CPT® code 99342 is used to report an evaluation and management (E/M) service provided to a new patient in a domiciliary, rest home, or custodial care facility. This code represents a moderate-complexity visit involving a detailed history and examination, along with moderately complex medical decision-making. It applies when a provider delivers care in a non-hospital residential setting, such as an assisted living facility or group home.
When to Use CPT® Code 99342
Report 99342 when:
- The visit occurs in a domiciliary, rest home, or custodial care environment.
- The patient is new (not previously seen by the provider or within the same group practice).
- The provider performs a detailed history and examination with medical decision-making of moderate complexity.
- The service includes management of one or more chronic conditions, medication review, or coordination of care.
- If the medical decision-making is of lower or higher complexity, use CPT® 99341 (straightforward/low) or 99343–99345 (moderate to high complexity for new patients) as appropriate.
Documentation Requirements
To support billing for 99342, documentation must include:
- Location of the service (e.g., assisted living, group home)
- Reason for the encounter and chief complaint
- Detailed history and physical examination findings
- Assessment of current medical conditions and related functional concerns
- Moderate-complexity medical decision-making (number and complexity of problems, amount of data reviewed, and risk of complications)
- Care plan and follow-up instructions
- Provider credentials, date, and signature
If counseling or coordination of care dominates the encounter (more than 50% of total time), time-based documentation may also be used
Billing Guidelines
- 99342 is used only for new patients in domiciliary or custodial settings—not for hospital care.
- It may be billed once per day, per patient, even if multiple providers are involved.
- The code includes both face-to-face and non-face-to-face work performed on the date of service.
- Use place of service (POS) codes 13 (assisted living facility) or 33 (custodial care facility) as applicable.
- Verify payer-specific documentation requirements for E/M complexity and visit frequency.
Example
A nurse practitioner visits a new patient in an assisted living facility to manage hypertension and type 2 diabetes. The provider conducts a detailed exam, reviews lab results, adjusts medication, and coordinates care with the patient’s dietitian. The encounter involves moderate-complexity decision-making and is billed under CPT® code 99342.
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