Nursing facility billing is a nuanced area connected to evaluation and management (E/M). When a qualified healthcare professional (QHP) or physician evaluates a patient in a medical setting or nursing facility, they must accurately match the level according to the patient’s case and the severity of the condition.
Typically, this is done during admission and determines the complexity of the encounter. In medical billing, professionals must use an accurate code to report such encounters, and among those is CPT code 99304.
99304 is considered the lowest-level code within the initial nursing facility care code range, and understanding its reporting requirements is necessary for accurate submissions and timely claim reimbursements.
CPT Code 99304 – Description
According to the AAPC, as maintained in the Current Procedural Terminology (CPT) codebook, CPT 99304 is a procedural code that indicates:
Initial nursing facility care in a given day for the evaluation and management of a patient, which requires medically appropriate history and/or examination, with a low level of medical decision-making, or at least 25 minutes total time on the date of the encounter.
It is important to note that CPT code 99304 falls within the Initial Nursing Facility Care subsection (codes ranging from 99304 to 99306) as prescribed in the Nursing Facility Services section in the E/M chapter of the CPT codebook.
Key Code Selection Criteria
The American Medical Association (AMA) revised the descriptors for nursing facility services codes, aligning them with the Office and Other Outpatient Services changes in 2021. The changes have been effective since January 1, 2023, according to which, history and physical examination are no longer required when selecting the code.
Instead, the new requirements mandate an examination or medically appropriate history as pertinent. Moreover, the code level is determined by either of the following:
- Low level of medical decision-making (MDM).
- Minimum 25 minutes of service on the encounter date.
Important Note: The total time threshold applicable to CPT code 99304 ranges between 25 and 34 minutes. However, if the total time is 35 minutes or more, CPT 99305 (moderate MDM) must be reported.
Appropriate Use Cases for CPT Code 99304
Reporting the 99304 CPT code accurately is crucial for seamless claim processing, which requires an understanding of its application and appropriate use cases.
For instance, the 99304 does not apply to outpatient office settings or assisted living facilities. The following scenarios showcase accurate CPT code 99304 usage in medical billing:
Post-Surgical Recovery
Consider the case of a 60-year-old patient who is admitted to a skilled nursing facility (SNF) following an elective knee replacement surgery. His admission became medically necessary due to a lack of a safe home environment and the need for assistance with mobility.
The physician performs a medically appropriate review of the patient’s surgical information during the initial visit. He also confirms the patient’s current medication list along with relevant comorbidities.
The visit is considered a low complexity case or a limited diagnosis with low risk. Therefore, the physician prescribes a straightforward medication regimen and performs minimal data review during an encounter that lasts 27 minutes.
After the visit, the billing team uses CPT code 99304 for reimbursement.
Quick Tip: Billing teams should review the global period for the surgical knee procedure, confirming the E/M service is not bundled with the surgical fee.
Stable Chronic Condition Admission
Say a 55-year-old patient with type 2 diabetes and hypertension is admitted to a nursing facility as he showcases signs of functional decline. The attending physician at the time of admission performs the evaluation and re-checks the patient’s diagnoses.
He also reconciles medications after seeing that the patient’s type 2 diabetes is controlled, and documents a care plan. The MDM is of a low-complexity level, but the conditions require routine management, as they are chronic yet stable.
Lastly, the billing team applies CPT code 99304 to charge the payer for services.
Modifiers to Append with CPT Code 99304
Modifiers are crucial pieces of information in medical billing, used to convey specific patient scenarios or procedure details that may impact reimbursement rates. Therefore, medical billing teams should apply appropriate modifiers (when necessary) to the CPT code.
The following table summarizes modifiers applicable to CPT code 99304:
| Modifier | Description | When It Can Be Appended |
|---|---|---|
| AI | Principal physician of record. | Used in cases where the principal or attending physician provides services for overall care with multiple team members. |
| 25 | Separate, significant, identifiable E/M service. | When a separate E/M service is performed on the same patient by the same physician on the same day. |
| GV | The external attending physician provides services but is not employed or paid by the hospice facility. | When a physician is not affiliated with the Medicare hospice program, but renders services to the patient. |
Note: Medicare hospice benefits apply to eligible patients living in nursing facilities. Hence, modifier GV is applicable to the nursing facility care visit code 99304.
Reimbursement Guidelines for CPT Code 99304
As per the latest guidelines, the following rules apply to CPT code 99304 for reimbursements:
Place of Service Codes
CPT code 99304 is exclusively applicable to care visits at nursing facilities or skilled nursing facilities. Therefore, documenting the Place of Service (POS) is necessary on every claim. According to the CMS guidance, the following can be used:
- POS 31 (Skilled Nursing Facility)
Used when the patient is enrolled in a Medicare-covered skilled nursing facility stay under Part A.
- POS 32 (Nursing Facility)
This POS can be used for patients who do not have Part A benefits or for those who are in a non-covered SNF stay. Similarly, it can be appended for long-term care stays at a nursing facility.
Incorrectly using the POS code is a common billing error and will result in claim denials or incorrect reimbursement.
Documentation Requirements
Claims for CPT code 99304 should contain the following medical record:
- Test results, coordination of care activities, or medication prescribed to the patient.
- Level of MDM, as well as the total time spent on the visit on the day of service (at least 25 minutes).
- Existing care plan and patient status.
- Document showcasing the reason for the patient’s admission into the nursing facility.
- Medically appropriate history and/or examination (as clinically relevant).
Important Note: Since 2023, medical practitioners are no longer legally required to consider the history or examination elements for code level selection. Instead, documenting the actual clinical work performed as well as the MDM complexity is now a priority.
Medicare Reimbursement Rate
The Medicare Physician Fee Schedule dictates the reimbursement rate for CPT code 99304. However, this rate varies based on the geographic location.
The best way to determine the right amount for your Medicare Administrative Contractor (MAC) locality is to review the CMS Physician Fee Schedule Lookup Tool for accurate estimates.
However, in 2026, the national average Medicare reimbursement approximations for the CPT 99304 are as follows:
- Non-facility Rate = $81.16
- Facility Rate = $71.14
Note: These estimated amounts are reported according to the national average relative value units (RVUs) as well as the 2026 Conversion Factor.
More importantly, (according to the CY 2026 Medicare Physician Fee Schedule Final Rule), CPT 99304 through 99316 for nursing facility E/M codes are exempt from the -2.5% efficiency adjustment, which applies to work RVUs for service-based (non-time-based) services in 2026.
Reporting Frequency
CPT code 99304 is reported once per admission, per physician or QHP, typically by the admitting provider responsible for the patient’s overall care.
Medical Necessity
Documenting the medical necessity of the nursing facility admission and the initial care visit is mandatory for the claim’s successful processing.
Also, if a provider performs a limited evaluation that does not meet the requirements for initial nursing facility care, they may report a subsequent care code (99307-99310) instead.
Payer-Specific Guidelines
Although most service providers follow Medicare guidelines, billing professionals must always review payer-specific guidelines to avoid errors in claim submissions.
Improve Nursing Facility Coding with NeuraBill
CPT code 99304 indicates an initial nursing facility care visit that lasts at least 25 minutes. It is the lowest level code for an initial E/M service and must be reported while keeping the guidelines discussed in this blog in mind.
99304 has its unique documentation requirements and reimbursement rates (which may vary based on the geographical location).
If your in-house billing team encounters challenges while securing reimbursement for 99304, professional medical billing and coding services like those provided by NeuraBill can accelerate claim acceptance.
