CPT 99345E&M

Home/res vst new high mdm 75

CPT code 99345 is used when a doctor visits a new patient at their home or residence for a complex medical problem that requires about 75 minutes of care and high-level medical decision making.

Showing rates for

National Average

Base Medicare rate

$193.76

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

3.88

PE RVU (NF)

1.86

MP RVU

0.25

Total RVU

5.99

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 (face-to-face and non-face-to-face activities), as 99345 can be selected by time (75 minutes) or MDM level (high complexity)
Impact: Time-based coding can justify 99345 even when MDM is borderline; comprehensive time documentation can prevent downcoding to 99344, protecting $48+ in revenue per visit
Clearly document high MDM by addressing at least 2 of 3 elements: extensive problems addressed (1 chronic illness with severe exacerbation or 3+ chronic illnesses), extensive data review/analysis, or high risk of complications/morbidity
Impact: Inadequate MDM documentation is the leading cause of downcoding from 99345 to 99344, resulting in $48 loss per claim
Bill using place of service code 12 (home) for private residences or 13 (assisted living) for ALF settings to ensure proper reimbursement
Impact: Incorrect POS codes trigger automatic denials or payment adjustments; using office POS 11 with 99345 will result in claim rejection
Verify new patient status (no professional services from same physician/group within past 3 years) before billing 99345; established patients require 99347-99350
Impact: Billing new patient codes for established patients results in automatic denials and potential audit flags; established patient codes reimburse $33-85 less
Document medical necessity for home visit rather than office visit, including homebound status, safety concerns, or medical complexity preventing office-based care
Impact: Payers may deny home visits if medical necessity for location is not documented, particularly for commercial plans; this prevents denials and supports medical necessity appeals

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Frequently asked questions

What is the Medicare reimbursement rate for CPT code 99345 in 2025?

The 2025 Medicare national average reimbursement rate for CPT code 99345 is $193.76 for both facility and non-facility settings. This rate is based on 5.99 total RVUs multiplied by the 2025 conversion factor of $32.3465. Actual payment may vary by locality based on geographic practice cost indices (GPCI).

How long does a 99345 home visit need to be?

CPT code 99345 typically requires 75 minutes of total time spent on the date of the encounter, including both face-to-face and non-face-to-face time. Alternatively, you can select 99345 based on high complexity medical decision making regardless of time. Time-based selection requires documentation of total time with specific activities performed.

What is the difference between CPT codes 99345 and 99350?

CPT 99345 is for new patient home visits requiring high complexity MDM and 75 minutes, while 99350 is for established patients requiring high complexity MDM and 60 minutes. New patients are those who have not received professional services from the physician/group within the past 3 years. 99345 reimburses at $193.76 while 99350 typically reimburses at a slightly lower rate.

Can you bill 99345 for assisted living facility visits?

Yes, CPT 99345 can be billed for assisted living facility (ALF) visits using place of service code 13. However, you cannot use 99345 for skilled nursing facility (SNF) visits, which require domiciliary/rest home codes 99324-99328 or nursing facility codes 99304-99310 depending on the specific setting and payer guidelines.

What medical decision making level is required for CPT 99345?

CPT 99345 requires high level medical decision making, meaning you must meet 2 of 3 criteria: (1) high number/complexity of problems (1 chronic illness with severe exacerbation, progression, or side effects, OR 3+ chronic illnesses), (2) extensive amount/complexity of data to review and analyze, or (3) high risk of complications, morbidity, or mortality from treatment decisions.

How many RVUs is CPT code 99345 worth?

CPT code 99345 has 5.99 total RVUs for 2025, broken down as: 3.88 work RVUs, 1.86 practice expense RVUs (both facility and non-facility), and 0.25 malpractice RVUs. This makes it one of the higher-valued E/M codes, reflecting the complexity and time involved in comprehensive home visits.

What documentation is needed to bill 99345 instead of 99344?

To bill 99345 instead of 99344, you must document either: (1) high complexity MDM with 2 of 3 elements at high level (versus moderate for 99344), or (2) 75 minutes of total time on date of encounter (versus 60 minutes for 99344). Specifically document extensive problems addressed, comprehensive data analysis, high-risk treatment decisions, or detailed time logs with specific activities to justify the higher code level.