CPT 99342E&M

Home/res vst new low mdm 30

CPT 99342 is billed when a doctor visits a new patient at their home or residence for a straightforward medical problem that requires about 30 minutes of time and low-complexity medical decision making.

Showing rates for

National Average

Base Medicare rate

$75.69

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

1.65

PE RVU (NF)

0.62

MP RVU

0.07

Total RVU

2.34

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

NCCI bundling edits

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Billing tips

Document total time spent on the date of encounter including face-to-face and non-face-to-face time on that date, as 99342 is time-based with typical time of 30 minutes
Impact: Time documentation is critical for audit defense; missing time notation is the #1 reason for downcoding to 99341 ($53.49) resulting in $22.20 loss per claim
Verify patient is truly new (no professional services from same specialty within previous 3 years) before using 99342 instead of established patient codes
Impact: Using new patient code incorrectly when patient is established causes automatic denials; established equivalent 99347 pays $62.77, and incorrect billing triggers prepayment review
Confirm the location qualifies as a private residence or domiciliary (not assisted living facilities with on-site medical staff or nursing homes)
Impact: Wrong place of service code triggers denials; nursing facility visits require 99304-99310 codes, and billing location errors account for 18% of home visit claim rejections
Document two of three key components (history, exam, MDM) at the appropriate level, with low complexity MDM requiring limited diagnoses/data and low risk
Impact: Insufficient MDM documentation results in downcoding; ensure problem list shows limited complexity to justify 99342 vs 99341, protecting the $22.20 differential
Bill on the actual date of service, not the date documentation is completed, and ensure calendar date matches claim submission
Impact: Date discrepancies between documentation and claims cause processing delays and potential denials requiring costly resubmission and appeal efforts
For Medicare patients, verify homebound status is documented when coordinating with home health services to support medical necessity

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Frequently asked questions

What is the Medicare reimbursement rate for CPT 99342 in 2025?

The 2025 Medicare national average payment for CPT 99342 is $75.69 for both facility and non-facility settings. This rate is based on 2.34 total RVUs multiplied by the 2025 conversion factor of $32.3465.

How long should a CPT 99342 home visit take?

CPT 99342 has a typical time of 30 minutes of total time on the date of the encounter. This includes both face-to-face time with the patient and other time spent on that date related to the encounter, such as reviewing records or coordinating care.

What is the difference between CPT 99342 and 99341?

CPT 99342 requires low complexity medical decision making while 99341 requires straightforward MDM. 99342 involves more complex problems, more data review, or higher risk than 99341, and reimburses at $75.69 compared to $53.49 for 99341, a difference of $22.20.

Can CPT 99342 be billed for assisted living facility visits?

It depends on the facility type. 99342 can be used for domiciliary/custodial care facilities without on-site medical staff. Assisted living facilities with medical staff or nursing homes require different codes (99324-99328 for domiciliary new or 99304-99310 for nursing facilities). Verify the facility classification before coding.

What defines a new patient for CPT 99342 billing purposes?

A new patient is one who has not received any professional face-to-face services from the physician or another physician of the same specialty in the same group practice within the previous three years. All three criteria must be met to bill 99342 instead of established patient code 99347.

What RVU values are assigned to CPT 99342 in 2025?

CPT 99342 has 1.65 work RVUs, 0.62 practice expense RVUs (both facility and non-facility), 0.07 malpractice RVUs, totaling 2.34 total RVUs. These values are from the CMS Physician Fee Schedule RVU25A released December 23, 2024.

Can nurse practitioners and physician assistants bill CPT 99342?

Yes, nurse practitioners and physician assistants can bill CPT 99342 when operating within their scope of practice and state regulations. Medicare typically reimburses NPs and PAs at 85% of the physician fee schedule amount when billing under their own NPI, which would be $64.34 for 99342.