A Guide To CPT Codes Used in Assisted Living Facilities

Billing in assisted living facilities can be overwhelming, especially when it comes to understanding CPT codes. With approximately 1.3 million seniors living in nursing homes across the U.S., accurate coding is crucial for ensuring proper reimbursement and smooth operations. However, many providers struggle to determine which CPT codes apply to the wide variety of services they offer. 

This guide will walk you through the essential CPT codes used in assisted living facilities, helping you simplify your billing process and maintain compliance. 

Before diving deeper, let’s start by understanding what CPT codes actually are and how they specifically relate to assisted living.

What Are CPT Codes in Assisted Living?

CPT (Current Procedural Terminology) codes are alphanumeric codes maintained by the American Medical Association (AMA). They are used universally to report medical procedures and services for billing and documentation purposes. While CPT codes are not exclusive to assisted living, they play a unique role in your setting due to the hybrid nature of care, which blends health services with residential living.

In ALFs, CPT codes may be used for:

• Physician visits to residents
• Routine health assessments
• Physical therapy sessions
• Behavioral health interventions
• Chronic disease management

These codes help ensure that the services you provide are correctly recognized, billed, and reimbursed by insurance providers.

Also Read: What is Medical Coding? A Comprehensive Guide

Now that you know what CPT codes are, let’s explore how they fit into your day-to-day operations and healthcare services.

The Role of CPT Codes in Assisted Living Care and Services

While ALFs may not be as medically intensive as nursing homes, they still cater to residents with significant healthcare needs. CPT codes serve several key functions in these facilities:

• Billing and Reimbursement: Properly coded services are essential for receiving payment from Medicare, Medicaid (in applicable states), and private insurance.
• Regulatory Compliance: Using CPT codes accurately helps ensure compliance with healthcare laws and regulations.
• Quality Assurance: Documenting services with CPT codes ensures that care plans are followed and outcomes can be tracked over time.

To better understand how CPT codes work, it’s helpful to distinguish them from other medical coding systems you may encounter.

CPT vs. ICD vs. HCPCS: What’s the Difference?

Understanding how CPT codes differ from other medical coding systems is vital:

• CPT Codes describe what was done (procedures and services).
• ICD (International Classification of Diseases) Codes explain why a service was provided (diagnoses).
• HCPCS (Healthcare Common Procedure Coding System) Codes are a supplement to CPT, often used for non-physician services, durable medical equipment, and supplies.

In an ALF, these codes often work together. For instance, an ICD code may indicate a diagnosis of diabetes, while a CPT code covers a follow-up visit, and an HCPCS code may specify the type of glucometer used.

With all of this in mind, let’s focus on why CPT codes are so important in the unique context of assisted living.

Why Are CPT Codes Important in Assisted Living?

CPT codes are essential in assisted living facilities as they ensure accurate billing and reimbursement for medical services. These codes also help maintain compliance, streamline communication, and support the delivery of efficient care:

1. Healthcare Reimbursement: CPT codes ensure that your facility gets reimbursed for eligible medical services. Without proper coding, even the best care may go uncompensated.

2. Billing Accuracy: Mistakes in CPT coding can lead to audits, penalties, or claim denials. Accurate documentation helps you maintain smooth billing cycles and reduces administrative workload.

3. Communication Across the Care Spectrum CPT codes create a shared language between you, healthcare providers, insurers, and residents. This standardization ensures that everyone is on the same page about the care being provided and billed.

Let’s now delve into the heart of assisted living care and explore what types of services are covered by CPT codes.

Types of Services Covered by CPT Codes in ALFs (In-Depth)

As an assisted living facility (ALF), you provide a range of services to meet the daily and medical needs of your residents. Many of these services are covered by CPT codes, which standardize billing and ensure proper reimbursement. 

