CPT Code 99307: Subsequent nursing facility care billing guide

Key Takeaways

CPT Code 99307 describes a subsequent nursing facility visit requiring a medically appropriate history and/or exam with straightforward medical decision making (MDM).

Straightforward MDM means minimal problems addressed, minimal data reviewed, and minimal risk of complications. Selecting 99308 without meeting the low-complexity MDM threshold creates upcoding exposure.

The 2026 Medicare blended national average payment for CPT Code 99307 is approximately $42, but POS 31 (skilled nursing facility) and POS 32 (nursing facility) no longer pay identically under CY2026 rules. Confirm the exact per-POS figure via the CMS Physician Fee Schedule Look-Up Tool.

Pabau’s claims management software and digital forms help NF care providers document MDM complexity correctly, flag coding mismatches before submission, and track RVU productivity across nursing facility visits.

CPT Code 99307 is a subsequent nursing facility care E/M code, billed when a physician or other qualified healthcare professional performs a medically appropriate history and/or exam with straightforward medical decision making (MDM). It is the lowest-complexity tier in the 99307-99310 code family.

Bill one level up without documentation to support it and the claim carries upcoding risk. Bill 99307 when the note documents higher complexity, and the practice leaves reimbursement on the table.

This guide covers the official descriptor, MDM thresholds, documentation checklist, 2026 Medicare reimbursement rates, RVUs, ICD-10 crosswalk, and billing guidelines for CPT Code 99307, including how it fits within the 99307-99310 range and the full 99304-99318 nursing facility care family.

CPT Code 99307: Official description and key details

According to the American Medical Association (AMA), which owns and publishes the CPT code set, CPT Code 99307 describes a subsequent nursing facility care service in which the physician or other qualified healthcare professional (QHP) performs a medically appropriate history and/or physical examination with straightforward medical decision making.

It is an Evaluation and Management (E/M) code used exclusively for patients who are already residents of a nursing facility and who have been seen there at least once before. It does not apply to the initial admission assessment (99304-99306) or the annual reassessment (99318).

The 2023 AMA E/M guideline revisions, which extended the 2021 office-visit changes to nursing facility codes, eliminated the requirement to document a specific history and examination level. The medically appropriate history and exam is now at the clinician’s discretion, and MDM complexity alone determines which subsequent NF care code applies.

Medical decision making requirements for CPT Code 99307

Straightforward MDM, as defined by the AMA 2023 E/M guidelines, requires that the clinician address a minimal number of problems, review minimal data, and face minimal risk of complications or morbidity. In practice, a typical straightforward NF visit involves one stable chronic condition being monitored without any active management change.

The table below compares all four subsequent nursing facility care codes by MDM level, which is the sole distinguishing criterion since 2023.

*These figures are blended national averages and should be treated as rough approximations only. Under the CY2026 Medicare Physician Fee Schedule final rule, the practice-expense RVU methodology changed so POS 31 (skilled nursing facility) and POS 32 (nursing facility) no longer receive identical payment.

POS 31 is reimbursed at the lower facility-adjusted practice-expense rate, while POS 32 is reimbursed at the higher non-facility-adjusted rate, so the two place-of-service codes are no longer interchangeable for payment purposes.

Pull the exact per-code, per-POS payment amount from the CY2026 PFS final rule Addendum B or the CMS Physician Fee Schedule Look-Up Tool before billing, rather than relying on the blended figures above.

Documentation requirements for CPT Code 99307

Inadequate documentation is the leading cause of 99307 audits and downcodes. The medical record must support the MDM level selected. Standardizing medical forms ensures each NF visit note captures the required elements before the claim leaves the building.

The following elements are required for a defensible 99307 claim:

• Date of service and place of service (POS 32 or 31)
• Provider identity and credentials (name, NPI, specialty)
• Chief complaint or reason for visit (medically appropriate history)
• Relevant physical examination findings (at the clinician’s clinical discretion)
• MDM documentation specifically supporting the “straightforward” level: problem(s) addressed, data reviewed, and risk of complications
• Assessment and plan that is consistent with the MDM recorded
• Provider signature (electronic or wet ink)

A note that documents two chronic conditions with an active medication change will not support 99307. That scenario meets low-complexity MDM and belongs under 99308. Matching the note content to the code is not optional. Payers cross-reference MDM documentation against the billed code during claims review. Using digital forms with structured MDM fields reduces the risk of underdocumented or mismatched claims.

CPT Code 99307 vs 99308 vs 99309 vs 99310: Key differences

The 99307-99310 range covers all subsequent nursing facility visits. Each code maps to one MDM complexity level. There is no overlap. The most common billing error is using 99307 as a default code for routine visits rather than selecting the code the documented MDM supports.

