localis
Calculator

Describe a service in plain words, or type a CPT/HCPCS code.

Long New Patient Office Visit

CPT 99204

Also known as New patient office visit

A patient's first visit with this clinician, covering a full history and examination and an initial plan, usually for someone bringing more than one concern. Medicare reported 12.7 million services under this code in CY2024.

Plain-language context only — not the official CPT descriptor and not coding guidance

$167.10
in a doctor’s own office or clinic
$153.09–$213.00 across payment localities

Nationally priced under PFS, using the RVU formula.

This is the national Q3 2024 rate, before the ~2% sequestration cut · full calculator

How much did Medicare pay for CPT 99204 in Q3 2024? Copy link

Medicare paid $167.10 for CPT 99204 in the office (non-facility) setting and $132.15 in a facility under the Q3 2024 Physician Fee Schedule, effective July 2024. These are the national allowed amounts before the ~2% sequestration cut and before locality (GPCI) adjustment. Across payment localities, the office amount is $153.09–$213.00 and the facility amount is $123.03–$175.21. This price has been unchanged since Q1 2024, when it decreased 0.2%.

Source: Physician relative value file (Q3 2024) · effective July 2024 · materially updated Aug 13, 2026 · compact facts

Why this amount?

  • Status A (Active): Medicare calculates a national payment amount for this code and pays it separately when the service is covered.
  • Q3 2024 conversion factor: $33.2875.
  • National baseline uses GPCI 1.000 — enter a ZIP for your locality's payable amount.

CMS evidence · 2 sources

Open evidence
Physician relative value file (Q3 2024) · rvu24c-updated-09-09-2024.zip (PPRRVU24_JUL.csv row 18,503)

See full source & method below

Rates by locality Copy link

The amounts above use GPCI 1.000, a national baseline no locality actually bills at. Medicare rescales every code by the local Geographic Practice Cost Indices before paying it, so what 99204 pays depends on where the service is furnished. Tap a state for its localities.

Maine: $157.99–$165.23 across 2 localities ME Wisconsin: $158.64 WI Vermont: $162.74 VT New Hampshire: $168.76 NH Montana: $166.93 MT North Dakota: $163.24 ND Minnesota: $163.33 MN Michigan: $162.03–$172.08 across 2 localities MI New York: $161.26–$194.52 across 5 localities NY Massachusetts: $171.37–$184.19 across 2 localities MA Rhode Island: $170.89 RI Washington: $169.04–$185.62 across 2 localities WA Idaho: $156.12 ID Wyoming: $165.02 WY South Dakota: $162.17 SD Iowa: $156.45 IA Illinois: $163.76–$177.51 across 4 localities IL Indiana: $157.33 IN Ohio: $160.91 OH Pennsylvania: $161.21–$174.44 across 2 localities PA New Jersey: $178.98–$185.38 across 2 localities NJ Connecticut: $177.26 CT Oregon: $163.24–$173.21 across 2 localities OR Nevada: $165.86 NV Utah: $161.68 UT Colorado: $170.26 CO Nebraska: $155.52 NE Missouri: $156.66–$163.57 across 3 localities MO Kentucky: $157.48 KY West Virginia: $159.75 WV Virginia: $164.16 VA Maryland: $169.09–$176.96 across 2 localities MD Delaware: $166.89 DE California: $171.55–$203.81 across 29 localities CA Arizona: $164.12 AZ New Mexico: $161.80 NM Kansas: $156.61 KS Oklahoma: $157.70 OK Arkansas: $153.09 AR Tennessee: $155.91 TN North Carolina: $159.06 NC South Carolina: $159.33 SC District of Columbia: $187.31 DC Texas: $159.64–$171.80 across 8 localities TX Louisiana: $158.32–$163.63 across 2 localities LA Mississippi: $154.51 MS Alabama: $154.20 AL Georgia: $159.61–$167.91 across 2 localities GA Florida: $166.48–$181.05 across 3 localities FL Alaska: $213.00 AK Hawaii: $174.41 HI
$153–$163 $163–$173 $173–$183 $183–$193 $193–$203 $203–$213

Highest-paying locality

$213.00

AK flag Alaska, AK

Lowest-paying locality

$153.09

AR flag Arkansas, AR

99204 non-facility rate by metro area

Highest-paying metro first. Each figure is that payment locality's own GPCI-adjusted amount.