Here’s a breakdown of standard services and their corresponding CPT codes:

1. Personal Care Services

Personal care services are the backbone of assisted living. These services include assistance with activities of daily living (ADLs), such as:

• Bathing
• Dressing
• Grooming

While these services are generally not billable through traditional CPT codes if provided by non-licensed staff, they may be reimbursed when offered by licensed practitioners under certain medical necessity. 

For example:

• T1019: Personal care services, per 15 minutes
• G0299: Skilled nursing services by a registered nurse

You can use these codes when personal care is delivered as part of a medical plan or under the direction of a healthcare provider.

2. Medical Services

Routine healthcare monitoring is common in ALFs, where your residents often require regular health checks to ensure their well-being. Some of the most common services you provide include:

• Blood pressure checks
• Vital sign monitoring
• Routine physical exams

The CPT codes most frequently used for these services include:

• 99324–99328: Domiciliary or rest home visit for new patients
• 99334–99337: For established patients in ALFs

These codes cover comprehensive visits, including physical examinations, ongoing care, and follow-up appointments.

3. Therapies and Rehabilitation Services

Therapy services are essential in assisted living for residents recovering from illnesses or surgeries or managing chronic conditions. The following therapies are commonly coded:

• 97110: Therapeutic exercises
• 92507: Speech-language therapy, individual
• 97161–97163: Physical therapy evaluation codes

These codes ensure that you can receive reimbursement for the essential therapies your residents need, both for evaluation and treatment.

4. Skilled Nursing Services

When your residents need more intensive care, skilled nursing services are required. Common skilled services in ALFs include:

• Medication administration
• Wound care
• Catheter care

For skilled nursing services, relevant CPT codes include:

• 99504: Home visit for mechanical ventilation care
• 99600: Unlisted home visit service (used when no specific code fits)

You can use these codes when services are medically necessary, often prescribed by a healthcare provider, to manage specific medical conditions.

5. Other Services

In addition to the above, you may also provide several other important services, such as:

• Nutritional counseling
• Mental health assessments
• Podiatry care

The applicable CPT codes for these services include:

• 97802–97804: Medical nutrition therapy
• 96127: Brief emotional/behavioral assessment
• 99201–99205: Office/outpatient visits for evaluation and management

These codes ensure that essential care, such as mental health services or nutritional counseling, is adequately reimbursed.

Now, let’s review the revised codes for Assisted Living Facilities, effective January 1, 2023. These updates ensure accurate coding, streamline reimbursement, and maintain compliance with current standards.

Revised Codes for Assisted Living Facilities

Effective January 1, 2023, there were significant updates to the CPT codes used in assisted living facilities. These changes primarily affect codes related to boarding homes, rest homes, and domiciliary care. These updates aim to help you streamline your billing process, ensure accurate reimbursement, and stay compliant with current healthcare standards.

1. Removal of Certain Codes

With the revised guidelines, CPT codes specific to boarding homes, rest homes, and domiciliary care have been removed. These codes were used to report services in residential settings that no longer fit the updated categories. Now, you will need to use the new codes for billing services provided to residents, ensuring alignment with the revised healthcare billing practices.

2. Introduction of New Revised Codes

The new revised codes now include:

• 99341–99345: These codes apply to new patients in assisted living facilities. They cover services like initial assessments, evaluation, and the creation of personalized care plans. You will use these codes to bill for services provided during new patient visits, ensuring you capture all necessary documentation and are reimbursed accurately.’
• 99347–99350: These codes are for established patients in assisted living facilities. These codes are used for ongoing care and follow-up visits to monitor residents’ health. They ensure you’re properly reimbursed for routine check-ups, medication management, and chronic condition monitoring.

Impact on Billing and Documentation

The revised codes are crucial for ensuring you receive the correct reimbursement for both new and established patients. 

• For new patients, the updated codes (99341–99345) reflect the comprehensive nature of the initial evaluation, where you’ll assess the resident’s medical history and create a care plan. 
• For established patients, the revised codes (99347–99350) ensure that you’re reimbursed for the ongoing care you provide, including regular health checks, management of chronic conditions, and preventive services.

