and intensity.

2. Achilles tendonitis

Achilles tendonitis is another common foot issue. This condition occurs in the back of the foot in the area where the tendon inserts into the heel bone and the area 1 to 3 inches above where the blood supply is at its lowest. That naturally slower blood flow renders the Achilles tendon less elastic and weaker in structure. Therefore, older patients are more prone to rupturing this area. The pain may also ascend into the leg and the calf muscles.

Regular stretching of the calf muscles and Achilles tendons can help prevent pain.

3. Neuromas 

Neuromas, also called interdigital neuromas or a Morton’s neuroma, are nerve enlargements that are often found right below your toes in the front of the foot.

Patients with neuromas usually feel symptoms, including:

• A burning or tingly sensation under their toes
• Pain radiating into the tips of the toes
• The sensation that a sock is rolled up in the front of the shoe

Neuromas are often brought on by long periods of wearing poorly fitting shoes that are too narrow and constricting. Another cause of neuromas is obesity. The uneven weight distribution of carrying excess weight can cause more pressure to be applied to the nerves in the foot, resulting in the enlargement and the formation of a bursa sac around the nerve.

4. Bunions 

Bunions – also known as hallux valgus – are very common in all active age groups. They are painful, bony bumps that develop on the outside of the big toe joint. They tend to develop slowly over time, as pressure on the big toe joint pushes the toe inward, toward the second toe.

Bunions are caused by abnormal biomechanics forces in the big toe, ill-fitting and tight shoes and arthritis in the joint . Bunions are especially common in women due to wearing ill-fitting footwear such as high heels or pointy-toed shoes. The bunion becomes enlarged and sometimes painful when the tissue covering the big toe joint becomes stressed, irritated and inflamed.

The area directly below the big toe, called the sesamoid apparatus, endures a large amount of stress and force. It acts as a pulley system composed of bones, muscles, tendons and ligaments that propels the foot forward for walking and running. This area can be the site for a fair amount of pain and discomfort, making walking and exercise extremely difficult and painful.

5. Fat pad atrophy

The fat pad is one of few places in the body where fat is a welcome addition. The foot relies on the fat pad in both the front of the foot and in the heel area to better absorb the tremendous forces the foot is subjected to during the day. Over time, the fat pad degenerates and can lead to inflammation of the heel bone, the plantar fascia and bones in the front of the foot, known as metatarsals.

6. Hammertoes 

Hammertoes are very common foot deformities that can be painful, especially if a hard area of skin, known as a corn, develops over the hammertoe. Every step can be painful, especially when there is contact with the top of the shoe. The term "hammertoe" refers to a toe that points upward, rather than lying flat.

This constant friction and irritation can cause the development and inflammation of a bursa, which is a fluid-filled sac that protects a bony prominence. Hammertoes are sometimes the result of neurological disorders such as neuropathy and stroke. Hammertoes may also affect balance and posture .

The big toe is a favorite spot for the development of gout , a metabolic inflammation of the joint that causes extreme pain. Diets rich in certain proteins and substances known as purines, dehydration, overindulgence in alcohol and coffee, red meat, shellfish, legumes and certain systemic diseases can precipitate a very painful gout attack.

How to Avoid Common Foot Problems

Obesity can increase your risk of suffering from foot pain. As people's body mass index, or BMI, increases from the normal range to obesity, so do the odds that they will have foot pain as they get older; this is true for men and women.

Compromised blood flow to the feet can cause or worsen foot pain. Various factors can affect the quality of blood flow to the feet, including whether you smoke or have diabetes , peripheral neuropathy or blood clots .

Shoe fit is always an important consideration. One study showed that almost 90% of the population is wearing the wrong shoe size. A person’s shoe size at age 20 isn’t necessarily going to be the same at age 50.

As our bodies shrink with age, our feet often seem to get bigger. Feet do not literally grow, orthopedists agree. Rather, over the years, tissue in our feet degenerates and ligaments become looser, which causes strain on joints and can lead to arthritis. The degeneration of ligaments can cause feet to flatten and become wider. In addition, pregnancy has also been shown to cause increases in shoe size.

It is always best to have your new shoe fit in the afternoon when the swelling is greatest, not in the morning. If shoes are not comfortable when you try them on, don’t buy them in the hopes you will break them in. Poor shoe fit causes many overuse injuries in the muscles, tendons, ligaments and bones. The best shoe should have a slightly wider toe box to allow for afternoon swelling and a small to medium heel height that will protect against knee problems as well as plantar fasciitis and Achilles tendonitis.

Orthotic devices

Orthotic devices are very useful to support areas of the foot that have structural (high arches/low arches) and functional deficits. Patients commonly use either over-the-counter or prescription orthotics. OTC inserts are best suited for comfort and cushion in a shoe. They provide little to no orthopedic support, are accommodative in nature and do not change the mechanics of the foot.

Prescription orthotics, prescribed by a doctor, are designed to improve the shock absorbing capability and make the motion relationship between the front, middle and back of the foot more ideal. They have been shown to improve function and decrease pain in the knee, hip and lower back.

Compression socks

Compression socks are useful to wear in the presence of venous congestion and varicose veins . Prior to wearing these devices check with your doctor to make sure they’re right for you.

Foot surgery should always be the last resort. Most foot and ankle problems can be managed successfully without surgery. Don't self-diagnose. If an issue persists for more than one week, you should seek medical attention by a health care professional.

Importance of Healthy Feet for Health

Walking has many benefits that lead to a healthier lifestyle. It can promote better circulation, leading to lower incidence of cardiovascular disease, arterial sclerosis and high blood pressure.

In addition, walking also promotes better regulation of glucose, the primary type of sugar found in your blood and your body’s primary source of energy. Proper glucose control is important especially for people with Type 2 diabetes , a disease that has increased over the last two decades. Walking has been prescribed by endocrinologists in diabetic cases, where they’ve seen helpful results, especially with the geriatric population.

Bottom Line

Ultimately, the importance of healthy foot and ankle function can never be underestimated.

It has been shown in numerous studies how a painful and compromised foot can lead to musculoskeletal problems elsewhere in the body, including the knee, hip, spine and even the TMJ joint in the jaw .

More and more clinicians are appreciating and recognizing the role of the foot in preventing these issues. And if there’s one thing we can agree on, it’s that foot and ankle problems may not be life-threatening, but they certainly are lifestyle-threatening and affect our overall health, especially when it comes to older adults.

If you experience any of these common feet problems or experience other issues with your feet, talk to your primary care physician or podiatrist.

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