Beyond MDM level and payment rate, the four codes share the same documentation structure, the same eligible provider types, and the same place-of-service rules. The only functional difference is the clinical complexity threshold. A clear grasp of medical decision making is what separates a defensible 99307 claim from an audit flag.

How to distinguish 99307 from 99308 in practice

The boundary between 99307 (straightforward) and 99308 (low complexity) is where most upcoding scrutiny falls. Low complexity requires at least two of the following:

• Two or more stable chronic conditions
• An undiagnosed new problem with uncertain prognosis
• A prescription drug management decision

If only one stable chronic condition is addressed with no management change, 99307 is correct. If the clinician adjusts a medication for that condition, the visit crosses into low complexity.

How CPT 99307 relates to initial nursing facility care codes (99304-99306)

The full nursing facility E/M code family spans 99304-99318. Understanding where 99307 sits within this range prevents billing the wrong category entirely, which is a common error when a patient transfers facilities or returns from a hospital stay.

A patient returning from a hospital stay and readmitted to the same nursing facility requires a new initial care code (99304-99306), not 99307. The subsequent care codes apply only once the patient is established in the facility following that admission assessment.

Good patient care management workflows prevent this category error by flagging readmission events in the scheduling system before the visit note is created. A standardized family medical history form keeps that initial comprehensive assessment consistent across admissions.

Medicare reimbursement rate for CPT Code 99307 (2026)

Medicare is the dominant payer for nursing facility services. The 2026 national blended average payment for CPT Code 99307 is approximately $42 per visit, but this blended figure no longer reflects how Medicare pays the code under CY2026 rules.

Under the CY2026 Medicare Physician Fee Schedule final rule, the practice-expense RVU methodology now pays POS 31 (skilled nursing facility) and POS 32 (nursing facility) differently. POS 31 receives the lower facility-adjusted practice-expense rate, and POS 32 receives the higher non-facility-adjusted rate.

Treat the $42 blended figure as a rough approximation only. Confirm the exact per-POS payment for your locality using the CY2026 PFS final rule Addendum B or the CMS Physician Fee Schedule Look-Up Tool.

Relative value units (RVUs) for CPT 99307

RVUs translate directly into payment. The formula is: Total RVU x Geographic Practice Cost Index (GPCI) x Conversion Factor. For 2026, the Medicare conversion factor is approximately $33.40 for clinicians not participating in an Advanced Alternative Payment Model (APM), and approximately $33.57 for qualifying APM participants.

Use the FastRVU 2026 lookup tool to pull the current work, practice expense, and malpractice RVU components for 99307 by locality.

These RVU values are approximate and blended for illustration only. Under CY2026 rules, the practice-expense RVU (and therefore the total RVU) now varies by place of service, since POS 31 uses the lower facility-adjusted practice-expense rate and POS 32 uses the higher non-facility-adjusted rate.

Verify the exact, POS-specific RVU components against the CMS Physician Fee Schedule Addendum B or the Physician Fee Schedule Look-Up Tool for your specific locality and provider type.

Federally mandated nursing facility visit requirements for CPT Code 99307

CMS requires that physicians (or their authorized NPP designees) visit nursing facility patients on a federally mandated schedule. These mandated visits are billable under CPT Code 99307 through 99310 depending on the MDM documented. The mandate matters most for physicians who split time between a direct primary care panel and nursing facility rounds, where a missed mandated visit is both a compliance problem and a lost billing opportunity.

Under CMS Medicare Claims Processing Manual (Pub 100-04) Transmittal R808CP, the mandatory visit schedule for nursing facility patients is:

• First 90 days of a nursing facility stay: At least one physician visit every 30 days
• After the first 90 days: At least one physician visit every 60 days
• Alternating visits permitted: After the first required visit, non-physician practitioners (NPs, PAs) may alternate with the physician on subsequent mandated visits

Each mandated visit must generate a compliant note. 99307 is appropriate when the mandated check-in involves stable, low-acuity monitoring with no management changes. Practices using HIPAA-compliant documentation practices in their NF workflows can schedule and document these mandatory visits consistently and avoid missed encounters. The HIPAA compliance checklist outlines the documentation standards that apply to these mandated encounters.

ICD-10-CM codes commonly billed with CPT Code 99307

CPT Code 99307 requires a supporting ICD-10-CM diagnosis code on every claim. The diagnosis code must reflect the condition addressed during the visit, not a general “nursing facility” status. Payers cross-reference the diagnosis against the MDM level and the clinical scenario documented in the note. Using AAPC’s CPT code reference alongside CMS ICD-10 guidance helps coders confirm current FY2026 code validity before submission.

