Billing code 99204: Office visitMedicare rate & RVUs

Medicare pays $177.36 for 99204 nationally in the office and $116.90 in a hospital or facility. Local office rates run $161.84–$222.54.

Medicare allowed amount for participating (non-QP) physicians, before deductible, coinsurance and claim adjustments. Not a patient’s bill or a hospital charge.

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.

Where 99204 pays more and less

The same RVUs, adjusted for each area’s costs. Open a locality for its calculation, history and nearby areas.

109 of 109 payment localities

99204 rates by state

Office rate range in each state. Select a state to see its payment localities.

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.

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.

99204 compared with similar codes

How to choose

99214Office visit

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 visit

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.

99244Off/op cnsltj new/est mod 40

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 visit

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.

Codes related to 99204

Related codes aren’t interchangeable: bill the code that matches the service performed.

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

Open CMS sourceHow we calculate rates