San Jose, CA flag San Jose, CA $202.69 San Francisco, CA flag San Francisco, CA $200.69 Long Island, NY flag Long Island, NY $194.52 Queens, NY flag Queens, NY $190.57 New York City, NY flag New York City, NY $190.02 Washington, DC flag Washington, DC $187.31 Seattle, WA flag Seattle, WA $185.62 Northern New Jersey, NJ flag Northern New Jersey, NJ $185.38 Boston, MA flag Boston, MA $184.19 Los Angeles, CA flag Los Angeles, CA $182.34 Miami, FL flag Miami, FL $181.05 San Diego, CA flag San Diego, CA $179.97 Sacramento, CA flag Sacramento, CA $177.85 Chicago, IL flag Chicago, IL $177.51 Baltimore, MD flag Baltimore, MD $176.96 Suburban Chicago, IL flag Suburban Chicago, IL $175.63 Philadelphia, PA flag Philadelphia, PA $174.44 Riverside, CA flag Riverside, CA $174.20 Portland, OR flag Portland, OR $173.21 Fort Lauderdale, FL flag Fort Lauderdale, FL $173.11 Detroit, MI flag Detroit, MI $172.08 Houston, TX flag Houston, TX $171.80 Austin, TX flag Austin, TX $169.75 Atlanta, GA flag Atlanta, GA $167.91 Dallas, TX flag Dallas, TX $167.58 Fort Worth, TX flag Fort Worth, TX $167.13 New Orleans, LA flag New Orleans, LA $163.63 St. Louis, MO flag St. Louis, MO $163.57 Kansas City, MO flag Kansas City, MO $163.27
Maine: $126.08–$129.85 across 2 localities ME Wisconsin: $125.19 WI Vermont: $128.04 VT New Hampshire: $132.62 NH Montana: $131.98 MT North Dakota: $128.29 ND Minnesota: $127.50 MN Michigan: $130.19–$137.62 across 2 localities MI New York: $128.09–$152.58 across 5 localities NY Massachusetts: $134.29–$142.35 across 2 localities MA Rhode Island: $134.58 RI Washington: $132.69–$142.97 across 2 localities WA Idaho: $124.38 ID Wyoming: $130.07 WY South Dakota: $127.21 SD Iowa: $124.54 IA Illinois: $131.89–$141.76 across 4 localities IL Indiana: $125.10 IN Ohio: $129.07 OH Pennsylvania: $128.81–$137.64 across 2 localities PA New Jersey: $140.32–$144.42 across 2 localities NJ Connecticut: $139.13 CT Oregon: $128.77–$134.66 across 2 localities OR Nevada: $130.91 NV Utah: $129.07 UT Colorado: $133.46 CO Nebraska: $123.47 NE Missouri: $126.64–$130.30 across 3 localities MO Kentucky: $126.83 KY West Virginia: $129.62 WV Virginia: $129.77 VA Maryland: $133.58–$139.28 across 2 localities MD Delaware: $132.22 DE California: $133.35–$153.65 across 29 localities CA Arizona: $130.04 AZ New Mexico: $130.06 NM Kansas: $124.94 KS Oklahoma: $126.56 OK Arkansas: $123.03 AR Tennessee: $124.60 TN North Carolina: $126.69 NC South Carolina: $127.42 SC District of Columbia: $145.65 DC Texas: $128.08–$136.74 across 8 localities TX Louisiana: $127.53–$130.95 across 2 localities LA Mississippi: $124.73 MS Alabama: $123.83 AL Georgia: $128.75–$133.06 across 2 localities GA Florida: $133.63–$145.15 across 3 localities FL Alaska: $175.21 AK Hawaii: $134.25 HI
$123–$132 $132–$140 $140–$149 $149–$158 $158–$167 $167–$175

Highest-paying locality

$175.21

AK flag Alaska, AK

Lowest-paying locality

$123.03

AR flag Arkansas, AR

99204 facility rate by metro area

Highest-paying metro first. Each figure is that payment locality's own GPCI-adjusted amount.

