Home/res vst new high mdm 75
CPT 99345 covers a home or residence visit for a new patient requiring highly complex medical decision-making, typically lasting about 75 minutes. This is used when a physician evaluates a new patient at their home who has multiple serious medical conditions or complex treatment decisions.
RVU breakdown
Conversion factor: 32.3465 · Source: CMS MPFS RVU25A · Confidence: High
Billing tips
Document all three MDM elements under 2021 E/M guidelines: number/complexity of problems (high = 1+ chronic illness with severe exacerbation), amount/complexity of data reviewed (extensive records, independent historian, or ordering Category 3 tests), and risk of complications (high = drug therapy requiring intensive monitoring or decision regarding hospitalization). Only two of three elements need to meet 'high' threshold.
Impact: Proper MDM documentation is the primary defense against downcoding from 99345 ($193.76) to 99344 ($140.25), a difference of $53.51 per visit or 38% reduction
Establish medical necessity for the home visit itself in documentation. Note why the patient cannot be safely transported to the office due to medical contraindications, mobility limitations, or clinical need for environmental assessment.
Impact: Lack of medical necessity justification is the leading cause of complete denial; including 1-2 sentences can prevent $193.76 payment loss and potential recoupment
For new patient definition, verify no professional services by same physician or same specialty group within past 36 months. Document new patient status explicitly if there's any ambiguity.
Impact: Incorrect new vs established coding leads to automatic downcoding to 99350 ($162.40), a $31.36 loss per visit, plus potential fraud flags for pattern issues
Time may be used for code selection only when counseling/coordination of care dominates (>50% of encounter) or when prolonged service beyond typical time is documented. For 99345, typical time is 75 minutes; document total time and activities if using time-based selection.
Impact: While MDM is typically more favorable for level 5 selection, time-based coding provides alternative pathway when extensive counseling occurs; clear time documentation prevents audit challenges
Bill place of service code 12 (home) for private residence, 13 for assisted living, or 14-16 for group homes depending on setting. Incorrect POS code triggers denials.
Impact: POS mismatches cause automatic system denials requiring corrected claims resubmission, delaying payment by 30-45 days
Link diagnosis codes that support high complexity MDM. Include all conditions addressed during the visit with specificity codes (CHF with specific type, COPD with exacerbation, etc.). Avoid using only generic or screening codes.
Impact: Vague or insufficient diagnosis coding on claims with high-level E/M codes triggers prepayment review 40% more frequently; specific coding reduces audit risk
Common denials
Medical necessity not established for home visit setting versus office visit
How to appeal: Submit clinical notes documenting specific medical contraindications to office transport (severe deconditioning, oxygen dependence, recent hospitalization with mobility restrictions, fall risk, etc.). Include physician attestation that office visit was not medically appropriate. Reference LCD requirements for home visits in your MAC jurisdiction.
Documentation does not support high complexity MDM (level downcoded to 99344 or 99343)
How to appeal: Provide detailed MDM grid showing how encounter met high complexity threshold under 2021 E/M criteria. Highlight: (1) chronic illnesses with severe exacerbation or threat to life, (2) extensive data review with external records or independent interpretation, (3) high-risk management decisions. Quote specific documentation excerpts supporting each MDM element. Cite CMS's 2021 E/M guidelines clarifying only 2 of 3 elements must be met at high level.
Claim denied as patient not considered 'new' (billed as established patient code should be used)
How to appeal: Submit documentation proving no professional services by physician or same-specialty group member within prior 36 months. If patient was seen in different setting (hospital) but never for professional office/home service, clarify the distinction. Provide practice records search results showing no prior home or office E/M services. Reference CPT definition of new patient.
Frequency limitations or duplicate service denial when billed with other E/M codes same day
How to appeal: Demonstrate services were separate and distinct encounters. If hospital discharge and home visit occurred same day, show separate documentation and medical necessity for both. Generally avoid billing 99345 same day as other comprehensive E/M codes unless clearly different encounters with distinct purposes. Consider using modifier 25 if minor procedure was also performed.
Frequently asked questions
What is the difference between CPT 99345 and 99350?
CPT 99345 is for new patients requiring high complexity MDM during a home visit, while 99350 is for established patients with high complexity MDM. The new patient designation means no professional service from the same physician or group within 36 months. Medicare pays $193.76 for 99345 versus $162.40 for 99350 in 2025, reflecting the additional work of establishing a new patient relationship.
How much does Medicare pay for CPT code 99345 in 2025?
Medicare pays $193.76 for CPT 99345 in 2025 based on the national average non-facility rate. The code has 5.99 total RVUs (3.88 work RVU, 1.86 practice expense, 0.25 malpractice) multiplied by the 2025 conversion factor of 32.3465. Actual payment may vary slightly by geographic locality based on GPCI adjustments.
What medical decision making level is required for 99345?
CPT 99345 requires high complexity medical decision-making under the 2021 E/M guidelines. This means at least 2 of 3 MDM elements must meet the high threshold: (1) high number/complexity of problems such as 1+ chronic illness with severe exacerbation, (2) extensive data review/analysis including independent interpretation or discussion with external providers, or (3) high risk of complications such as drug therapy requiring intensive monitoring or decision regarding hospitalization.
Can I bill 99345 for a telehealth visit?
Telehealth billing for home visit codes like 99345 depends on current CMS policy and Public Health Emergency waivers. Traditionally, home visit codes require in-person presence at the patient's residence. During COVID-19 PHE, temporary waivers allowed telehealth for some scenarios. Check current CMS telehealth policy and use modifier 95 if telehealth is permitted. As of 2025, most home visit codes require physical presence unless specific waivers apply.
What documentation is required to bill CPT 99345?
Documentation must include: confirmation of new patient status, medical necessity for home visit location, high complexity MDM with at least 2 of 3 elements at high level (problems, data, risk), appropriate history and examination, assessment and plan for all conditions addressed, and provider signature. If using time for code selection, document 75 minutes total time with activities breakdown. Place of service code (12, 13, or 14-16) must match actual location.
How often can I bill 99345 for the same patient?
CPT 99345 can only be billed once per patient per physician/group, as it is a new patient code. After the initial visit, subsequent home visits must use established patient codes (99347-99350). If the patient has not received any professional services from your practice for 36 months, they may again qualify as a new patient, allowing another 99345 if appropriate level of complexity is met.
What is the typical time associated with CPT 99345?
The typical time for CPT 99345 is 75 minutes of face-to-face time with the patient and/or family. This time can be used for code selection when counseling and coordination of care dominate the encounter (>50%), or under the 2021 E/M guidelines when using time-based selection instead of MDM. However, most providers use MDM criteria for level 5 home visit selection as it typically better captures the service complexity.