CPT 99306E&M

1st nf care high mdm 50

CPT 99306 is used when a doctor performs the first comprehensive evaluation of a patient newly admitted to a nursing home or skilled nursing facility, involving high-complexity medical decision-making and typically 50 minutes of time.

Showing rates for

National Average

Base Medicare rate

$175.32

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

3.5

PE RVU (NF)

1.7

MP RVU

0.22

Total RVU

5.42

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

NCCI bundling edits

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Billing tips

Document all three elements of high-complexity MDM: extensive complexity of problems (multiple chronic illnesses with exacerbation or new problems), extensive data review (independent interpretation of tests, discussion with external providers), and high risk of complications or invasive interventions
Impact: Proper MDM documentation justifies the $175.32 rate versus $129.72 for 99305 or $92.88 for 99304—a difference of $45.60 to $82.44 per encounter
Bill 99306 only once per nursing facility admission; subsequent visits use 99307-99310 codes even if performed by a different physician in the same group
Impact: Billing a second 99306 during the same admission will result in automatic denial and potential audit flags
Time-based coding is not applicable for 99306; focus documentation on MDM complexity rather than total time spent, though typical time of 50 minutes helps support the service level
Impact: Unlike office visits, you cannot use prolonged service codes to escalate payment; the $175.32 rate is fixed regardless of time beyond typical
Ensure the date of service is within 24-48 hours of nursing facility admission or document medical necessity for any delay beyond admission date
Impact: Delayed initial visits may trigger payer scrutiny or denial; timely documentation supports medical necessity and facility compliance
Include comprehensive medication reconciliation, review of hospital discharge summaries, and facility-specific care plan in your documentation
Impact: These elements support the extensive data review component of high-complexity MDM and reduce risk of downcoding during audits
Verify whether the patient is in a Medicare Part A SNF stay versus custodial care, as this affects whether you bill Medicare Part B or facility-consolidated billing applies

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Frequently asked questions

What is the difference between CPT 99306 and 99305?

CPT 99306 requires high-complexity medical decision-making and reimburses at $175.32, while 99305 requires moderate-complexity MDM and pays $129.72. The difference of $45.60 reflects the greater complexity of problems, data review, and risk level documented for 99306. Choose 99306 when the patient has multiple severe chronic conditions with acute exacerbation, requires extensive diagnostic workup review, or faces high risk of complications.

Can you bill 99306 for a nursing home resident you've been seeing in the hospital?

Yes, 99306 is appropriate when the patient transitions from hospital to nursing facility, as this represents an initial nursing facility encounter even if you provided hospital care. You would have billed hospital discharge (99238-99239) on the last hospital day and then 99306 for the first nursing facility visit. These are separate care settings with distinct E/M code families.

How many times can you bill CPT 99306?

CPT 99306 can only be billed once per nursing facility admission per provider or group. All follow-up visits during the same admission use subsequent nursing facility care codes 99307-99310, even if performed weeks or months later. If the patient is discharged and later readmitted to the nursing facility, a new 99306 may be billed for the new admission.

What is the Medicare reimbursement for CPT 99306 in 2025?

The 2025 Medicare national average reimbursement for CPT 99306 is $175.32 for both facility and non-facility settings. This is based on 5.42 total RVUs (3.5 work + 1.7 PE + 0.22 MP) multiplied by the 2025 conversion factor of 32.3465. Actual payment may vary by geographic locality based on GPCI adjustments.

Does CPT 99306 require a certain amount of time to bill?

No, CPT 99306 is not time-based and does not require 50 minutes to bill. The code is selected based solely on the complexity of medical decision-making documented. The 50-minute typical time is for reference only and cannot be used for code selection. Unlike office visits, prolonged service time cannot upgrade the service level for nursing facility care.

Can a nurse practitioner bill CPT 99306?

Yes, nurse practitioners and physician assistants can bill CPT 99306 when performing initial nursing facility evaluations within their scope of practice and state regulations. Medicare reimburses NPs at 85% of the physician rate when billing under their own NPI ($148.85 for 99306). Some facilities may require physician co-signature or have credentialing limitations.

What documentation supports high-complexity MDM for 99306?

High-complexity MDM requires meeting thresholds in 2 of 3 elements: (1) extensive number/complexity of problems such as 1+ chronic illness with severe exacerbation or threat to life, (2) extensive data review including independent interpretation of tests or discussion with external providers, and (3) high risk of complications, invasive interventions, or decisions regarding hospitalization. Document specific problems addressed, tests reviewed with your interpretation, and risk assessment with management options considered.