Long Island, NY flag Long Island, NY $152.58 San Jose, CA flag San Jose, CA $152.53 San Francisco, CA flag San Francisco, CA $151.09 New York City, NY flag New York City, NY $149.26 Queens, NY flag Queens, NY $148.80 Washington, DC flag Washington, DC $145.65 Miami, FL flag Miami, FL $145.15 Northern New Jersey, NJ flag Northern New Jersey, NJ $144.42 Seattle, WA flag Seattle, WA $142.97 Boston, MA flag Boston, MA $142.35 Chicago, IL flag Chicago, IL $141.76 Los Angeles, CA flag Los Angeles, CA $140.61 Baltimore, MD flag Baltimore, MD $139.28 Suburban Chicago, IL flag Suburban Chicago, IL $139.00 San Diego, CA flag San Diego, CA $138.34 Fort Lauderdale, FL flag Fort Lauderdale, FL $138.23 Philadelphia, PA flag Philadelphia, PA $137.64 Detroit, MI flag Detroit, MI $137.62 Sacramento, CA flag Sacramento, CA $137.45 Houston, TX flag Houston, TX $136.74 Riverside, CA flag Riverside, CA $136.00 Portland, OR flag Portland, OR $134.66 Austin, TX flag Austin, TX $133.19 Atlanta, GA flag Atlanta, GA $133.06 Dallas, TX flag Dallas, TX $132.38 Fort Worth, TX flag Fort Worth, TX $132.25 New Orleans, LA flag New Orleans, LA $130.95 St. Louis, MO flag St. Louis, MO $130.30 Kansas City, MO flag Kansas City, MO $130.13

Look up your exact locality →

Q3 2024 amounts, computed with each locality's own GPCIs, before the ~2% sequestration cut. A state with more than one payment locality shows a range — its tile is colored by the mean across those localities, which is a shading choice, not an amount anyone is paid.

How this amount is computed Copy link

CPT 99204 has a work RVU of 2.60, a non-facility practice expense RVU of 2.18, a facility practice expense RVU of 1.13 and a malpractice RVU of 0.24 — for total non-facility RVUs of 5.02 and total facility RVUs of 3.97 in the Q3 2024 release.

amount = (work RVU × work GPCI + PE RVU × PE GPCI + MP RVU × MP GPCI) × conversion factor. National amounts use GPCI = 1.000. To price an RVU figure of your own, use the RVU-to-dollars converter.

Release Q3 2024
Component RVU
Work RVU 2.60
Practice expense RVU (non-facility) 2.18
Practice expense RVU (facility) 1.13
Malpractice RVU 0.24

Every rate combines three parts: work (the clinician’s time, skill and effort), practice expense (office overhead — higher when the service is done in a doctor’s own office), and malpractice (the share of liability-insurance cost). A blank means CMS publishes no national number for that part. Read it as unknown, and never as zero.

What does 99204 cost? Copy link

Four numbers get called the cost of a code. Each answers a different question.

Computed from the Q3 2024 CMS release

Medicare allowed amount

What Medicare recognizes as the full price for 99204 in the office (non-facility) setting. Every figure below derives from it.

$167.10
Medicare's share

80% of the allowed amount, before the ~2% sequestration cut.

$133.68
Patient coinsurance

The remaining 20%, once the annual Part B deductible is met. Medigap or Medicaid often covers it.

$33.42
Limiting charge

The ceiling a non-participating provider can bill a patient on an unassigned claim — 109.25% of the allowed amount.

$182.56

National Q3 2024 figures at GPCI 1.000. Adjust for your locality and sequestration, or see the questions below for each figure in full.

Common questions Copy link

Is $167.10 what a practice actually receives?

It's the national allowed amount — the starting point. Medicare pays 80% of it ($133.68) and the patient owes 20% coinsurance ($33.42). Sequestration trims Medicare's share by about 2%, your locality's GPCIs scale the total up or down, and the expected-payment calculator applies all three. What lands is practice revenue: staff, space, equipment and billing, not clinician take-home pay. The practice-expense RVU above is CMS's estimate of that overhead share.

Sources: Budget Control Act sequestration provisions; CMS Medicare Fee-for-Service payment guidance; CMS Geographic Practice Cost Index (GPCI) files; CMS Physician Fee Schedule overview (cms.gov).

Why are the facility and non-facility amounts different?

Only the practice-expense RVU changes with the setting. For 99204 it's 2.18 RVUs in the office versus 1.13 in a facility — the whole $34.95 gap between $167.10 and $132.15. In an office the practice bears the overhead, so Medicare pays more; in a hospital or ASC the facility bills its own fee, so the professional payment is lower. See facility vs non-facility.

Sources: CMS Medicare Physician Fee Schedule Relative Value Files; CMS Practice Expense methodology (cms.gov).

What's the non-participating amount for 99204?

$158.74 in the office (non-facility) setting — 95% of the $167.10 participating fee schedule amount above. A participating provider takes the fee schedule amount as payment in full on every claim. A non-participating provider is paid this reduced amount, but chooses claim by claim whether to accept assignment. See participating vs non-participating.

