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CMS RVU26D · Effective 2026-10-01

99205 in Modesto

Office / nonfacility

$243.58

Base rate per service

Facility setting

$159.75

Base rate per service

Amounts below use the non-QP conversion factor for participating physicians. These are base physician payments before claim-level adjustments, not patient costs or total hospital charges.

Evaluation and management

About 99205: New patient office visit, high complexity

Highest-level new patient office or outpatient visit, reported when medical decision making is high or the billing practitioner's total time reaches 60 minutes.

This visit is for a patient who has not received professional services from the billing practitioner or another practitioner of the same specialty and subspecialty in the same group during the past three years. Potential high-complexity presentations include a severe exacerbation of chronic disease or an acute illness threatening life or bodily function; the diagnosis alone does not establish the level. Physicians, nurse practitioners, and physician assistants provide these visits in offices and hospital outpatient clinics. The facility practice expense value applies to the professional service in a facility-based outpatient setting.

Select 99205 for high medical decision making or at least 60 minutes of the billing practitioner's time on the encounter date. High decision making requires two of three elements: high-complexity problems, extensive data analysis, and high management risk. Decisions about hospitalization or emergency major surgery and drug therapy requiring intensive toxicity monitoring can support high risk. When selecting by time, document total minutes and qualifying activities; exclude clinical staff time and separately reported services. Document a medically appropriate history and examination, but do not use their extent to select the level.

Where the value comes from

  • Work RVU3.50 · 49%
  • Practice expense (office) RVU3.23 · 46%
  • Malpractice RVU0.36 · 5%

3.1M

Medicare services in 2024 · #60 by national volume

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.

99205 compared with similar codes

Office rates for Modesto, from the same CMS release.

99204

Office visit

New patient, moderate complexity

$183.04

Choose 99204 for moderate medical decision making or at least 45 minutes when 99205 criteria are not met. Choose 99205 for high decision making or at least 60 minutes.

99215

Office visit

Established patient, high complexity

$199.54

99215 is for an established patient; 99205 is for a patient with no professional services from the practitioner or a same-specialty, same-subspecialty group member in the past three years.

99245

Off/op consltj new/est hi 55

No office rate

99245 is for a qualifying office consultation when the payer accepts consultation codes. Medicare does not pay 99245; report 99205 for a Medicare patient only when new-patient status and the visit level are supported.

99223

Initial hospital visit

High decision making or 75 minutes

No office rate

99223 is an initial hospital inpatient or observation visit. Use 99205 for a qualifying new patient encounter in an office or outpatient clinic, rather than an inpatient or observation encounter.

The same code, a different location

How does Modesto compare?

In Bakersfield, the office rate for 99205 is $244.69—$1.11 higher than the $243.58 rate in Modesto. Both use the same code, release and participation basis.

99205 across payment areas

Same release and payment basis · bars start at $0

  1. Modesto · This locality

    $243.58

  2. Bakersfield

    $244.69

    $1.11 higher than Modesto

  3. Chico

    $243.58

    The same base rate than Modesto

  4. El Centro

    $243.64

    $0.06 higher than Modesto

  5. Fresno

    $243.58

    The same base rate than Modesto

  6. Hanford-Corcoran

    $243.58

    The same base rate than Modesto

  7. Los Angeles-Long Beach-Anaheim (Los Angeles/Orange Cnty)

    $257.31

    $13.73 higher than Modesto

Other payment areas listed in California appear first, followed by selected cross-country examples. The chart compares amounts, not distance.

Across 109 of 109 CMS payment localities with a supported office rate, 99205 ranges from $215.77 in Arkansas to $296.88 in Alaska*. This is a geographic range, not an average.

The code’s RVUs stay the same in these comparisons. Geographic adjustments to work, practice expense and malpractice change the dollar amount. A city name alone may not identify the payment area for a service address.

Compare all 108 other payment areas

  • Madera

    California · 99205

    Office

    $243.58

    Facility

    $159.75

    The same base rate than Modesto for the office setting.

