Long-term care forms, admission and placement, 03.04D


All of the following criteria must be met:

  • Different steps are involved in having someone admitted to a long-term care facility.
  • Typically, the placement is followed by admission (when a bed becomes available). These events occur on different dates of service.


  • Requires an examination and form completion.
  • This should be submitted as a visit service appropriate to the visit provided, i.e., 03.03A, 03.04A (if a 03.04A hasn’t been claimed in the last 365 days), 03.03N, etc.
  • Complex modifiers apply when time criteria are met.
  • Time spent completing the forms on the same day the visit occurs may be included in the total time submitted for complex modifiers.
  • There are no additional fees for form completion, and fees cannot be charged to the patient for completing the forms.


  • Admission occurs the day the patient is admitted to the long-term care facility.
  • This process requires the physician to complete all components of the admission to the facility. There is nothing billable to the patient.
  • The code to claim for the admission is:
    • 03.04D long-term care admission (nursing home/auxiliary hospital or a long-term care bed in a general hospital). 

Additional information:

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