cpt code for home health nurse visit

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Healthcare Insights

Top home health billing codes of 2021

Published Apr 15th, 2022

When a person undergoes a major surgery or procedure that requires extensive therapy and constant medical attention, they may be able to choose where and how they recover and receive treatment. For some, the assurance that a medical expert is always nearby and immediately available may sway them into staying in a hospital or nursing home.  

However, even a day or two at a hospital or nursing home can cost thousands of dollars.  Some patients may not have the money to cover these costs, or they may just prefer the freedom that comes with care received at their home.  

For these reasons (and a few others below), home health care has become a popular alternative to traditional care settings. Home health care primarily includes skilled nursing care and physical or occupational therapy.  

Looking at HCPCS codes , we can determine the most common procedures performed in a home health setting. The top 10 are listed below.  

Fig. 1 Data is from the Definitive Healthcare LongTermCareView product. Data is accurate as of April 2022.   

What was the top procedure code in 2021? 

The top home health billing code of 2021 was T1019, which details an array of miscellaneous personal care services provided in 15-minute intervals. These services include activities of daily living such as bathing, dressing, preparing meals and more. This procedure was performed more than 18 million times and equated to more than $2 billion in charges.  

Other HCPCS codes like G0299 and G0300 detail specific skilled nursing services including observation, assessment and evaluation of the patient. Additional functions like educating and training parents, guardians and nonprofessional caregivers also fall under these codes.  

HCPCS codes G0151, G0152 and G0157 deal with the administration of physical or occupational therapy in 15-minute intervals.  

In total, the top 10 HCPCS codes account for over 82 million procedures and $14 billion in charges.  

What is home health care? 

Home health care refers to short-term rehabilitative care administered to patients in their own homes. Care is often provided to Medicare beneficiaries or other select patients through a home health agency . These organizations connect patients with physicians who can provide skilled nursing care and physical or occupational therapy.  

Why are so many patients using home health care? 

Home health care is an increasingly popular alternative for specific patients who don’t want to or otherwise can’t receive treatment in a doctor’s office. Four benefits of home health care are:  

More convenient and less expensive for all patients including people living with disabilities or chronic conditions 

A more personal experience for the patient with a healthcare worker providing full and undivided attention 

Safer for patients with compromised immune systems or who are otherwise at-risk of contracting healthcare associated infections  

Potentially more comprehensive. Healthcare professionals can possibly deliver a more detailed diagnosis and treatment plan with visibility into their patients’ daily lives and environment  

You can learn more about home health care and how COVID-19 impacted it by reading our blog: The growing demand for at-home care . 

Learn more 

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• Top Home Health Billing Codes of 2021

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Skilled Home Health Care Nursing Services

• Clinical Policy Bulletins
• Medical Clinical Policy Bulletins

Number: 0201

Table Of Contents

Skilled nursing care is health care given when a person needs skilled nursing staff (registered nurse (RN) or licensed practical nurse (LPN)) to manage, observe, and evaluate care.  Skilled nursing care requires the involvement of skilled nursing staff in order to be given safely and effectively.  Care that can be given by non-professional staff is not considered skilled nursing care.  The goal of skilled nursing care is to help improve the patient's condition or to maintain the patient's condition and prevent it from getting worse.

Custodial care is care that helps persons with usual daily activities like walking, eating, or bathing.  It may also include care that most people do themselves, like using eye drops, oxygen, and taking care of colostomy or bladder catheters.

Coverage of skilled home health care nursing services are limited to persons who are homebound. CMS guidelines state the following:

Any absence of an individual from the home attributable to the need to receive health care treatment, including regular absences for the purpose of participating in therapeutic, psychosocial, or medical treatment in an adult day-care program that is licensed or certified by a State, or accredited, to furnish adult day-care services in the State shall not disqualify an individual from being considered to be confined to his home. Any other absence of an individual from the home shall not so disqualify an individual if the absence is of infrequent or of relatively short duration. For purposes of the preceding sentence, any absence for the purpose of attending a religious service shall be deemed to be an absence of infrequent or short duration.

Glossary of Terms

The above policy is based on the following references:

• American Medical Association, Council on Scientific Affairs. Home care in the 1990s. JAMA. 1990;263(9):1241-1244.
• Bernstein LH, et al. Primary Care in the Home. New York, NY: J.B. Lippincott Company; 1987.
• Birmingham J. Understanding the Medicare "Extended Care Benefit" a.k.a. the 3-midnight rule. Prof Case Manag. 2008;13(1):7-16.
• Cartier C. From home to hospital and back again: Economic restructuring, end of life, and the gendered problems of place-switching health services. Soc Sci Med. 2003;56(11):2289-2301.
• Corkery E. Discharge planning and home health care: What every staff nurse should know. Orthopaed Nurs. 1989;8(6):18-27.
• Kadushin G. Home health care utilization: A review of the research for social work. Health Soc Work. 2004;29(3):219-244.
• Maguire GH, ed. Care of the Elderly: A Health Team Approach. Boston, MA: Little, Brown and Co.; 1985.
• Martinson IM, et al. Home Health Care Nursing. Philadelphia, PA: W.B. Saunders Co.; 1989.
• Office of the Secretary, Department of Defense. TRICARE; Sub-acute care program; Uniform skilled nursing facility benefit; Home health care benefit; Adopting Medicare payment methods for skilled nursing facilities and home health care providers. Final rule. Fed Regist. 2005;70(204):61368-61379.
• Olson HH. Home health nursing. Caring. 1986;Aug:53-61.
• Stein J. Medicare and long-term care. Issue Brief Cent Medicare Educ. 2003;4(4):1-6.
• Suddarth DS. Lippincott Manual of Nursing Practice. Philadelphia, PA: J.B. Lippincott Co.; 1991.
• U.S. Department of Health and Human Services, Health Care Financing Administration (HCFA). Skilled nursing care. Home Health Agency Manual §205.1. HCFA Pub. 11. Baltimore, MD: HCFA; 2000.
• Vincent HK, Vincent KR. Functional and economic outcomes of cardiopulmonary patients: A preliminary comparison of the inpatient rehabilitation and skilled nursing facility environments. Am J Phys Med Rehabil. 2008;87(5):371-380.

Policy History

Effective: 05/15/1998

Next Review: 02/13/2025

Review History

Definitions

Additional Information

Clinical Policy Bulletin Notes

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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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List of CPT/HCPCS Codes

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]

• Code Sets and Indexes
• Publications

Home Health Procedures and Services CPT ® Code range 99500- 99602

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• 90281-90399
• 90460-90474
• 90785-90899
• 90901-90913
• 90935-90999
• 91010-91322
• 91304-90749
• 92002-92499
• 92502-92700
• 92920-93799
• 93880-93998
• 94002-94799
• 95004-95199
• 95249-95251
• 95700-96020
• 96040-96040
• 96105-96146
• 96156-96171
• 96202-96203
• 96360-96549
• 96567-96574
• 96900-96999
• 97010-97799
• 97151-97158
• 97802-97804
• 97810-97814
• 98925-98929
• 98940-98943
• 98960-98962
• 98966-98981
• 99000-99091
• 99100-99140
• 99151-99157
• 99170-99199
• 99500-99602
• 99605-99607
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