  • Merced

    California · 99205

    Office

    $243.58

    Facility

    $159.75

    The same base rate than Modesto for the office setting.

  • Napa

    California · 99205

    Office

    $272.57

    Facility

    $171.76

    $28.99 higher than Modesto for the office setting.

  • Oxnard-Thousand Oaks-Ventura

    California · 99205

    Office

    $255.19

    Facility

    $164.78

    $11.61 higher than Modesto for the office setting.

  • Redding

    California · 99205

    Office

    $243.58

    Facility

    $159.75

    The same base rate than Modesto for the office setting.

  • Rest Of California

    California · 99205

    Office

    $243.58

    Facility

    $159.75

    The same base rate than Modesto for the office setting.

  • Riverside-San Bernardino-Ontario

    California · 99205

    Office

    $247.51

    Facility

    $163.68

    $3.93 higher than Modesto for the office setting.

  • Sacramento-Roseville-Folsom

    California · 99205

    Office

    $253.03

    Facility

    $164.07

    $9.45 higher than Modesto for the office setting.

  • Salinas

    California · 99205

    Office

    $252.01

    Facility

    $163.36

    $8.43 higher than Modesto for the office setting.

  • San Diego-Chula Vista-Carlsbad

    California · 99205

    Office

    $255.96

    Facility

    $164.48

    $12.38 higher than Modesto for the office setting.

  • San Francisco-Oakland-Berkeley (Marin Cnty)

    California · 99205

    Office

    $285.65

    Facility

    $177.80

    $42.07 higher than Modesto for the office setting.

  • San Francisco-Oakland-Berkeley (San Francisco/San Mateo/Alameda/Contra Costa Cnty)

    California · 99205

    Office

    $285.24

    Facility

    $177.39

    $41.66 higher than Modesto for the office setting.

  • San Jose-Sunnyvale-Santa Clara (San Benito Cnty)

    California · 99205

    Office

    $291.78

    Facility

    $181.48

    $48.20 higher than Modesto for the office setting.

  • San Jose-Sunnyvale-Santa Clara (Santa Clara Cnty)

    California · 99205

    Office

    $290.11

    Facility

    $179.81

    $46.53 higher than Modesto for the office setting.

  • San Luis Obispo-Paso Robles

    California · 99205

    Office

    $248.22

    Facility

    $161.10

    $4.64 higher than Modesto for the office setting.

  • Santa Cruz-Watsonville

    California · 99205

    Office

    $256.88

    Facility

    $163.95

    $13.30 higher than Modesto for the office setting.

  • Santa Maria-Santa Barbara

    California · 99205

    Office

    $252.42

    Facility

    $163.23

    $8.84 higher than Modesto for the office setting.

  • Santa Rosa-Petaluma

    California · 99205

    Office

    $259.34

    Facility

    $165.41

    $15.76 higher than Modesto for the office setting.

  • Stockton

    California · 99205

    Office

    $243.58

    Facility

    $159.75

    The same base rate than Modesto for the office setting.

  • Vallejo

    California · 99205

    Office

    $271.98

    Facility

    $171.17

    $28.40 higher than Modesto for the office setting.

  • Visalia

    California · 99205

    Office

    $243.58

    Facility

    $159.75

    The same base rate than Modesto for the office setting.

  • Yuba City

    California · 99205

    Office

    $243.58

    Facility

    $159.75

    The same base rate than Modesto for the office setting.

  • Dc + Md/Va Suburbs

    District of Columbia · 99205

    Office

    $263.69

    Facility

    $173.58

    $20.11 higher than Modesto for the office setting.

  • Miami

    Florida · 99205

    Office

    $259.62

    Facility

    $180.00

    $16.04 higher than Modesto for the office setting.

  • Chicago

    Illinois · 99205

    Office

    $253.74

    Facility

    $176.87

    $10.16 higher than Modesto for the office setting.

