CPT 99304 Fee Schedule
Healthcare providers use this code to document and receive reimbursement for visits that address moderate-level medical decision-making, often including multiple diagnoses or prescription management.
| Key Fact | Detail |
|---|---|
| Service Type | • Evaluation and Management • Nursing Facility Services |
| Common Place of Service | • 99 - Other POS • None |
| Common Modifiers | • None • 25 - Significant, separately identifiable E/M service same day • AI - Principal Physician of Record |
| Complexity Level | Moderate |
National average reimbursement for CPT 99304 by major payers:
$101.85
$80.66
$91.29
$132.80
| Payer | Code | Rate | NPI | Tax ID | State | Specialty |
|---|---|---|---|---|---|---|
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CPT 99304 vs. Other Nursing Facility Services Codes
The CPT 99304 code is part of the Evaluation and Management services used for Nursing Facility Services. It represents a moderate-complexity encounter and is one of several codes that vary based on time spent, level of medical decision-making, and documentation requirements.
The CPT 99304 code involves more provider time and moderate medical decision-making, unlike lower-level codes that require less time and simpler assessments. It typically includes multiple diagnoses, medication management, or test interpretation, leading to higher reimbursement and more detailed documentation requirements.
| Code | Complexity | Description |
|---|---|---|
| 99304 | Low | Initial Nursing Facility Care Per Day For The Evaluation And Management Of A Patient Which Requires A Medically Appropriate History And/Or Examination And Straightforward Or Low Level Of Medical Decision Making. When Using Total Time On The Date Of The Encounter For Code Selection 25 Minutes Must Be Met Or Exceeded. (Desc Rvsd 1/1/23) |
| 99305 | Moderate | Initial Nursing Facility Care Per Day For The Evaluation And Management Of A Patient Which Requires A Medically Appropriate History And/Or Examination And Moderate Level Of Medical Decision Making. When Using Total Time On The Date Of The Encounter For Code Selection 35 Minutes Must Be Met Or Exceeded. (Desc Rvsd 1/1/23) |
| 99306 | High | Initial Nursing Facility Care Per Day For The Evaluation And Management Of A Patient Which Requires A Medically Appropriate History And/Or Examination And High Level Of Medical Decision Making. When Using Total Time On The Date Of The Encounter For Code Selection 50 Minutes Must Be Met Or Exceeded. (Desc Rvsd 1/1/2024) |
| 99307 | Low | Subsequent Nursing Facility Care Per Day For The Evaluation And Management Of A Patient Which Requires A Medically Appropriate History And/Or Examination And Straightforward Medical Decision Making. When Using Total Time On The Date Of The Encounter For Code Selection 10 Minutes Must Be Met Or Exceeded. (Desc Rvsd 1/1/23) |
What is a fee schedule?
A fee schedule is a list of fixed prices that healthcare providers charge for specific services, including CPT 99304. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 99304 fee schedule helps patients estimate costs and providers optimize billing for accurate reimbursements.
Factors that affect fee schedules
Medicare & Medicaid Rates
Government-set reimbursement amounts
Private Insurance Rates
Negotiated rates between providers and insurance companies
Geographic Location
Costs may be higher in urban areas.
Provider Type
Hospital providers may have different rates than private practice.
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Medicare Reimbursement Lookup Tool
Medicare localities are geographic regions used to adjust reimbursement rates based on local costs. Rates vary by locality to reflect differences in wages, rent, and other expenses. Sign up to see commercial rates (United/BCBS/Cigna/Aetna)
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| Year | Billing Code | Locality | Non-Facility Fee | Facility Fee |
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