Note the J44.1 example above: a COPD exacerbation typically raises MDM to moderate complexity, which belongs under 99309. Pairing J44.1 with 99307 on the same claim creates a clinical inconsistency that triggers payer review.

By contrast, the stable E11.9 diabetes scenario above supports 99307 only while glucose control stays on the established regimen. Sharing a structured diabetes diet plan with the care team helps keep that “no regimen adjustment” finding accurate.

Billing guidelines and common errors for CPT Code 99307

CMS and commercial payers apply specific rules when processing 99307 claims. Violating any of these creates denials, audits, or repayment demands. Practices implementing a paperless HIPAA-compliant practice workflow catch these issues at the point of documentation rather than during post-submission audit.

• One code per day per provider: Only one subsequent NF care code (99307-99310) may be billed per day by the same provider for the same patient, regardless of visit duration.
• Do not upcode to 99308 as a default: 99307 is not a “starter” code to avoid. It is the clinically correct code when MDM is genuinely straightforward. Routinely billing 99308 for all NF visits is an OIG audit flag.
• Modifier -25 for same-day procedures: If a separate E/M service is medically necessary on the same day as a procedure, append modifier -25 to 99307 to indicate a significant, separately identifiable service.
• Telehealth with modifier -95 or -GT: Some payers allow 99307 via telehealth for established nursing facility patients. Append modifier -95 (synchronous telemedicine) or -GT per payer-specific policy.
• Split/shared visit rules: When a physician and an NP or PA both contribute to the same NF visit, the supervising physician must review and contribute to the final note, and the claim should reflect the provider who performed the substantive portion of the visit.
• Incident-to billing does not apply in NF settings: Incident-to rules that apply in office settings do not extend to nursing facility care. NPPs must bill under their own NPI in this setting, which also means they receive 85% of the physician fee schedule rate under Medicare — there is no incident-to exception in this setting.

Modifier reference for CPT 99307

Who can bill CPT Code 99307?

CPT Code 99307 may be billed by any qualified healthcare professional with recognized scope of practice for nursing facility E/M services. Many of these clinicians also run a GP clinic panel alongside their NF rounds, so their billing workflow needs to handle both settings. Eligible provider types under CMS include:

• Medical Doctors (MD) and Doctors of Osteopathy (DO)
• Nurse Practitioners (NP) billing under their own NPI (85% of physician rate under Medicare)
• Physician Assistants (PA) billing under their own NPI (85% rate)
• Clinical Nurse Specialists (CNS) with appropriate state scope authorization

NPs and PAs can bill 99307 independently in nursing facility settings, but incident-to rules do not apply here. Each NPP bills under their own NPI.

State-specific scope-of-practice rules determine whether an NP or PA can practice independently in a nursing facility without a supervising physician agreement. These rules vary by state and should be verified against current state law before establishing a billing model.

Knowing the practice management vs EMR difference helps practices structure their billing workflows correctly by provider type from the outset. The nurse practitioner private practice guide covers NP billing authority rules in more detail for practices building out their NF care teams.

Automate your nursing facility billing workflow

Pabau helps NF care providers document MDM complexity correctly, match ICD-10 codes to visit notes, and track RVU productivity across all providers – so your 99307-99310 claims go out clean the first time.

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How practice management software supports accurate 99307 billing

Billing CPT Code 99307 accurately at scale, across dozens of NF patients seen weekly, requires more than coding knowledge. It requires systems that flag MDM mismatches before submission, enforce documentation completeness, and surface productivity data by provider.

Pabau’s claims management software gives NF care practices structured claim workflows that keep what is documented aligned with what is billed. Structured client records with templated MDM fields mean each subsequent NF visit note captures the problem list, data reviewed, and risk level before the provider signs off.

Combined with automated billing workflows, the system can route flagged claims for review before submission rather than after a denial arrives.

Practice managers overseeing multi-provider NF rosters can use practice management software reporting to track RVU productivity by provider, identify patterns of undercoding (e.g., a provider billing 99307 for every visit regardless of clinical complexity), and build the audit trail that protects the practice during payer review. Going paperless accelerates this by ensuring NF visit notes are structured, searchable, and tied to the billed code at the claim level.

Conclusion

CPT Code 99307 is the right code when the visit, the note, and the MDM all point to straightforward complexity. Getting it wrong in either direction, whether undercoding 99309 visits as 99307 or defaulting to 99307 for all NF checks, costs the practice money or creates audit exposure. The fix is simple in principle: document what happened, then select the code the note supports.

Pabau’s claims management platform helps nursing facility care teams connect clinical documentation to correct code selection, with structured MDM templates, claim pre-submission review, and RVU tracking built in. To see how Pabau supports NF billing workflows, explore the claims management feature or speak with the team.

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Frequently Asked Questions