Summary & Overview
CPT 99318: Annual Evaluation and Management in Nursing Facility
CPT code 99318 was a key billing code for annual evaluation and management services provided to adult patients in nursing facilities, including skilled nursing facilities. This code enabled healthcare professionals to document comprehensive assessments of residents, supporting quality care and appropriate reimbursement. Effective January 1, 2023, CPT 99318 was deleted from the CPT code set, impacting how providers report annual nursing facility visits.
Major national payers such as Blue Cross Blue Shield, Cigna Health, and UnitedHealthcare previously covered services billed under CPT 99318. The deletion of this code reflects evolving clinical and billing standards for nursing facility care, prompting providers to use alternative codes for similar services. Readers will learn about the clinical context of the code, its historical use, and implications of its removal from the CPT code set. The publication also highlights related codes, common modifiers, and associated clinical taxonomies, offering a comprehensive overview of billing and policy changes affecting nursing facility evaluation and management services.
This summary provides essential information for healthcare administrators, billing professionals, and clinicians seeking to understand the impact of the deletion of CPT 99318 and the transition to updated coding practices for nursing facility care.
CPT Code Overview
CPT 99318 represented an annual evaluation and management service for patients residing in a nursing facility, such as a skilled nursing facility. This code was used to document comprehensive assessments performed by healthcare professionals, including physicians and nurse practitioners, to evaluate the overall health status of adult patients in these settings. The service type was Evaluation and Management (E/M), specifically tailored to the needs of individuals in nursing facilities. As of January 1, 2023, CPT 99318 has been deleted and is no longer valid for reporting these services.
Clinical & Coding Specifications
Clinical Context
A typical patient scenario for CPT code 99318 involved an adult resident in a nursing facility, such as a skilled nursing facility, undergoing an annual evaluation and management (E/M) visit. The provider, often a geriatric medicine physician or nurse practitioner, would perform a comprehensive assessment of the patient's medical status, review chronic conditions, screen for new health concerns, and update care plans. This visit was generally scheduled as part of routine annual care, focusing on preventive health and management of age-related issues, such as physical debility or cognitive changes. The workflow included reviewing the patient's history, conducting a physical examination, and documenting findings relevant to ongoing care in the facility.
Coding Specifications
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Modifiers:
Modifier Code Description 25Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service AIPrincipal Physician of Record - Modifier
25was used when an E/M service was provided in addition to another procedure on the same day, indicating the E/M service was distinct and separately identifiable. - Modifier
AIidentified the principal physician responsible for the patient's care in the nursing facility.
- Modifier
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Provider Taxonomies:
Taxonomy Code Specialty 207QG0300XGeriatric Medicine Physician 207RG0300XGeriatric Medicine (Internal Medicine) Physician 163WG0000XGeriatric Nurse Practitioner - These taxonomies represent providers specializing in geriatric medicine and care for older adults in nursing facilities.
Related Diagnoses
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Z00.00: Encounter for general adult medical examination without abnormal findings- Used when the annual assessment finds no new or abnormal issues.
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Z00.01: Encounter for general adult medical examination with abnormal findings- Applied when the annual assessment identifies new or abnormal health concerns.
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Z13.89: Encounter for screening for other disorder- Relevant for preventive screening performed during the annual visit.
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R41.3: Other amnesia- Used if cognitive impairment or memory issues are identified during the assessment.
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R54: Age-related physical debility- Applied when the patient exhibits physical decline associated with aging, often addressed in the annual evaluation.
Related CPT Codes
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99307‑99310: Subsequent nursing facility care codes- These codes are used for ongoing evaluation and management visits after the initial or annual assessment. They represent subsequent care provided to residents in nursing facilities.
- In clinical workflow,
99307‑99310were commonly reported for follow-up visits, while99318was used for the annual comprehensive assessment. After the deletion of99318, providers may use these subsequent care codes for routine visits.
National Reimbursement Benchmarks
National mean rates for CPT code 99318 show that BUCA (average commercial) rates are $190.12, while Medicare rates are not available in the input. Among the commercial payers, Cigna has the highest mean rate at $239.77, followed by BUCA, UnitedHealth Group ($166.23), and Blue Cross Blue Shield ($162.89).
Rate dispersion, measured by the difference between the 75th and 25th percentiles, varies significantly across payers. Blue Cross Blue Shield has the tightest range at $63.75, while Cigna exhibits the widest spread at $124.00. UnitedHealth Group and BUCA have intermediate ranges of $138.00 and $92.63, respectively. This indicates that Cigna's rates are more variable, while Blue Cross Blue Shield's rates are more consistent nationally.
The table and chart below present the full breakdown of national benchmarks for CPT code 99318 by payer.
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