Sources: CMS Physician Fee Schedule overview (cms.gov); CMS Medicare Fee-for-Service payment guidance.

What's the limiting charge for 99204?

$182.56 in the office (non-facility) setting — the ceiling on what a non-participating provider can bill the patient on an unassigned claim. That's 109.25% of the $167.10 amount above. The non-participating amount is 95% of the fee schedule rate ($158.74), and the statutory cap is 115% of that. See limiting charge.

Sources: CMS Physician Fee Schedule overview (cms.gov); CMS Medicare Fee-for-Service payment guidance.

Why would a Medicare claim for 99204 be denied or paid less?

These come from CMS indicators on this page, not general billing advice.

Payer-specific coverage and documentation rules live outside these files, so a claim that clears every check here can still be denied on other grounds.

When does this rate change?

CMS publishes a fee schedule release every quarter (January, April, July, October), and each is versioned here. The 99204 rate last moved in Q1 2026 (+8.6% non-facility) — see its rate history or what changed each release, or get an email when a new release moves rates.

Sources: CMS Medicare Physician Fee Schedule Relative Value Files.

Payment rules

Applicable payment rules Copy link

Only the rules that can matter for 99204, each linking to its detail on this page.

Facility/non-facility Applies Professional/technical component Does not apply Bilateral adjustment Does not apply Multiple-procedure reduction Does not apply Assistant/co-surgeon treatment Does not apply Global surgery Does not apply NCCI same-day edits Not modeled MUE behavior Not modeled Other fee-schedule routing Does not apply Contractor pricing Does not apply

Modifier amounts: -26/TC, -50, -80/81/82, -AS, -62, -66 Copy link

National non-facility amounts for the modifiers this code's indicators support. Single-line modifiers only. -51 (multiple-procedure reduction) depends on the other codes on the same claim, so it's a claim-level number rather than a per-code one. Use the calculator for a locality-adjusted, sequestration-aware amount.

Modifier What it means Amount
-26/TC Professional/technical split Not payable
-50 Bilateral procedure Not payable
-80/81/82 Assistant surgeon (physician) Not payable
-AS Assistant at surgery (PA, NP, or CNS) Not payable
-62 Co-surgeons, each Not payable
-66 Team surgery Not payable

These apply standard MPFS percentages — assistant surgeon 16%, co-surgeon 62.5%, bilateral 150% — to the national non-facility amount above, so its source citation covers them too. They are derived here rather than read from a CMS column: check them against the current Medicare Claims Processing Manual before relying on them for payment.

Can you bill it with another code? Copy link

Enter a second CPT or HCPCS code billed on the same date of service. We'll check the current NCCI procedure-to-procedure edit between it and 99204.

See every current NCCI pair for 99204 →

History

Rate history by release Copy link

National non-facility amount for 99204 across quarterly releases. +6.7% increase since Q2 2014 · high $177.36 in Q1 2026

$177 $162 $147 $132 $117 Q2 2014 · $166.22 Q3 2014 · $166.22 (0.0%) Q4 2014 · $166.22 (0.0%) Q1 2015 · $165.90 (-0.2%) Q2 2015 · $165.90 (0.0%) Q3 2015 · $165.90 (0.0%) Q4 2015 · $166.73 (+0.5%) Q1 2016 · $166.13 (-0.4%) Q2 2016 · $166.13 (0.0%) Q3 2016 · $166.13 (0.0%) Q4 2016 · $166.13 (0.0%) Q1 2017 · $166.16 (0.0%) Q2 2017 · $166.16 (0.0%) Q3 2017 · $166.16 (0.0%) Q4 2017 · $166.16 (0.0%) Q1 2018 · $167.40 (+0.7%) Q2 2018 · $167.40 (0.0%) Q3 2018 · $167.40 (0.0%) Q4 2018 · $167.40 (0.0%) Q1 2019 · $166.86 (-0.3%) Q2 2019 · $166.86 (0.0%) Q3 2019 · $166.86 (0.0%) Q4 2019 · $166.86 (0.0%) Q1 2020 · $167.09 (+0.1%) Q2 2020 · $167.09 (0.0%) Q3 2020 · $167.09 (0.0%) Q4 2020 · $167.09 (0.0%) Q1 2021 · $169.93 (+1.7%) Q2 2021 · $169.93 (0.0%) Q3 2021 · $169.93 (0.0%) Q4 2021 · $169.93 (0.0%) Q1 2022 · $169.57 (-0.2%) Q2 2022 · $169.57 (0.0%) Q3 2022 · $169.57 (0.0%) Q4 2022 · $169.57 (0.0%) Q1 2023 · $167.40 (-1.3%) Q2 2023 · $167.40 (0.0%) Q3 2023 · $167.40 (0.0%) Q4 2023 · $167.40 (0.0%) Q1 2024 · $167.10 (-0.2%) Q2 2024 · $167.10 (0.0%) Q3 2024 · $167.10 (0.0%) Q4 2024 · $167.10 (0.0%) Q1 2025 · $163.35 (-2.2%) Q2 2025 · $163.35 (0.0%) Q3 2025 · $163.35 (0.0%) Q4 2025 · $163.35 (0.0%) Q1 2026 · $177.36 (+8.6%) Q2 2026 · $177.36 (0.0%) Q3 2026 · $177.36 (0.0%) Q2 2014 Q4 2016 Q2 2019 Q3 2021 Q1 2024 Q3 2026
Non-facility Facility
Release Status Non-facility Facility
Q3 2026 Jul 1, 2026 – present A $177.36 (0.0% no change ) $116.90 (0.0% no change )
Q1 2026 Jan 1, 2026 – Mar 31, 2026 A $177.36 (+8.6% increase ) $116.90 (-9.4% decrease )

