Sbsq nf care sf mdm 10
CPT 99307 covers a follow-up visit to a patient in a nursing facility or skilled nursing facility where the physician performs a straightforward medical decision-making evaluation. This is the lowest level of subsequent nursing facility care.
RVU breakdown
Conversion factor: 32.3465 · Source: CMS MPFS RVU25A · Confidence: High
Billing tips
Document specific MDM elements to support straightforward complexity: limited number of diagnoses (typically 1-2 self-limited or stable chronic conditions), minimal data review (no independent interpretation), and low risk (e.g., prescription drug management)
Impact: Prevents downcoding denials and supports the $38.49 reimbursement; inadequate MDM documentation is the leading cause of audit recoupment
Bill 99307 only once per calendar day regardless of multiple brief encounters; if complexity increases significantly during reassessment, consider 99308 or 99309 instead
Impact: Avoids duplicate billing denials; upgrading to 99308 increases reimbursement to approximately $56-62 when MDM supports it
Verify the patient is in a Medicare Part A SNF stay versus custodial nursing home care, as consolidated billing rules affect what can be billed separately
Impact: Failure to use modifier AI when required results in claim denials; approximately 15-20% of nursing facility claims are initially rejected for consolidated billing errors
For NPP visits, ensure compliance with state scope of practice laws and Medicare incident-to requirements (85% payment rate when billing under NPP NPI)
Impact: NPP services billed under their own NPI receive $32.72 (85% of $38.49); billing under physician NPI with proper supervision yields full $38.49
Time is NOT a factor for 99307 selection under 2023+ guidelines; base code selection solely on MDM complexity or history/exam when MDM not met
Impact: Documenting time without appropriate MDM justification increases audit risk; focus documentation on problem complexity, data, and risk elements
Use 99307 for required 30-day federally mandated nursing facility visits when patient is stable; document medical necessity even for routine required visits
Impact: Medical necessity documentation prevents LCD-based denials that can result in 100% payment recoupment ($38.49 per visit)
Common denials
Medical necessity not established - visit appears to be custodial care rather than medically necessary physician service
How to appeal: Submit clinical notes demonstrating active medical decision-making (medication adjustments, symptom monitoring, diagnostic interpretation). Include references to facility regulations requiring physician oversight. Cite LCD requirements for nursing facility care and document changes in patient status or treatment plan.
Insufficient documentation of straightforward MDM complexity - notes lack required MDM elements (number/complexity of problems, data reviewed, risk)
How to appeal: Provide detailed breakdown of MDM elements present in original documentation. Submit addendum clarifying diagnoses addressed, data reviewed, and risk level. Reference 2023 E&M guidelines showing straightforward MDM criteria met. Include comparison to teaching examples in CPT codebook.
Consolidated billing violation - service billed during SNF Part A stay without appropriate modifier or when bundled into SNF PPS rate
How to appeal: Verify patient's Medicare Part A status and SNF consolidated billing requirements. If physician is principal physician of record, resubmit with modifier AI. If service is excluded from SNF PPS, provide documentation supporting exclusion and cite CMS SNF consolidated billing regulations.
Frequency limitation exceeded - multiple E&M services billed on same date or visits exceeding payer's coverage policy
How to appeal: Document separate and distinct medical reasons for multiple visits if applicable. Submit facility records showing different encounters occurred. If multiple providers saw patient, clarify distinct specialties/purposes. Reference Medicare guidelines allowing one E&M per specialty per date when medically necessary.
Frequently asked questions
What is the Medicare reimbursement rate for CPT 99307 in 2025?
The 2025 Medicare national average payment for CPT 99307 is $38.49 for both facility and non-facility settings. This is based on 1.19 total RVUs multiplied by the 2025 conversion factor of 32.3465. Actual payment may vary by geographic locality based on GPCI adjustments.
How often can you bill CPT 99307 for the same patient?
CPT 99307 can be billed once per calendar day per patient. Medicare and most payers expect nursing facility visits at intervals appropriate to the patient's condition, typically ranging from daily to monthly. The federally required 30-day visit for nursing facility residents can be billed as 99307 when complexity supports this level. More frequent visits require clear medical necessity documentation.
What is the difference between CPT 99307 and 99308?
CPT 99307 requires straightforward medical decision-making (limited problems, minimal data, low risk), while 99308 requires low complexity MDM (multiple problems, limited data, low to moderate risk). The key difference is problem complexity and risk level. 99308 reimburses approximately $20 more than 99307's $38.49 rate, making accurate MDM documentation critical.
Can nurse practitioners bill CPT 99307?
Yes, nurse practitioners and physician assistants can bill CPT 99307 for nursing facility visits within their scope of practice. When billing under their own NPI, NPPs receive 85% of the physician fee schedule amount ($32.72). When billing incident-to under physician supervision where permitted, the full rate of $38.49 applies. State laws and facility policies govern NPP independent practice.
What documentation is required for CPT 99307?
Documentation must include medically appropriate history and exam, plus straightforward MDM elements: the number and complexity of problems addressed (typically 1-2 stable conditions), amount and complexity of data reviewed (minimal), and risk of complications (low). Include assessment of patient status, treatment plan, and medical necessity for the visit. Signature, credentials, and date are required.
Do you need modifier AI for CPT 99307 in skilled nursing facilities?
Modifier AI is required when the billing physician is the principal physician of record managing the patient during a Medicare Part A SNF stay. This modifier ensures proper claim processing under SNF consolidated billing rules. Failure to append AI when required results in claim denial. Modifier AI does not change the $38.49 reimbursement amount but is essential for payment.
What is straightforward medical decision making for CPT 99307?
Straightforward MDM for 99307 requires minimal complexity: typically 1-2 self-limited or stable chronic illnesses, minimal or no data review and interpretation, and low risk such as routine prescription drug management. Examples include monitoring stable diabetes, adjusting blood pressure medications for controlled hypertension, or following stable dementia. If problems are multiple or unstable, consider 99308 or higher.