Why These Changes Matter?

These revisions are designed to make your billing process more accurate and streamlined. By replacing outdated codes with more relevant ones, you can:

• Ensure proper reimbursement for the complexity of care provided to new and established residents
• Improve your documentation process, making it easier to stay compliant and reduce errors
• Align your facility’s billing practices with current healthcare standards

By staying informed about these changes and using the updated codes correctly, you will ensure your facility remains compliant and well-compensated for the care you provide.

Now that you understand the types of services covered, let’s break down some of the most commonly used CPT codes in ALFs and how to ensure you’re using them correctly.

Common CPT Codes Used in Assisted Living Facilities

Here are some of the frequently used CPT codes in ALFs and the associated services:

• 99327: Domiciliary or rest home visit for evaluation and management, moderate severity
• 99335: Follow-up visits for established patients
• 97535: Self-care/home management training (e.g., cooking, safety)
• 97112: Neuromuscular reeducation

Each of these codes serves a distinct function. For instance, you might use 99327 for a new patient intake, while 97535 could be part of a rehabilitation plan focusing on self-care and independence.

Before you can master CPT coding, it’s essential to understand where things often go wrong. Many Assisted Living Facilities unknowingly fall into coding traps that lead to rejected claims and compliance headaches.

Common Mistakes to Avoid in CPT Coding for Assisted Living

Even with the best intentions, CPT coding errors can occur and in the healthcare world, even small mistakes can result in denied claims, compliance issues, or even revenue loss. 

Here are some frequent slip-ups that Assisted Living Facilities (ALFs) must watch out for:

• Misidentifying the Service Provided: Selecting codes that don’t match the actual medical services or level of care given
• Incorrect Use of Modifier Codes: Modifiers are essential in specifying nuances of care (e.g., if a procedure was bilateral or reduced), and misusing them can lead to claim denials.
• Lack of Documentation: CPT codes must be backed by clear, concise, and complete records. Inadequate notes can trigger audits or reimbursement delays.
• Using Outdated Codes: CPT codes are updated annually. Using expired or deleted codes may result in your payment not being processed.

Keep a centralized resource with the latest CPT updates, and conduct periodic reviews. Tools like ProMantra simplify this process with real-time updates, error alerts, and built-in coding support, reducing the chances of costly oversights. 

Once the codes are correctly assigned, the next hurdle is navigating the billing landscape. This is where coding truly connects with the financial side of assisted living services.

Billing and Reimbursement Process in Assisted Living

CPT codes don’t just support documentation; they drive billing. Let’s walk through how these codes influence reimbursement and what role insurance providers and Medicare/Medicaid play.

Here’s how the process typically unfolds:

• Submission of Claims: ALFs submit CPT-coded services to payers, including Medicare, Medicaid, or private insurance companies.
• Insurance Review: Insurers verify the codes, match them with covered benefits, and evaluate medical necessity.
• Payment or Denial: Based on coding accuracy, claims are either paid or flagged for issues, such as mismatched codes or insufficient documentation.

Understanding Reimbursement Cycles:

Payment timelines can vary, but errors in CPT coding often lead to delays of several weeks. Clean claims are typically processed faster, usually within 15 to 30 days, while incorrect claims can take months due to the need for resubmission. 

The platform integrates seamlessly with EHRs and billing systems, providing automated billing workflows, claim status tracking, and error flagging to ensure smooth transitions from care delivery to cash flow.

While billing and coding may seem straightforward on paper, ALFs face a distinct set of real-world challenges that make maintaining consistent accuracy tough.

Challenges and Considerations for Assisted Living Facilities

Assisted living facilities face challenges in managing diverse resident needs and evolving regulations. These factors impact both care delivery and operational efficiency.

