Home/res vst new low mdm 30
CPT 99342 is billed when a physician visits a new patient at home or in a residential facility (like assisted living) for a straightforward medical problem requiring low-complexity medical decision making during a 30-minute visit.
RVU breakdown
Conversion factor: 32.3465 · Source: CMS MPFS RVU25A · Confidence: High
Billing tips
Verify and document the exact location type of the visit (private residence vs. assisted living vs. group home) as this determines whether 99342 or place-of-service-specific codes apply
Impact: Incorrect place of service coding can result in 100% claim denial or recoupment; use POS 12 for home visits
Ensure medical decision making (MDM) meets 2021 E&M guideline criteria for 'low' complexity: limited problems, limited data, or low risk—only two of three elements required
Impact: Upcoding to 99343 (moderate MDM, $116.49) without proper documentation triggers audits; downcoding from 99342 to 99341 loses $22.62 per visit
Document total visit time spent on the date of encounter if time is used to select the code level due to counseling/coordination exceeding 50% of visit time
Impact: For 99342, total time of 30 minutes may justify the level when MDM is difficult to categorize; improper time documentation fails medical necessity
Bill established patient codes (99347-99350) instead if patient has been seen by same physician or another physician of same specialty in same group within past 3 years
Impact: New vs. established patient errors result in automatic denials; 99347 (established low MDM) pays $80.92, $5.23 more than 99342
Separate documentation from facility-based E&M on same date by different providers in same group to avoid consolidation denials
Impact: When same-group providers see patient in office and home same day, Medicare may bundle services resulting in loss of $75.69
Review payer-specific policies on home visit coverage as some Medicare Advantage and commercial payers have stricter homebound or medical necessity requirements
Impact: Commercial rates average 120-180% of Medicare ($90.83-$136.24); denial rate varies 15-40% by payer without proper authorization
Common denials
Incorrect place of service code submitted (e.g., POS 11 office instead of POS 12 home)
How to appeal: Submit corrected claim with POS 12 and include documentation clearly indicating visit occurred at patient's private residence or qualifying residential facility; reference LCD policy for home visits
Patient classified as established rather than new, with payer records showing prior visit within 3 years
How to appeal: Verify patient history; if truly new, provide documentation showing no prior visits by physician of same specialty in group within 36 months; if established, accept correction to 99347 code
Medical necessity not supported by documentation for home visit instead of office visit
How to appeal: Provide clinical documentation establishing homebound status, mobility limitations, or medical justification for home setting; include physician attestation of why office visit was not appropriate
Insufficient documentation of medical decision making complexity to support low MDM level
How to appeal: Submit complete visit note demonstrating at least two of three MDM elements at low level per 2021 guidelines; include problem list, data reviewed, and risk assessment; reference AMA CPT guidelines
Frequently asked questions
What is the Medicare reimbursement rate for CPT 99342 in 2025?
The 2025 Medicare national average payment rate for CPT 99342 is $75.69 for both facility and non-facility settings, based on 2.34 total RVUs and a conversion factor of 32.3465.
What is the difference between CPT 99342 and 99343?
CPT 99342 is for new patient home visits with low medical decision making complexity (30 minutes typical time), while 99343 involves moderate complexity MDM (45 minutes typical). The MDM level determines the appropriate code, not just time spent.
Can CPT 99342 be billed for assisted living facility visits?
Yes, 99342 can be billed for visits to assisted living facilities that function as the patient's private residence, using place of service code 12 or 13. However, if the facility operates a centralized clinic, domiciliary codes (99324-99328) may be more appropriate.
How many RVUs is CPT code 99342 worth?
CPT 99342 has 2.34 total RVUs for 2025, composed of 1.65 work RVUs, 0.62 practice expense RVUs, and 0.07 malpractice RVUs. Both facility and non-facility PE RVUs are identical at 0.62.
What qualifies a patient as new for CPT 99342 billing purposes?
A patient is considered new if they have not received any professional services from the physician or another physician of the exact same specialty in the same group practice within the previous three years.
Can nurse practitioners bill CPT 99342 independently?
Yes, nurse practitioners and physician assistants can bill 99342 under their own NPI when working within their scope of practice and state licensure. Medicare reimburses NPs at 85% of the physician fee schedule rate ($64.34) unless billing incident-to a physician.
What place of service code should be used with CPT 99342?
Use place of service code 12 (home) for private residences or assisted living facilities. For group homes or custodial care facilities, POS 13 may apply. Using incorrect POS codes like 11 (office) will result in claim denial.