  • Manhattan

    New York · 99205

    Office

    $268.82

    Facility

    $179.94

    $25.24 higher than Modesto for the office setting.

  • Alaska*

    Alaska · 99205

    Office

    $296.88

    Facility

    $215.42

    $53.30 higher than Modesto for the office setting.

  • Alabama

    Alabama · 99205

    Office

    $218.11

    Facility

    $151.18

    $25.47 lower than Modesto for the office setting.

  • Arkansas

    Arkansas · 99205

    Office

    $215.77

    Facility

    $150.07

    $27.81 lower than Modesto for the office setting.

  • Arizona

    Arizona · 99205

    Office

    $231.74

    Facility

    $157.62

    $11.84 lower than Modesto for the office setting.

  • Colorado

    Colorado · 99205

    Office

    $242.49

    Facility

    $161.10

    $1.09 lower than Modesto for the office setting.

  • Connecticut

    Connecticut · 99205

    Office

    $249.98

    Facility

    $167.61

    $6.40 higher than Modesto for the office setting.

  • Delaware

    Delaware · 99205

    Office

    $234.89

    Facility

    $159.32

    $8.69 lower than Modesto for the office setting.

  • Fort Lauderdale

    Florida · 99205

    Office

    $247.93

    Facility

    $170.45

    $4.35 higher than Modesto for the office setting.

  • Rest Of Florida

    Florida · 99205

    Office

    $238.11

    Facility

    $164.99

    $5.47 lower than Modesto for the office setting.

  • Atlanta

    Georgia · 99205

    Office

    $241.31

    Facility

    $163.59

    $2.27 lower than Modesto for the office setting.

  • Rest Of Georgia

    Georgia · 99205

    Office

    $227.47

    Facility

    $159.24

    $16.11 lower than Modesto for the office setting.

  • Hawaii, Guam

    Hawaii · 99205

    Office

    $246.53

    Facility

    $159.56

    $2.95 higher than Modesto for the office setting.

  • Iowa

    Iowa · 99205

    Office

    $220.39

    Facility

    $150.40

    $23.19 lower than Modesto for the office setting.

  • Idaho

    Idaho · 99205

    Office

    $221.84

    Facility

    $151.48

    $21.74 lower than Modesto for the office setting.

  • East St. Louis

    Illinois · 99205

    Office

    $240.37

    Facility

    $170.01

    $3.21 lower than Modesto for the office setting.

  • Rest Of Illinois

    Illinois · 99205

    Office

    $234.20

    Facility

    $164.36

    $9.38 lower than Modesto for the office setting.

  • Suburban Chicago

    Illinois · 99205

    Office

    $249.83

    Facility

    $171.27

    $6.25 higher than Modesto for the office setting.

  • Indiana

    Indiana · 99205

    Office

    $222.76

    Facility

    $151.85

    $20.82 lower than Modesto for the office setting.

  • Kansas

    Kansas · 99205

    Office

    $220.49

    Facility

    $151.35

    $23.09 lower than Modesto for the office setting.

  • Kentucky

    Kentucky · 99205

    Office

    $223.82

    Facility

    $155.82

    $19.76 lower than Modesto for the office setting.

  • New Orleans

    Louisiana · 99205

    Office

    $232.08

    Facility

    $160.11

    $11.50 lower than Modesto for the office setting.

  • Rest Of Louisiana

    Louisiana · 99205

    Office

    $223.90

    Facility

    $156.21

    $19.68 lower than Modesto for the office setting.

  • Metropolitan Boston

    Massachusetts · 99205

    Office

    $261.21

    Facility

    $169.89

    $17.63 higher than Modesto for the office setting.

  • Rest Of Massachusetts

    Massachusetts · 99205

    Office

    $241.96

    Facility

    $161.42

    $1.62 lower than Modesto for the office setting.

  • Baltimore/Surr. Cntys

    Maryland · 99205

    Office

    $249.41

    Facility

    $167.34

    $5.83 higher than Modesto for the office setting.