• Diverse Patient Profiles: Residents often have multiple chronic conditions, requiring a range of services across different disciplines. Accurately capturing this complexity is a challenge.
• Care Overlap with External Providers: ALFs may coordinate with visiting physicians, specialists, or therapy providers, raising issues around documentation ownership and responsibility.
• Changing Code Regulations: CPT codes and payer rules evolve frequently. Staying current is difficult without a robust support system.
• Administrative Burden: Many ALFs lack dedicated medical coders, and the task often falls to nurses or care managers, which can lead to burnout or mistakes.

So, how do you overcome these challenges and ensure your facility stays compliant and efficient? The answer lies in adopting proactive strategies and leveraging the proper techniques. Let’s look at it. 

Advanced Strategies for Enhancing CPT Code Accuracy and Compliance

To move from reactive to proactive coding management, ALFs must invest in smarter systems and smarter people. Here’s how:

1. Regular Staff Training: A Continuous Investment

Make coding education a cornerstone of your facility’s culture. Schedule monthly or quarterly training workshops to keep everyone, from medical staff to administrative teams, up-to-date with the latest codes, modifiers, and common coding mistakes. Continuous learning is the key to maintaining accuracy and avoiding costly errors.

2. Establish Standardized Protocols: A Blueprint for Consistency

Create clear and standardized internal coding Standard Operating Procedures (SOPs). This ensures everyone follows the same process, whether it’s a nurse documenting a care plan or an admin staff member entering the data into the system. Consistency is crucial for minimizing mistakes and ensuring regulatory compliance.

3. Embrace Smart Coding: Where Efficiency Meets Accuracy

Here’s where ProMantra’s expertise comes in. With its advanced, intuitive platform, it helps elevate your coding accuracy. ProMantra offers: 

• Auto-suggestions for CPT Codes: Based on care notes, the system will recommend the most appropriate codes for your patients, reducing the likelihood of human error.
• Flagging of Incorrect Code Combinations: ProMantra instantly flags any incompatible code combinations, preventing costly errors before they happen.
• Real-time Insurance Updates: Stay ahead with real-time updates on insurance policies and their specific billing rules, ensuring your facility is always compliant with the latest regulations.

ProMantra supports coding by enhancing it, streamlining workflows, and improving your team’s efficiency.

4. Conduct Routine Coding Audits: Stay Ahead of the Game

Proactive is better than reactive. Conduct internal audits every quarter to review trends, identify recurring issues, and make improvements before an external audit comes around. This not only ensures compliance but also gives you a chance to tweak processes, increase accuracy, and stay on top of evolving coding rules.

5. Designate a Coding Champion: Your Internal Expert

Appoint a coding champion within your team, someone who stays informed on the latest coding practices, updates, and industry changes. This person should be the go-to resource for questions, troubleshooting, and ensuring that the team is always working in line with the latest standards. With the right leadership in place, CPT coding becomes less of a burden and more of a strategic asset.

With the right tools, training, and protocols in place, your facility will not only meet the requirements for CPT coding c1ompliance but exceed them, creating a smoother, more efficient environment for both staff and residents.  

Investing in platforms like ProMantra enhances your coding and billing processes, providing real-time insurance updates, error flagging, and seamless integration with EHRs and billing systems. Its automated workflows and custom alerts ensure your team stays on track, reducing errors and boosting overall efficiency. With ProMantra, you elevate your facility’s operations to new standards of excellence.

Conclusion

Understanding and using CPT codes correctly is crucial for assisted living facilities (ALFs) to ensure proper reimbursement and compliance with regulations. By staying current with code changes, maintaining consistent documentation practices, and utilizing innovations like  ProMantra, ALFs can enhance accuracy and streamline their billing processes. 

ProMantra helps simplify coding and billing, offering automated solutions and expert support to ensure your facility remains compliant and well-compensated.

Visit ProMantra today to learn how our tools and services can help your facility stay compliant and improve reimbursement accuracy.