Home or residence visit for a new patient that requires high medical decision making or at least 75 minutes of total time.

3 sources ↓

Medicare: $210.09
Work RVU: 3.88
Global, days
Region: General

Drawn from CMS

Documentation requirements

What must appear in the operative or office note to support the claim.

Source · Editorial brief grounded in 3 cited references ↓

Place of residence (home, assisted living, group home) and matching place of service code
Reason for seeing the patient at the residence (not a Medicare requirement, but payers and auditors ask)
History and exam relevant to the complaint
Assessment and plan supporting high MDM, or at least 75 minutes of total time
Coordination with home health or caregivers, if any

Applicable modifiers

Modifiers commonly billed with this code.

Source · AMA CPT modifier descriptors · CMS NCCI Policy Manual

25 Significant separate E/M 24 Unrelated E/M during global 57 Decision for surgery

What this code covers

Source · Editorial summary grounded in 3 cited references ↓

99345 reports a visit to a new patient at their home or residence, including assisted living and group homes, with high decision making or at least 75 minutes of total time. Since 2023 the home and domiciliary codes are combined, so the same codes are used for a private home and an assisted living facility.

High MDM at home is unusual in ortho. It fits a frail patient with a new, serious problem, for example a suspected hip fracture where the visit leads to a decision about hospital transfer and surgery.

Medicare does not require homebound status. Bill place of service 12, 13, or 14 to match a private home, assisted living, or group home. Nursing facility residents go to the nursing facility codes instead. Any visit tied to surgery still inside its global is included in the surgical payment.

RVU & reimbursement

Component RVUs and Medicare national rate. Actual payment varies by GPCI locality.

Source · CMS Physician Fee Schedule, RVU26A · January 2026

Work RVU vs. total RVU

The work RVU (3.88) is the surgeon's own effort — the figure physician pay and productivity targets are built on. The total RVU (6.29) adds practice overhead and malpractice, and is what drives the Medicare payment below.

Work RVU	3.88
Practice expense RVU	2.16
Malpractice RVU	0.25
Total RVU	6.29
Medicare national rate	$210.09
Global period	days

Payment by site of service

Medicare pays different rates by setting. HOPD typically pays substantially more than ASC for the same procedure.

Source · CMS OPPS Addendum B·ASC HCPCS payment rates·2026

Setting	Medicare rate (national)
Office (PFS non-facility) Procedure performed in physician's office	$210.09

Common denial reasons

The recurring reasons claims for CPT 99345 get rejected.

Source · Editorial brief grounded in CMS NCCI edits, AAOS coding appeals, and cited references ↓

Place of service does not match a home or residence setting
Postop visit inside a surgical global period
MDM or time does not support the level billed
New patient code used for a patient seen in the office within three years

Frequently asked questions

Source · Generated from the editorial pipeline, verified against 3 cited references ↓

01When is 99345 appropriate?

When a new patient visit at home involves high-risk decisions, such as whether to hospitalize, or total time is at least 75 minutes.

02Can 99345 be billed with modifier 57?

Yes, if this visit is where the decision for major surgery is made on the day of or day before surgery.

03Can prolonged time be added to 99345?

Under CPT, 99417 can be added once time passes the 99345 threshold by at least 15 minutes. Medicare does not accept 99417 and uses its own HCPCS G code for prolonged home visits with a later time threshold, so check the current CMS rules before billing.