  • Rest Of Maryland

    Maryland · 99205

    Office

    $238.29

    Facility

    $160.88

    $5.29 lower than Modesto for the office setting.

  • Rest Of Maine

    Maine · 99205

    Office

    $223.64

    Facility

    $153.27

    $19.94 lower than Modesto for the office setting.

  • Southern Maine

    Maine · 99205

    Office

    $231.40

    Facility

    $155.60

    $12.18 lower than Modesto for the office setting.

  • Detroit

    Michigan · 99205

    Office

    $241.29

    Facility

    $167.47

    $2.29 lower than Modesto for the office setting.

  • Rest Of Michigan

    Michigan · 99205

    Office

    $228.98

    Facility

    $159.14

    $14.60 lower than Modesto for the office setting.

  • Minnesota

    Minnesota · 99205

    Office

    $231.48

    Facility

    $152.77

    $12.10 lower than Modesto for the office setting.

  • Metropolitan Kansas City

    Missouri · 99205

    Office

    $229.95

    Facility

    $158.13

    $13.63 lower than Modesto for the office setting.

  • Metropolitan St. Louis

    Missouri · 99205

    Office

    $231.66

    Facility

    $158.84

    $11.92 lower than Modesto for the office setting.

  • Rest Of Missouri

    Missouri · 99205

    Office

    $221.61

    Facility

    $155.68

    $21.97 lower than Modesto for the office setting.

  • Mississippi

    Mississippi · 99205

    Office

    $218.68

    Facility

    $152.82

    $24.90 lower than Modesto for the office setting.

  • Montana**

    Montana · 99205

    Office

    $236.79

    Facility

    $160.30

    $6.79 lower than Modesto for the office setting.

  • North Carolina

    North Carolina · 99205

    Office

    $225.24

    Facility

    $153.88

    $18.34 lower than Modesto for the office setting.

  • North Dakota**

    North Dakota · 99205

    Office

    $229.67

    Facility

    $153.18

    $13.91 lower than Modesto for the office setting.

  • Nebraska

    Nebraska · 99205

    Office

    $221.03

    Facility

    $150.43

    $22.55 lower than Modesto for the office setting.

  • New Hampshire

    New Hampshire · 99205

    Office

    $239.73

    Facility

    $160.11

    $3.85 lower than Modesto for the office setting.

  • Northern Nj

    New Jersey · 99205

    Office

    $262.26

    Facility

    $173.53

    $18.68 higher than Modesto for the office setting.

  • Rest Of New Jersey

    New Jersey · 99205

    Office

    $252.58

    Facility

    $169.06

    $9.00 higher than Modesto for the office setting.

  • New Mexico

    New Mexico · 99205

    Office

    $230.27

    Facility

    $160.14

    $13.31 lower than Modesto for the office setting.

  • Nevada**

    Nevada · 99205

    Office

    $234.91

    Facility

    $158.35

    $8.67 lower than Modesto for the office setting.

  • Nyc Suburbs/Long Island

    New York · 99205

    Office

    $274.99

    Facility

    $184.04

    $31.41 higher than Modesto for the office setting.

  • Poughkpsie/N Nyc Suburbs

    New York · 99205

    Office

    $254.85

    Facility

    $171.09

    $11.27 higher than Modesto for the office setting.

  • Queens

    New York · 99205

    Office

    $269.24

    Facility

    $178.84

    $25.66 higher than Modesto for the office setting.

  • Rest Of New York

    New York · 99205

    Office

    $227.85

    Facility

    $155.18

    $15.73 lower than Modesto for the office setting.

  • Ohio

    Ohio · 99205

    Office

    $227.52

    Facility

    $157.69

    $16.06 lower than Modesto for the office setting.

  • Oklahoma

    Oklahoma · 99205

    Office

    $222.59

    Facility

    $154.28

    $20.99 lower than Modesto for the office setting.

