Nursing Facility Billing Code Reference Form
Document and reference billing codes used within the nursing facility for accurate and consistent billing practices.
Billing Reference ID
*
Date of Entry
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Department / Unit
*
Please Select
Skilled Nursing
Rehabilitation
Long-Term Care
Memory Care
Other
Service Type
*
Routine Care
Therapy
Medication Administration
Lab/Diagnostics
Other
Billing Code Type
*
Please Select
CPT
HCPCS
ICD-10
Revenue Code
Other
Billing Code
*
Code Description
*
Effective Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Expiration Date (if applicable)
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Internal Notes
Submit Reference
Should be Empty: