Home/res vst est high mdm 60
CPT 99350 is billed when a physician makes a house call to see an established patient at home or in a residential facility for a complex medical problem requiring extensive evaluation and medical decision-making, typically spending about 60 minutes.
RVU breakdown
Conversion factor: 32.3465 · Source: CMS MPFS RVU25A · Confidence: High
Billing tips
Document total time spent face-to-face with patient/family and clearly note it exceeded 60 minutes to support the high-level code
Impact: Prevents downcoding to 99349 ($133.35) which would reduce reimbursement by $44.56 (25% reduction)
Explicitly document high complexity MDM elements: extensive number/complexity of problems addressed, extensive data reviewed (labs, imaging, records from hospitalizations), and high risk of complications or morbidity
Impact: Medicare contractors frequently audit home visit codes; clear MDM documentation prevents downcoding that could cost $44-88 per visit
For patients in assisted living or group homes, verify the facility is not considered a nursing facility; use 99310-99316 for nursing facility visits instead
Impact: Using wrong code family can result in 100% denial; nursing facility codes have different payment rates ($73-170 range)
Bill place of service code 12 (home) for private residences or assisted living; incorrect POS codes trigger automatic denials
Impact: POS errors account for 15-20% of home visit denials, delaying payment by 30-60 days during correction and resubmission
For patients receiving hospice services, coordinate with hospice to determine if service relates to terminal condition and use appropriate GW/GV modifiers
Impact: Improper hospice billing results in 100% denial or recoupment; proper modifier use ensures $177.91 payment versus $0
When billing same-day home visit with a procedure, append modifier 25 to 99350 and document that E&M was separately identifiable and above pre/post-procedure work
Impact: Without modifier 25, E&M portion may be denied entirely, losing $177.91 in legitimate reimbursement
Applicable modifiers
When to use: When a separately identifiable E&M service is performed on the same day as a procedure or other service
Reimbursement impact: Allows full reimbursement for both services; without modifier 25, the E&M may be bundled and denied
When to use: When the home visit is conducted via synchronous telemedicine (if allowed by payer policy)
Reimbursement impact: May reduce reimbursement by 0-25% depending on payer; some payers reimburse at parity with in-person visits
When to use: Principal physician of record (used in team-based care or when multiple physicians are managing the patient)
Reimbursement impact: Informational modifier; typically no direct payment impact but clarifies care coordination roles
When to use: Service not related to the hospice terminal condition for hospice patients
Reimbursement impact: Ensures Medicare Part B payment rather than bundling into hospice per diem; critical for avoiding denials
When to use: Attending physician not employed or paid under arrangement by the hospice (for hospice patients)
Reimbursement impact: Allows separate billing by non-hospice-employed physicians; ensures proper payment channel
When to use: Repeat visit by same physician on same day for separate medical necessity
Reimbursement impact: May reduce second visit payment by 50% or require exceptional documentation to justify full payment
Common denials
Insufficient documentation of medical necessity for highest-level home visit code
How to appeal: Submit appeal with complete visit note highlighting: number of chronic conditions addressed (3+), medication changes made, diagnostic results reviewed, and risk assessment. Include comparison chart showing why 99350 criteria met versus 99349. Reference Medicare's E&M guidelines showing high complexity MDM justification.
Patient location not considered appropriate for home visit codes (e.g., nursing facility)
How to appeal: Provide documentation proving patient residence type: lease agreement, facility admission paperwork showing assisted living (not skilled nursing), or facility attestation letter. Reference Medicare Benefit Policy Manual Chapter 15 §80 defining home visit settings. If residence type was misidentified, correct and rebill with appropriate code family.
Frequency limitations - multiple home visits within short timeframe flagged as excessive
How to appeal: Document medical necessity for each visit with specific, distinct clinical reasons: acute exacerbation events, medication titration requirements, post-hospitalization protocol, or complex disease management needs. Provide treatment timeline showing clinical progression requiring frequent reassessment. Include evidence-based guidelines supporting visit frequency for the conditions treated.
Denial due to hospice bundling when patient is receiving hospice services
How to appeal: If service was unrelated to terminal diagnosis, resubmit with modifier GW and supporting documentation showing the unrelated condition treated. If attending physician visit, confirm modifier GV was used and provide attestation of non-employment by hospice. Include itemized explanation of how service falls outside hospice benefit scope.
Frequently asked questions
What is the Medicare reimbursement rate for CPT 99350 in 2025?
The 2025 Medicare national average reimbursement rate for CPT 99350 is $177.91 for both facility and non-facility settings. This is based on 5.5 total RVUs multiplied by the 2025 conversion factor of 32.3465. Actual payment may vary by geographic locality based on the GPCI adjustments in your area.
How many RVUs is CPT code 99350 worth?
CPT 99350 has a total of 5.5 RVUs for 2025, consisting of 3.6 work RVUs, 1.67 practice expense RVUs, and 0.23 malpractice RVUs. This makes it one of the higher-valued E&M codes, reflecting the complexity and time required for comprehensive home visits.
What is the difference between CPT 99350 and 99349?
CPT 99350 requires high complexity medical decision-making while 99349 requires moderate complexity MDM. 99350 typically involves 60 minutes face-to-face time versus 40 minutes for 99349. The reimbursement difference is significant: 99350 pays $177.91 compared to approximately $133.35 for 99349, a difference of about $44.56.
Can CPT 99350 be billed for assisted living facility visits?
Yes, CPT 99350 can be billed for assisted living facilities, as these are considered private residences or domiciliary settings, not skilled nursing facilities. Use place of service code 12 (home) or 13 (assisted living). However, if the facility provides skilled nursing services and the patient resides in that section, you must use nursing facility visit codes (99310-99316) instead.
How often can you bill CPT 99350 for the same patient?
There is no specific Medicare frequency limitation on CPT 99350, but medical necessity must be documented for each visit. Frequent high-level home visits may trigger payer review, so documentation should clearly justify why each visit required high complexity decision-making and could not be managed via telehealth, office visit, or lower-level home visit code.
What documentation is required to support billing CPT 99350?
Documentation must support high complexity MDM through: multiple chronic conditions or acute problems addressed, extensive review of diagnostic data or records, high risk of morbidity without treatment, detailed examination findings, and comprehensive treatment plan adjustments. You should also document total face-to-face time (typically 60+ minutes) and explain why a home visit was medically necessary rather than an office visit.
Can nurse practitioners and physician assistants bill CPT 99350?
Yes, nurse practitioners and physician assistants can bill CPT 99350 within their scope of practice and state licensing. Medicare reimburses NPs and PAs at 85% of the physician fee schedule rate when billing under their own NPI, which would be approximately $151.22 for 99350. Some may also bill incident-to at 100% if all incident-to requirements are met, though this is less common for home visits.