CPT 99461E&M

Init nb em per day non-fac

CPT 99461 is used to bill for the first day of evaluation and management services provided to a healthy newborn in a non-hospital facility setting, such as a birthing center or office. This covers the initial daily assessment and care coordination for a newborn typically within the first few days of life.

Showing rates for

National Average

Base Medicare rate

$88.63

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

1.26

PE RVU (NF)

1.4

MP RVU

0.08

Total RVU

2.74

Conversion factor: 32.3465 · Source: CMS MPFS RVU25A · Confidence: High

NCCI bundling edits

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Billing tips

Verify place of service (POS) code accuracy: 99461 requires non-facility POS codes (11, 50, etc.). Using POS 21-23 (hospital) triggers denials or downcoding to facility rate.
Impact: Incorrect POS reduces payment from $88.63 to $58.22 (34% reduction or $30.41 loss per claim)
Do not bill 99461 and 99460 for the same infant on the same date of service. 99460 is the facility-based equivalent; billing both constitutes duplicate billing.
Impact: Automatic denial of duplicate claim; may trigger audit flags and recoupment of $88.63 plus potential penalties
Document time spent on counseling and coordination of care, even though 99461 is not time-based. This supports medical necessity and complexity if audited.
Impact: Reduces audit risk and supports medical necessity; prevents potential denials that average $88.63 per claim
Bill 99461 only for the initial day of newborn care in non-facility setting. Subsequent days should be billed with 99462 (subsequent hospital care) or appropriate outpatient E&M codes (99391, 99381) depending on setting and timing.
Impact: Using 99461 for multiple days results in denials; appropriate code selection maintains cash flow and prevents write-offs
Ensure diagnosis codes support newborn status: Use Z00.110 (newborn health examination) or appropriate Z38.x codes (liveborn infant) as primary diagnosis to support medical necessity.
Impact: Inappropriate diagnosis codes trigger denials; proper coding supports $88.63 payment and reduces appeals workload
Verify patient age is within acceptable range (typically 0-28 days). Most payers limit 99461 to neonatal period; billing for older infants triggers denials.

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Frequently asked questions

What is the difference between CPT 99461 and 99460?

CPT 99461 is for initial newborn evaluation in non-facility settings (birthing centers, offices) with 2025 Medicare reimbursement of $88.63, while 99460 is for hospital-based initial newborn care with facility rate of $58.22. The codes are mutually exclusive and determined by place of service, not the level of care provided.

How many times can you bill CPT 99461 for the same patient?

CPT 99461 can only be billed once per infant for the initial day of newborn care in a non-facility setting. Subsequent days require different codes: 99462 for subsequent hospital care or appropriate outpatient/well-child codes (99391, 99381) depending on setting and clinical context.

What is the Medicare reimbursement rate for CPT 99461 in 2025?

The 2025 Medicare national average reimbursement for CPT 99461 is $88.63 for non-facility settings and $58.22 for facility settings. These rates are based on 2.74 total RVUs multiplied by the 2025 conversion factor of 32.3465. Local rates may vary based on geographic adjustment factors.

Can CPT 99461 be billed with a circumcision code?

Yes, CPT 99461 can be billed with circumcision code 54150 when both services are performed on the same day, but modifier 25 must be appended to 99461 to indicate a significant, separately identifiable E&M service. Documentation must clearly support that the newborn evaluation was distinct from the pre-procedure assessment for circumcision.

What diagnosis codes should be used with CPT 99461?

Primary diagnosis codes for CPT 99461 typically include Z00.110 (health examination for newborn under 8 days old), Z00.111 (health examination for newborn 8 to 28 days old), or Z38.x codes indicating liveborn infant status. The diagnosis must support newborn status and medical necessity for the initial evaluation.

Who can bill CPT 99461?

CPT 99461 can be billed by physicians (MD/DO) including pediatricians, family medicine doctors, and neonatologists, as well as qualified non-physician practitioners such as nurse practitioners and certified nurse midwives who are credentialed and privileged to provide newborn care in their practice setting.

What RVU value is assigned to CPT 99461 in 2025?

CPT 99461 has a total RVU of 2.74 in 2025, consisting of 1.26 work RVU, 1.4 non-facility practice expense RVU (0.46 facility PE RVU), and 0.08 malpractice RVU. These values determine the Medicare payment rates when multiplied by the conversion factor of 32.3465.