  • Portland

    Oregon · 99205

    Office

    $247.58

    Facility

    $162.60

    $4.00 higher than Modesto for the office setting.

  • Rest Of Oregon

    Oregon · 99205

    Office

    $232.81

    Facility

    $156.63

    $10.77 lower than Modesto for the office setting.

  • Metropolitan Philadelphia

    Pennsylvania · 99205

    Office

    $245.66

    Facility

    $166.04

    $2.08 higher than Modesto for the office setting.

  • Rest Of Pennsylvania

    Pennsylvania · 99205

    Office

    $227.30

    Facility

    $157.09

    $16.28 lower than Modesto for the office setting.

  • Puerto Rico

    Puerto Rico · 99205

    Office

    $237.82

    Facility

    $160.49

    $5.76 lower than Modesto for the office setting.

  • Rhode Island

    Rhode Island · 99205

    Office

    $241.30

    Facility

    $162.28

    $2.28 lower than Modesto for the office setting.

  • South Carolina

    South Carolina · 99205

    Office

    $226.81

    Facility

    $156.13

    $16.77 lower than Modesto for the office setting.

  • South Dakota**

    South Dakota · 99205

    Office

    $228.83

    Facility

    $152.34

    $14.75 lower than Modesto for the office setting.

  • Tennessee

    Tennessee · 99205

    Office

    $221.43

    Facility

    $151.90

    $22.15 lower than Modesto for the office setting.

  • Austin

    Texas · 99205

    Office

    $241.93

    Facility

    $161.01

    $1.65 lower than Modesto for the office setting.

  • Beaumont

    Texas · 99205

    Office

    $226.25

    Facility

    $156.64

    $17.33 lower than Modesto for the office setting.

  • Brazoria

    Texas · 99205

    Office

    $234.13

    Facility

    $158.33

    $9.45 lower than Modesto for the office setting.

  • Dallas

    Texas · 99205

    Office

    $235.73

    Facility

    $159.54

    $7.85 lower than Modesto for the office setting.

  • Fort Worth

    Texas · 99205

    Office

    $234.80

    Facility

    $159.39

    $8.78 lower than Modesto for the office setting.

  • Galveston

    Texas · 99205

    Office

    $234.92

    Facility

    $158.97

    $8.66 lower than Modesto for the office setting.

  • Houston

    Texas · 99205

    Office

    $241.51

    Facility

    $165.56

    $2.07 lower than Modesto for the office setting.

  • Rest Of Texas

    Texas · 99205

    Office

    $230.14

    Facility

    $157.56

    $13.44 lower than Modesto for the office setting.

  • Utah

    Utah · 99205

    Office

    $229.11

    Facility

    $157.21

    $14.47 lower than Modesto for the office setting.

  • Virginia

    Virginia · 99205

    Office

    $231.44

    Facility

    $156.26

    $12.14 lower than Modesto for the office setting.

  • Virgin Islands

    United States Virgin Islands · 99205

    Office

    $237.82

    Facility

    $160.49

    $5.76 lower than Modesto for the office setting.

  • Vermont

    Vermont · 99205

    Office

    $229.79

    Facility

    $154.07

    $13.79 lower than Modesto for the office setting.

  • Rest Of Washington

    Washington · 99205

    Office

    $241.18

    Facility

    $160.63

    $2.40 lower than Modesto for the office setting.

  • Seattle (King Cnty)

    Washington · 99205

    Office

    $264.95

    Facility

    $171.10

    $21.37 higher than Modesto for the office setting.

  • Wisconsin

    Wisconsin · 99205

    Office

    $223.96

    Facility

    $150.68

    $19.62 lower than Modesto for the office setting.

  • West Virginia

    West Virginia · 99205

    Office

    $227.86

    Facility

    $161.39

    $15.72 lower than Modesto for the office setting.

  • Wyoming**

    Wyoming · 99205

    Office

    $233.69

    Facility

    $157.20

    $9.89 lower than Modesto for the office setting.

