CPT 99304: Initial Nursing Facility Care Visit, Straightforward/Low Complexity
Medicare pays $83 and commercial payers pay $103 on average nationally for this procedure.
CPT code 99304 describes an initial nursing facility care evaluation and management (E/M) visit for a patient in a nursing facility or skilled nursing setting, representing encounters with straightforward or low medical decision making or when the provider spends at least 25 minutes of total time on the date of service; the service type is an initial facility E/M visit and the typical site of service is a nursing facility or skilled nursing facility.
For related coverage guidance, see recent payer policy updates: Esophagogastroduodenoscopy (EGD) Coverage Policy, Magnetic Sphincter Augmentation for the Treatment of Gastroesophageal Reflux Disease (GERD), Fecal Analysis in the Diagnosis of Intestinal Dysbiosis and Fecal Microbiota Transplant Testing.
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National Reimbursement Benchmarks
Medicare average reimbursement for CPT 99304 sits at $83.4, closely aligned with Aetna’s mean of $83.4 and below BUCA’s broader commercial average of $102.6. Blue Cross Blue Shield and Cigna show notably higher mean levels ($97.1 and $124.4 respectively), while UnitedHealth Group’s mean ($116.3) also exceeds Medicare, highlighting a commercial-versus-Medicare spread concentrated around roughly $20–$40 for many national payers.
Dispersion measured by the interquartile range (P75–P25) is narrowest for Medicare at $5 and tight for Aetna at $25, indicating compressed commercial reimbursements near their medians. The widest IQRs appear for Cigna at $79 and UnitedHealth Group at $66, reflecting greater variability in commercial contract rates. Blue Cross Blue Shield and BUCA show intermediate dispersion ($36.8 and $47 respectively), placing them between the tight Medicare/Aetna band and the more variable Cigna/UnitedHealth Group cluster.