HCPCS G0104 Medicare rate in Q4 2022

Rates by locality Copy link

The national baseline uses GPCI 1.000. These locality-adjusted allowed amounts use each payment locality's own GPCIs. Select a state to see its localities.

Look up your exact locality →

Q4 2022 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

HCPCS G0104 has a work RVU of 0.84, a non-facility practice expense RVU of 4.72, a facility practice expense RVU of 0.69 and a malpractice RVU of 0.11—for total non-facility RVUs of 5.67 and total facility RVUs of 1.64 in the Q4 2022 release.

The formula is: (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.

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, never as zero.

Who’s billing it Copy link

The allowed amount depends on who bills the service: NPs and PAs get 85% of the fee schedule amount, social workers and counselors 75%. These are national Q4 2022 figures at GPCI 1.000.

There’s no CMS utilization data on file for G0104, so only the physician amounts are shown. Each percentage applies before the 80/20 split and sequestration.

Global period: what G0104's fee already covers Copy link

The fee covers pre-operative and post-operative work on the day of the procedure only—there is no follow-up window afterward. A visit the next day is separately payable.

A modifier reports what happened; it does not by itself make a service payable. Documentation has to support it.

Billing policy Copy link

These billing-policy indicators explain how G0104 is treated. They apply whether the code is nationally priced or carrier-priced: a restriction like "bilateral not allowed" still matters on a carrier-priced code. See modifier amounts below for the dollar figures these support.

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

National Office (non-facility) amounts for the modifiers this code's indicators support. These are 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.

Not payable with G0104: -26/TC (professional/technical split); -50 (bilateral procedure); -80/81/82 (assistant surgeon (physician)); -AS (assistant at surgery (PA, NP, or CNS)); -62 (co-surgeons, each); -66 (team surgery).

Each amount applies a standard MPFS percentage (assistant surgeon 16%, non-physician assistant at surgery 13.6%, co-surgeon 62.5%, bilateral 150%) to the national Office (non-facility) amount above. CMS doesn't publish these as a column; Localis derives them, so check them against the current Medicare Claims Processing Manual before relying on them for payment.

CMS RVU22D · October 1 – December 31, 2022 See file rows

Check a pair of codes 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 for the pair.

See every current NCCI pair for G0104 →

Payment review for G0104 Copy link

Four published payment rules can change what G0104 allows on a claim: the office/facility differential, the same-day global package, the standard multiple-procedure reduction and the assistant-at-surgery prohibition. Each is a legitimate reason for a paid amount to differ from the fee-schedule amount on this page.

Sources: CMS Medicare Physician Fee Schedule Relative Value Files; CMS Practice Expense methodology (cms.gov); CMS Medicare Claims Processing Manual (Pub. 100-04); 42 USC 1395w-4(i)(2) (SSA §1848(i)(2))—Assistants-at-surgery.

Rate history by release Copy link

National Office (non-facility) amount for G0104 across quarterly releases. +47.8% increase since Q1 2013 · peak $214.77 in Q1 2026

Why G0104's rate changed Copy link

National baseline (GPCI 1.000) · Office (non-facility) · Before sequestration

G0104's national amount rose $50.94 (+35.1%), from $145.28 in Q1 2013 to $196.22 in Q4 2022. Changes to the conversion factor, which CMS sets for every code, added $2.49. CMS revaluing G0104 itself added $48.45: +$53.64 from practice-expense RVUs, −$4.15 from work RVUs and −$1.04 from malpractice RVUs. The most recent change came in Q1 2022: +$0.82 (+0.4%), with +$2.43 from practice-expense RVUs and −$1.61 from the conversion factor.

CMS doesn't publish this split; we derive it from each release's RVUs and conversion factor. We apply the new conversion factor to the earlier RVUs first, then price each RVU change at the new conversion factor. Another order would move a few cents between columns, but every total stays the same.

Contracted rate: % of Medicare Copy link

Commercial contracts are often written as a percentage of Medicare ("115% of Medicare"). Enter yours to see what it means for G0104. A contract benchmarked to the fee schedule applies it to your locality's allowed amount, not the $196.22 national baseline; the calculator finds that amount from your service ZIP.

See how to find your contract's actual percentage.

How G0104 compares with other codes Copy link

Against every code with a national PFS amount in Q4 2022 · National baseline · Before sequestration

+245.7% Office over facility

G0104's Office amount is $139.47 more than its facility amount, because a facility bills its own overhead separately. Of the 7,260 codes priced in both settings, 1,981 have a higher Office amount. G0104's gap is larger than 84% of theirs; the median gap is +58.1%.

53.7% Highest vs. lowest locality

G0104's Office amount is 53.7% higher in its highest-paid payment locality than in its lowest. That spread is wider than 79% of the 7,221 codes compared; the median spread is 45.8%. How much a code's amount varies by locality depends on its mix of work, practice-expense and malpractice RVUs, since each has its own GPCI.

+35.1% Since Q1 2013

G0104's Office amount rose 35.1% from Q1 2013 to Q4 2022. Over the same period, the median code's amount rose 1.7%. That's higher than the change for 97% of the 6,507 codes priced in both releases.

These comparisons cover every code with a national Physician Fee Schedule amount: status A, R or T, with no blank RVUs. The locality comparison leaves out codes with an OPPS cap, because the cap, not the GPCIs, can set their amount in some localities.

Related codes Copy link

Codes near G0104 in the Medicare G-code services group, with their national Q4 2022 amounts at GPCI 1.000. A dash means the release publishes no payable PFS amount in that setting.

Localis groups these codes for payment research. The grouping isn't the AMA's code families.