CPT 99309E&M

Sbsq nf care moderate mdm 30

CPT 99309 is used when a physician provides a follow-up visit to a patient in a nursing facility (not the initial visit), involving moderate complexity medical decision-making and typically 30 minutes of care.

Showing rates for

National Average

Base Medicare rate

$104.16

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

1.92

PE RVU (NF)

1.17

MP RVU

0.13

Total RVU

3.22

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

NCCI bundling edits

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Billing tips

Document all three elements of moderate MDM: moderate number/complexity of problems addressed, moderate amount/complexity of data reviewed, and moderate level of risk
Impact: Proper MDM documentation is the sole determining factor under 2021+ guidelines; inadequate documentation can result in downcoding to 99308 ($74.57) causing a $29.59 loss per encounter
Bill 99309 only once per patient per day regardless of how many times you see the patient; combine all encounters into one visit level
Impact: Duplicate billing on the same date of service will result in denial of the second claim with 100% payment loss on that claim
Time alone cannot determine the level for 99309; unlike outpatient E/M, nursing facility codes are based solely on MDM complexity, though typical time is 30 minutes
Impact: Using time-based selection for nursing facility codes will not be supported on audit and may lead to downcoding
Ensure documentation shows patient reassessment and interval changes since last visit; merely reviewing previous notes without new findings does not support a billable visit
Impact: Medical necessity denials can result in 100% recoupment ($104.16 per visit) and potential fraud investigation if pattern identified
For Medicare Part B patients in SNFs, verify the patient is not in a Medicare Part A covered stay where physician services may be bundled
Impact: Billing during a Part A SNF stay can result in denial and recoupment; Part A consolidated billing rules apply
Use place of service code 32 (nursing facility) or 31 (skilled nursing facility) appropriately; incorrect POS can trigger denials

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Frequently asked questions

What is the Medicare reimbursement rate for CPT 99309 in 2025?

The 2025 Medicare national average reimbursement rate for CPT 99309 is $104.16 for both facility and non-facility settings. This is based on 3.22 total RVUs multiplied by the 2025 conversion factor of 32.3465. Actual payments may vary by geographic locality.

How is CPT 99309 different from 99308 and 99310?

CPT 99309 requires moderate complexity medical decision-making, while 99308 requires low complexity MDM and 99310 requires high complexity MDM. The difference is based on the complexity of problems addressed, amount of data reviewed, and level of risk - not on time spent. 99309 ($104.16) falls between 99308 ($74.57) and 99310 ($139.01) in reimbursement.

Can I bill CPT 99309 for a telehealth visit to a nursing facility?

Telehealth billing for nursing facility services is extremely limited. During the COVID-19 public health emergency, expanded telehealth was allowed, but post-PHE, most nursing facility E/M codes require in-person visits. Always verify current Medicare telehealth rules and use modifier 95 when telehealth is permitted and performed.

How often can I bill CPT 99309 for the same patient?

You can bill 99309 as frequently as medically necessary based on the patient's clinical condition. However, daily visits must be justified by documented changes in status, acute issues, or treatment response monitoring. Routine daily rounding without documented clinical need may be denied as not medically necessary.

What are the work RVUs for CPT code 99309?

CPT 99309 has 1.92 work RVUs, 1.17 practice expense RVUs (both facility and non-facility), and 0.13 malpractice RVUs, for a total of 3.22 RVUs in 2025. The work RVU reflects the physician time, skill, and intensity required for moderate complexity subsequent nursing facility care.

Can I bill 99309 during a Medicare Part A skilled nursing facility stay?

Generally no. When a patient is in a Medicare Part A covered SNF stay, physician services except those of the attending physician in certain circumstances are bundled into the Part A payment. You must verify the patient's coverage status. If the patient is in the facility but NOT on a Part A stay (e.g., long-term custodial care), then Part B billing of 99309 is appropriate.

What documentation is required to support moderate complexity MDM for 99309?

You need to document moderate complexity in at least two of three MDM elements: (1) moderate number/complexity of problems (e.g., multiple chronic conditions with exacerbation, new problem with uncertain prognosis), (2) moderate data review (e.g., review of tests, external records, independent historian), and (3) moderate risk (e.g., prescription drug management, decision regarding minor surgery, diagnosis with uncertain prognosis). Simply stating 'moderate complexity' is insufficient.