CPT code 99214: Office visit, established patient, moderate complexity2026 Medicare rate & RVUs in Massachusetts
Office or outpatient visit for an established patient that requires moderate medical decision making or at least 30 minutes of total practitioner time on the visit date.
Medicare pays $139.22–$150.68 for 99214 in the office in Massachusetts, from Rest of Massachusetts to Metropolitan Boston, MA. 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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What 99214 covers
This visit covers an established patient seen in an office or other outpatient setting for care involving moderate medical decision making. A patient is established when they received professional services from the same practitioner, or another of the same specialty and subspecialty in the same group, within the past three years. Moderate-level problems may include two stable chronic illnesses, such as hypertension and type 2 diabetes, a worsening chronic condition, or an undiagnosed problem with an uncertain prognosis. Another decision-making element must also reach the moderate level. Physicians, nurse practitioners, and physician assistants report these visits in primary care and specialty clinics. CMS ranks this code first among priced codes by Medicare service volume.
Select the level by medical decision making or time. Moderate decision making requires two of three elements: problems addressed, data reviewed or ordered, and risk of management. For time, document at least 30 minutes of the billing practitioner's total time on the visit date, including personally performed non-face-to-face work such as reviewing results and documenting, but excluding clinical staff time and separately billed services. Work RVUs make up 47% of the office total; practice expense is lower in a facility setting.
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 99214: G2211 add-on code
Where 99214 pays more and less in Massachusetts
| Payment locality | Office | Facility |
|---|---|---|
| Metropolitan Boston, MA | $150.68 | $89.66 |
| Rest of Massachusetts | $139.22 | $85.41 |
How the 99214 rate is calculated
Each of 99214’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 · 99214
RVUs × geographic indexes × conversion factor
Work1.92
1.92 RVUs× 1.000 GPCI
Practice expense2.00
2.00 RVUs× 1.000 GPCI
Malpractice0.14
0.14 RVUs× 1.000 GPCI
Adjusted RVUs
4.0600
Conversion factor
$33.4009
Medicare rate
$135.61
Every GPCI starts at 1.000, the national rate. Enter a ZIP or drag a slider.
Payment rules and modifiers for 99214
99214 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 · 99214
Which rate does Medicare pay?
The POS code on the claim line (CMS-1500 box 24B).
POS 11 · non-facility rate · national
$135.61
- Non-facility (office)
- $135.61
- Facility
- $84.50
Higher because the practice carries its own overhead.
99214 compared with similar codes
Compare codes · National
5 codes, side by side
How to choose
- 99213Office visitEstablished patient, low complexity
- 99213 fits low decision making or at least 20 minutes. 99214 requires two moderate decision-making elements, potentially including problems such as two stable chronic illnesses, or at least 30 minutes.
- 99215Office visitEstablished patient, high complexity
- 99215 requires two high decision-making elements or at least 40 minutes. A severe exacerbation or a hospitalization decision can contribute to high decision making but does not establish the level alone.
- 99204Office visitNew patient, moderate complexity
- 99204 is for a new patient and requires moderate decision making or at least 45 minutes. New-patient status depends on professional services received from the practitioner or another of the same specialty and subspecialty in the group within three years.
- 99232Subsequent hospital visitModerate MDM or 35 minutes
- 99232 applies to subsequent hospital inpatient or observation care. 99214 is for an established patient's office or outpatient clinic visit rather than inpatient or observation care.
99214 billing questions
How do I decide between 99214 and 99213?
Choose 99214 when two decision-making elements reach moderate or total practitioner time reaches 30 minutes. Choose 99213 for low decision making or at least 20 minutes when the 30-minute threshold is not met.
What activities count toward the 30 minutes?
Count the billing physician's or qualified practitioner's time on the encounter date, including preparing to see the patient, taking a history and performing an exam, counseling, ordering tests, care coordination, and documentation. Exclude clinical staff time and time spent on separately reported services.
Does prescription drug management alone support 99214?
Prescription drug management meets moderate risk, which is one of the three elements. A second element, such as problems addressed, must also meet the moderate level.
When is modifier 25 needed?
Append modifier 25 when a significant, separately identifiable visit occurs on the same day as a minor procedure, such as a joint injection or skin lesion removal. Document visit work beyond the assessment normally included in that procedure.
Can G2211 be added to 99214 for Medicare patients?
Yes, Medicare allows the G2211 add-on with office and outpatient visits when the practitioner serves as the continuing focal point for the patient's care or provides ongoing care for a serious or complex condition.
Does the history and exam determine the level?
No. Document a medically appropriate history and exam; select the visit level by medical decision making or total time.
99214 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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