Home/res vst est sf mdm 20
CPT code 99347 is used when a doctor visits an established patient at their home or residence to provide a medical evaluation that involves straightforward medical decision-making and typically takes about 20 minutes.
RVU breakdown
Conversion factor: 32.3465 · Source: CMS MPFS RVU25A · Confidence: High
Billing tips
Document the specific reason the visit must occur in the home rather than office setting
Impact: Prevents denials based on medical necessity; home visit codes require homebound or mobility-limited justification worth the full $43.67 reimbursement
Clearly distinguish straightforward MDM from low complexity (99348) by documenting limited diagnosis/treatment options and minimal data review
Impact: Upcoding to 99348 ($78.63) without proper MDM documentation triggers audits; correct level selection prevents $34.96 overpayment recovery
Record total face-to-face time when it exceeds typical time by more than 50%, allowing use of prolonged service codes
Impact: If visit reaches 35+ minutes, adding 99417 can increase payment by $43.26 per additional 15 minutes beyond threshold
For patients in assisted living or group homes, verify the facility is not a skilled nursing facility which requires different code sets (99307-99310)
Impact: Using home visit codes in SNF settings results in 100% denial; correct setting determination prevents complete claim rejection
Document all elements supporting 'established patient' status (seen within past 3 years by same physician or same specialty group)
Impact: New patient home visits (99344-99345) reimburse higher but require stricter documentation; incorrect status can trigger $45-80 payment adjustments
Bundle minor procedures performed during the same visit unless separately identifiable E&M is documented with modifier 25
Impact: Inappropriate separate billing of bundled services results in overpayment recovery averaging $40-60 per claim in audits
Common denials
Medical necessity not established for home-based service versus office visit
How to appeal: Submit appeal with documentation of patient's homebound status, mobility limitations, or medical contraindications to office transport. Include physician statement explaining clinical necessity of home setting.
Insufficient documentation of medical decision-making complexity supporting straightforward level
How to appeal: Provide complete visit note highlighting number of diagnoses addressed, amount of data reviewed, and risk level. Map documentation to 2021 E&M guidelines showing minimal diagnoses and minimal/no data reviewed qualify as straightforward MDM.
Incorrect place of service code used for assisted living versus skilled nursing facility
How to appeal: Submit facility documentation proving residence is custodial/domiciliary care (POS 13) not skilled nursing (POS 31/32). Include state licensing information showing facility type and patient's residency status versus short-term rehab stay.
Established patient relationship not documented within required 3-year timeframe
How to appeal: Provide records showing prior visit dates with same physician or same group/specialty within 36 months. Include patient registration records and previous encounter documentation establishing ongoing care relationship.
Frequently asked questions
What is the Medicare reimbursement rate for CPT 99347 in 2025?
The 2025 Medicare national average payment for CPT 99347 is $43.67 for both facility and non-facility settings. This is based on 1.35 total RVUs multiplied by the 2025 conversion factor of 32.3465.
How many RVUs is CPT code 99347 worth?
CPT 99347 has 1.35 total RVUs consisting of 0.9 work RVU, 0.41 practice expense RVU, and 0.04 malpractice RVU. These values are the same for both facility and non-facility settings.
What is the difference between CPT 99347 and 99348?
CPT 99347 requires straightforward medical decision-making while 99348 requires low complexity MDM. Code 99348 involves more diagnoses or treatment options, greater data review, and higher risk than 99347, resulting in higher reimbursement ($78.63 vs $43.67 for Medicare).
Can CPT 99347 be billed for assisted living facility visits?
Yes, CPT 99347 is appropriate for assisted living facilities classified as domiciliary or custodial care settings. However, if the patient is in a skilled nursing facility (SNF), you must use nursing facility codes 99307-99310 instead.
How long should a CPT 99347 visit take?
The typical face-to-face time for CPT 99347 is 20 minutes. While time is not the primary basis for code selection (medical decision-making is), documenting time is important if you need to report prolonged services or if time becomes the determining factor for level selection.
What modifiers are commonly used with CPT 99347?
Common modifiers for 99347 include modifier 25 (separately identifiable E&M with procedure), GW/GV (hospice-related services), and 95 (telemedicine when applicable). The modifier used depends on the specific circumstances of the visit and payer requirements.
Does CPT 99347 require the patient to be homebound?
While Medicare does not explicitly require homebound status for 99347 like it does for home health services, medical necessity for conducting the visit in the home setting must be documented. This typically involves mobility limitations, medical contraindications to office transport, or clinical benefit of home assessment.