Summary & Overview
CPT 99304: Initial Nursing Facility Evaluation and Management, Low Complexity
CPT code 99304 is a critical billing code for initial evaluation and management services in nursing facilities, representing a detailed history and physical examination with low complexity medical decision making. This code is widely used by physicians specializing in geriatric, family, and internal medicine to document and bill for the first encounter with patients in nursing facility settings. Nationally, CPT 99304 is recognized by major payers including Aetna, Blue Cross Blue Shield, Cigna Health, Medicare, and UnitedHealthcare, ensuring broad coverage for providers and patients.
This publication provides a comprehensive overview of CPT 99304, including its clinical context, typical site of service, and comparison to related codes such as 99305 and 99306. Readers will gain insight into payer coverage, common billing modifiers, and associated diagnoses relevant to initial nursing facility care. The analysis also highlights policy updates and benchmarks that impact reimbursement and compliance for this service. Understanding CPT 99304 is essential for healthcare professionals navigating the complexities of medical billing, documentation, and payer requirements in post-acute care environments.
CPT Code Overview
CPT 99304 is used for initial evaluation and management services provided to patients in a nursing facility. This code includes a detailed history and physical examination, along with medical decision making of low complexity. The typical time spent for this service is 25 minutes. The service is classified as Evaluation and Management – Initial nursing facility care and is most commonly performed in a Nursing Facility (Place of Service code 32).
Clinical & Coding Specifications
Clinical Context
A patient is newly admitted to a nursing facility, such as a skilled nursing or long-term care facility (Place of Service code 32). The provider, often a geriatric medicine, family medicine, or internal medicine physician, conducts an initial evaluation and management service. This includes a detailed history, a physical examination, and medical decision making of low complexity. The typical time spent is 25 minutes. The visit may be prompted by a general medical examination, age-related debility, or other malaise, and is documented as the initial care provided upon admission.
Coding Specifications
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Modifier
25: Used when a significant, separately identifiable evaluation and management service is performed by the same physician on the same day as another procedure or service. -
Modifier
AI: Indicates the principal physician of record for the patient in the nursing facility.
| Modifier Code | Description |
|---|---|
25 | Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service |