CPT 99304E&M

1st nf care sf/low mdm 25

CPT 99304 is used when a physician performs the first comprehensive evaluation of a new patient in a nursing facility or skilled nursing facility for a problem requiring straightforward or low medical decision-making.

Showing rates for

National Average

Base Medicare rate

$77.63

This calculator gives a typical-case estimate using standard Medicare modifier rules. Actual payment depends on payer policies, documentation, code-specific CMS status indicators, and locality. Verify before billing.

RVU breakdown

Work RVU

1.5

PE RVU (NF)

0.78

MP RVU

0.12

Total RVU

2.4

Conversion factor: 32.3465 · Source: CMS MPFS RVU25A · Confidence: High

NCCI bundling edits

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Billing tips

Verify admission date and ensure you bill only ONE initial nursing facility visit code (99304-99306) per admission; subsequent visits use 99307-99310
Impact: Billing a second initial visit code will result in automatic denial and $77.63 loss; can trigger audit flags
Document medical decision-making complexity elements clearly: if you have 2+ chronic conditions being managed or moderate risk, you likely qualify for 99305 ($123.17) or 99306 ($184.57) instead
Impact: Upgrading from 99304 to 99305 increases payment by $45.54 (59% increase); ensure MDM supports the level billed
Bill 99304 on the date of admission or initial encounter, not retrospectively; Medicare requires the service date match the actual face-to-face visit
Impact: Backdating claims can result in denial of the entire $77.63 payment and potential fraud investigation
For Medicare patients, append modifier AI to identify yourself as the principal physician of record if you will provide ongoing care coordination
Impact: Missing AI modifier may delay payment or cause care coordination issues; does not affect the $77.63 rate but ensures proper physician attribution
Confirm the facility is certified as a SNF or NF; assisted living facilities do not qualify for 99304—use domiciliary codes 99324-99328 instead
Impact: Wrong place-of-service code triggers automatic denial of $77.63; recode to appropriate setting-based E&M
Time is no longer a determining factor for code selection in 2025; focus documentation on MDM complexity (number/complexity of problems, data reviewed, risk)
Under 2021 E&M guidelines still in effect, prolonged service time cannot upgrade 99304 to 99305—only MDM or history/exam can justify higher levels

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Frequently asked questions

What is the Medicare reimbursement rate for CPT 99304 in 2025?

The 2025 Medicare national average payment for CPT 99304 is $77.63 for both facility and non-facility settings. This rate is based on 2.4 total RVUs multiplied by the 2025 conversion factor of 32.3465. Local rates may vary based on geographic practice cost indices (GPCI).

What is the difference between CPT 99304 and 99305?

Both are initial nursing facility visit codes, but 99304 requires straightforward or low medical decision-making (MDM) while 99305 requires moderate MDM. CPT 99304 pays $77.63 while 99305 pays $123.17. The key difference is complexity: 99305 requires either 3+ chronic conditions or a new problem with uncertain prognosis, versus 2 minor problems or 1 stable chronic condition for 99304.

How many times can you bill CPT 99304 for the same patient?

CPT 99304 can only be billed once per nursing facility admission. It is an initial visit code used for the first comprehensive evaluation when a patient is newly admitted to the facility. All subsequent visits during the same admission must use follow-up codes 99307-99310, and readmissions after discharge would allow another initial visit code.

Can a nurse practitioner bill CPT 99304?

Yes, nurse practitioners can bill CPT 99304 if they have privileges at the nursing facility and meet state scope-of-practice requirements. NPs are typically reimbursed at 85% of the physician rate for Medicare ($65.98 instead of $77.63) when billing under their own NPI, though some Medicare Advantage plans may have different policies.

What medical decision-making level is required for 99304?

CPT 99304 requires either straightforward or low medical decision-making. Straightforward MDM involves minimal problems (typically 1 self-limited/minor problem) and minimal risk. Low MDM involves 2+ self-limited problems or 1 stable chronic illness, limited data review, and low risk of complications. Higher complexity requires upgrading to 99305 or 99306.

What place of service code should be used with CPT 99304?

Use place of service (POS) code 31 for Skilled Nursing Facility or POS 32 for Nursing Facility when billing CPT 99304. The facility must be Medicare-certified as a SNF or NF. Assisted living facilities and residential care homes require different E&M codes (domiciliary visit codes 99324-99328), not 99304.

Does CPT 99304 require a specific time component to bill?

No, CPT 99304 does not have a time requirement under the current 2021 E&M guidelines. Code selection is based solely on the level of medical decision-making (straightforward or low) or the combination of history and examination performed. Time is only relevant if you are billing prolonged services separately, which is uncommon for this level of visit.