Code and billing changes Copy link

The most relevant verified changes to this code and related Medicare billing policy.

Planned Full interactive timeline, two-date comparison, and an exportable citation packet.

Effective Jan 1, 2024

G2211 became separately payable

Medicare began paying G2211 in addition to qualifying office/outpatient E/M base visits, codes 99202-99205 and 99211-99215. At launch, G2211 was not payable when the base visit carried modifier 25.

Effective Jan 1, 2021

The 45-59 minute time range took effect

When time is used instead of medical decision making to select 99204, the applicable total-time range is 45-59 minutes on the encounter date.

1 verified change took effect after this release. View the current code history.

View all 5 changes, review scope, and source evidence

Beyond Medicare

Contracted rate: % of Medicare Copy link

Commercial payer contracts usually price off the Medicare amount above ("BCBS pays 115% of Medicare"). Enter your contract's percentage below to see what 99204 pays at that rate — $167.10 is 100%.

We want to build this: store your multipliers once, and every code page shows your rate instead of Medicare's. Tell us if you'd use it →

See how to find your contract's actual percentage.

Usage & related

How often 99204 is billed Copy link

Across Original Medicare in CY2024, 99204 ranked #11 of the 7,879 CPT codes billed to Medicare that year, by patients served or total allowed dollars.

Beneficiaries
9.4M
Office + facility patients combined
Services
12.7M
Times it was billed
Allowed
$2.0B
Total Medicare allowed dollars
Compare: ↑ #10 more popular · 80061 ↓ #12 less popular · 84443

2024 Medicare fee-for-service national totals. They exclude Medicare Advantage, Medicaid and commercial volume, so real-world use runs higher. This is a calendar-year snapshot from the CMS Physician & Other Practitioners dataset, on a different cycle from the Q3 2024 fee schedule above.

Did this answer your question about CPT 99204?

We're building this out in the open. Tell us what you were actually trying to work out and we'll either answer you directly or build the page that does.

Did this page answer your question?

Source & method

Show sources

This is computed from CMS's Medicare Physician Fee Schedule Q3 2024 release (schedule pfs, effective July 2024). National amounts apply a GPCI of 1.000 and leave sequestration off. The status indicator decides payability, never the RVU values, so a blank RVU stays blank. Releases are immutable: a rate retrieved for a past quarter always reflects that release. Modifier amounts apply standard MPFS percentages to this code's billing indicators. We derive them here rather than read them from CMS, so confirm them against the current Claims Processing Manual before relying on them for payment. Our methodology covers the depth: sourcing, parsing, versioning, and how we cross-check claims before they ship.

Physician relative value file (Q3 2024) · rvu24c-updated-09-09-2024.zip (PPRRVU24_JUL.csv row 18,503)

Conversion factor $33.2875 read from the same file, row 11, column 25.

Use the (i) buttons next to each amount above for the exact row, columns, and math.

Cite this rate

This link keeps pointing at the Q3 2024 figures, even after a newer release lands.

CPT 99204 Medicare Physician Fee Schedule rate: $167.10 (Q3 2024). Localis. https://localishealth.com/cpt/99204/2024/C