CPT code 99204: Office visit, new patient, moderate complexity2026 Medicare rate & RVUs in Texas
Office or outpatient visit for a new patient reported for moderate medical decision making or at least 45 minutes of practitioner time on the visit date.
Medicare pays $169.36–$181.40 for 99204 in the office in Texas, from Beaumont, TX to Austin, TX. Which amount applies depends on the service address.
Medicare allowed amount for participating (non-QP) physicians, before deductible, coinsurance and claim adjustments. Not a patient’s bill or a hospital charge.
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On this page 9 sections
What 99204 covers
This office or outpatient visit is for a patient who has not received professional services from the practitioner, or another practitioner of the same specialty and subspecialty in the same group, within the past three years. Physicians, nurse practitioners, and physician assistants may perform it in offices, clinics, and hospital outpatient departments. The history and examination should be medically appropriate but do not determine the visit level. Two stable chronic illnesses, a chronic illness with exacerbation, or an undiagnosed new problem with uncertain prognosis may establish the moderate problems element; prescription drug management may establish the moderate risk element.
Select 99204 by moderate medical decision making, which requires two of the three MDM elements at the moderate level, or by at least 45 minutes of practitioner time on the encounter date. Count qualifying face-to-face and non-face-to-face work, such as reviewing outside records, ordering tests, and documenting. Exclude clinical staff time and time spent on separately reported services. If selecting by time and the 99205 threshold of 60 minutes is met, report 99205 instead. Document the supporting MDM elements or total time and activities performed.
This summary was written with AI assistance from CMS physician fee schedule data and checked against the CMS billing rules shown here. Rates on this page come directly from CMS files.
Billing guides for 99204: G2211 add-on code
Where 99204 pays more and less in Texas
The same RVUs, adjusted for each area’s costs. Open a locality for its calculation, history and nearby areas.
8 payment localities
$169.36 to $181.40
8 of 8 payment localities
| Payment locality | Office | Facility |
|---|---|---|
| Austin, TX | $181.40 | $117.44 |
| Beaumont, TX | $169.36 | $114.35 |
| Brazoria, TX | $175.55 | $115.64 |
| Dallas, TX | $176.67 | $116.46 |
| Fort Worth, TX | $175.95 | $116.34 |
| Galveston, TX | $176.10 | $116.06 |
| Houston, TX | $180.49 | $120.46 |
| Rest of Texas | $172.37 | $115.00 |
How the 99204 rate is calculated
Each of 99204’s three RVUs is multiplied by a geographic index (GPCI) for the payment locality, added up, and multiplied by the conversion factor. Drag the indexes or enter a ZIP to see what moves the rate.
How the rate is built · 99204
RVUs × geographic indexes × conversion factor
Work2.60
2.60 RVUs× 1.000 GPCI
Practice expense2.47
2.47 RVUs× 1.000 GPCI
Malpractice0.24
0.24 RVUs× 1.000 GPCI
Adjusted RVUs
5.3100
Conversion factor
$33.4009
Medicare rate
$177.36
Every GPCI starts at 1.000, the national rate. Enter a ZIP or drag a slider.
Payment rules and modifiers for 99204
99204 has no global surgery period, no multiple-procedure, bilateral or assistant-at-surgery adjustment, and no professional/technical split. What changes the payment is where the service happens: the place of service on the claim decides whether Medicare pays the office or the facility rate. Billing it with a same-day procedure? See modifier 25.
Place of service · 99204
Which rate does Medicare pay?
The POS code on the claim line (CMS-1500 box 24B).
POS 11 · non-facility rate · national
$177.36
- Non-facility (office)
- $177.36
- Facility
- $116.90
Higher because the practice carries its own overhead.
99204 compared with similar codes
Compare codes · National
5 codes, side by side
How to choose
- 99214Office visitEstablished patient, moderate complexity
- Both permit selection by moderate MDM. Use 99214 for an established patient or 99204 for a new patient; their respective time thresholds are 30 and 45 minutes.
- 99205Office visitNew patient, high complexity
- 99205 is selected for high MDM or, when selecting by time, at least 60 minutes. Use 99204 for moderate MDM or when its 45-minute time threshold is the highest one met.
- 99244Office consultationModerate level
- 99244 is an office consultation that may involve a new or established patient. Medicare does not pay it; for a new Medicare patient, choose 99204 only if the MDM or time supports that level.
- 99203New patient visitLow MDM or 30 minutes
- 99203 fits low MDM or a 30-minute time threshold. Multiple stable chronic illnesses or prescription drug management can establish one moderate MDM element; 99204 requires two moderate elements when selected by MDM.
99204 billing questions
When should 99204 be chosen over 99203 or 99205?
Choose 99204 for moderate MDM or at least 45 minutes when selecting by time. The corresponding thresholds are low MDM or 30 minutes for 99203, and high MDM or 60 minutes for 99205.
Can prolonged service time be added to 99204?
No. For Medicare office and outpatient E/M, G2212 pairs with 99205 only when its prolonged-time requirements are met; it cannot be reported with 99204.
What makes a patient new for this code?
The patient must not have received a professional face-to-face service from the same practitioner or a same-specialty, same-subspecialty colleague in the same group within the prior three years. A patient seen by a different specialty in the group can still be new.
Which modifier applies if a procedure is done at the same visit?
Append modifier 25 when the visit is significant and separately identifiable from a same-day procedure. Use modifier 57 when the visit results in the decision for major surgery.
Can G2211 be reported with 99204 for Medicare?
Yes, when the practitioner is the continuing focal point for the patient's care or provides ongoing care for a serious or complex condition. It generally cannot be reported with a modifier 25 visit, with limited exceptions for certain Medicare preventive services.
Does Medicare accept consult code 99244 instead of 99204?
Medicare does not pay office consultation codes. Report an appropriate office or outpatient visit code instead; choose 99204 only when the patient is new and the MDM or time supports that level.
99204 is in these specialty bundles: Primary care
Where these rates come from
FeeBase calculates base physician payments from CMS work, practice-expense and malpractice RVUs, adjusted by each locality’s geographic indexes and the conversion factor. Services without a published rate are labeled, never given a made-up amount. Amounts are Medicare allowed amounts before claim adjustments: not a patient’s bill or a commercial rate.
CMS RVU26D · effective Oct 1, 2026 through the day before Jan 1, 2027
Show the CMS file lines behind this rate
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