1st nf care sf/low mdm 25
CPT code 99304 covers the first visit when a doctor evaluates a new patient in a nursing home or skilled nursing facility for a straightforward or low-complexity medical problem.
RVU breakdown
Conversion factor: 32.3465 · Source: CMS MPFS RVU25A · Confidence: High
Billing tips
Document that this is the first encounter in the nursing facility by this physician/group - subsequent visits use different codes (99307-99310)
Impact: Incorrect use of initial vs subsequent codes can result in $20-60 payment differences and trigger audits
Ensure MDM is clearly documented as straightforward or low complexity; if complexity is moderate, use 99305 instead ($105.90, a $28.27 increase)
Impact: Undercoding costs $28.27 per visit; proper MDM documentation for moderate complexity justifies 99305
Bill only once per physician/group per nursing facility admission - if patient transfers to hospital and returns, a new initial visit may be billable
Impact: Duplicate billing of initial visits can result in complete denial of the $77.63 payment plus potential fraud investigation
Verify the patient's admission date and ensure the initial visit is billed within a reasonable timeframe (typically within 24-48 hours of admission)
Impact: Delays may require documentation explaining why initial assessment was postponed; late visits may be downgraded to subsequent codes
Document comprehensive history and exam even if MDM is low - all three key components must be met for 99304
Impact: Missing comprehensive history or exam elements can result in downcoding to lower-paying codes or complete denial
Do not bill 99304 on the same date as discharge services (99315-99316) or care plan oversight - different codes apply
Impact: Bundling edits will deny one service entirely, losing $77.63 or more in reimbursement
Common denials
Billed as initial visit when provider already saw patient in nursing facility during this admission
How to appeal: Provide documentation showing this is genuinely the first visit (e.g., new attending physician, patient readmitted after hospital transfer) or correct to appropriate subsequent visit code 99307-99310 and resubmit
Insufficient documentation of comprehensive history or comprehensive examination
How to appeal: Submit complete medical record showing all elements of comprehensive history (CC, HPI, ROS, PFSH) and comprehensive exam (8+ organ systems); if documentation is insufficient, accept downcoding to 99303
Medical decision-making level not supported - appears to be minimal complexity, warranting 99303 instead
How to appeal: Provide detailed documentation of data reviewed, diagnoses considered, and risk factors that support straightforward/low MDM; if unable to support, accept downcoding to 99303 ($61.70)
Service billed outside of acceptable timeframe relative to nursing facility admission date
How to appeal: Submit documentation explaining circumstances requiring delayed initial assessment (patient unavailable, emergency situation, etc.) or clarify admission date discrepancy with facility records
Frequently asked questions
What is CPT code 99304 used for?
CPT 99304 is used for the initial comprehensive evaluation of a patient in a nursing facility or skilled nursing facility when the medical decision-making is straightforward or low complexity. This code applies when a physician first assumes responsibility for a patient's care in these settings.
How much does Medicare pay for CPT 99304 in 2025?
Medicare pays $77.63 for CPT 99304 in 2025 based on the national average rate. Both facility and non-facility rates are identical at $77.63, with a total RVU of 2.4.
What is the difference between 99304 and 99305?
The difference is the level of medical decision-making: 99304 requires straightforward or low complexity MDM, while 99305 requires moderate complexity MDM. Medicare pays $77.63 for 99304 versus $105.90 for 99305, a difference of $28.27.
Can 99304 be billed more than once for the same patient?
No, 99304 can only be billed once per nursing facility admission by the same physician or group practice. Subsequent visits during the same admission should be coded using 99307-99310. If a patient is discharged and later readmitted, a new initial visit code may be appropriate.
What documentation is required for billing CPT 99304?
Documentation must include a comprehensive history, comprehensive examination (8+ organ systems), and medical decision-making at the straightforward or low complexity level. You must also document that this is the initial nursing facility encounter and include assessment and plan for all active problems.
Can nurse practitioners bill CPT code 99304?
Yes, nurse practitioners and physician assistants can bill 99304 within their scope of practice and according to state regulations and facility privileges. Medicare typically reimburses NPPs at 85% of the physician fee schedule rate when billing under their own NPI.
What are the RVUs for CPT code 99304?
CPT 99304 has a Work RVU of 1.5, Practice Expense RVU of 0.78 (both facility and non-facility), Malpractice RVU of 0.12, for a total RVU of 2.4 in 2025.