See how rates vary across the country

99205 · Office / nonfacility · Non-QP. Choose a state to explore its payment localities. A range means the amount varies within that state.

MEWIVTNHMTNDMNMINYMARIWAIDWYSDIAILINOHPANJCTORNVUTCONEMOKYWVVAMDDECAAZNMKSOKARTNNCSCDCTXLAMSALGAFLAKHI

Explore a state

Local rates. Clear comparisons.

Hover or focus a tile to see its rate range. Select it to open the state’s fee schedule.

$215.77

$296.88

Color shows the midpoint of each state’s locality range.

View all state and territory rates as a table
State / territoryRate rangeLocalities
AK$296.881
AL$218.111
AR$215.771
AZ$231.741
CA$243.58–$291.7829
CO$242.491
CT$249.981
DC$263.691
DE$234.891
FL$238.11–$259.623
GA$227.47–$241.312
GU$246.531
HI$246.531
IA$220.391
ID$221.841
IL$234.20–$253.744
IN$222.761
KS$220.491
KY$223.821
LA$223.90–$232.082
MA$241.96–$261.212
MD$238.29–$263.693
ME$223.64–$231.402
MI$228.98–$241.292
MN$231.481
MO$221.61–$231.663
MS$218.681
MT$236.791
NC$225.241
ND$229.671
NE$221.031
NH$239.731
NJ$252.58–$262.262
NM$230.271
NV$234.911
NY$227.85–$274.995
OH$227.521
OK$222.591
OR$232.81–$247.582
PA$227.30–$245.662
PR$237.821
RI$241.301
SC$226.811
SD$228.831
TN$221.431
TX$226.25–$241.938
UT$229.111
VA$231.44–$263.692
VI$237.821
VT$229.791
WA$241.18–$264.952
WI$223.961
WV$227.861
WY$233.691

Explore 99205 on the national rate map →

Where does this rate apply?

Modesto is a Medicare payment area. Our Census mapping connects it to 33 cities and communities in California, including the examples shown here.

Some communities span more than one payment area. Follow a city link to compare all of its mapped areas, or check the service-location ZIP above for an address-level starting point.

Browse all communities in California →

Why are the office and facility amounts different?

For 99205 in Modesto, the physician’s office rate is $243.58 and the facility-setting rate is $159.75: a difference of $83.83.

The calculation uses a different practice-expense RVU for each setting. Both amounts here are physician fee-schedule amounts. The facility figure does not include a hospital’s separate charges, so this comparison does not tell you the total cost of receiving care in each setting.

See the inputs behind this difference →

Use this rate

What is a percentage of Medicare worth?

Turn a percentage into dollars for 99205 in Modesto. This uses the base rate on this page, so the locality and release stay consistent.

Reference amount per service

$267.94

$243.58 × 110% = $267.94

A contract may specify another Medicare year or additional adjustments. This is percentage arithmetic on the displayed base rate, not a claim adjudication.

Working with a whole code list?

Compare an offer across your annual code mix, including an older Medicare schedule or flat per-code rates.

Compare your contract offer →

Primary care

Compare office and outpatient evaluation-and-management base rates.

How this local rate is calculated

Each RVU component is multiplied by its own geographic practice cost index (GPCI). The three adjusted components are added, then multiplied by the conversion factor. These are the inputs used for 99205 in Modesto.

PPRRVU2026_Oct_nonQPP.csv

13,012

Code
99205
Physician work
3.50
Practice expense
3.23
Malpractice
0.36

GPCI2026.csv

16

Locality
Modesto
Physician work
1.017
Practice expense
1.096
Malpractice
0.536
Office / nonfacility calculation for 99205 in Modesto
ComponentRVULocality factorAdjusted
Physician work3.50× 1.0173.5595
Practice expense3.23× 1.0963.5401
Malpractice0.36× 0.5360.1930
Total RVUs7.2925
Conversion factor× 33.4009

Office / nonfacility rate, Modesto$243.58

Open 99205 in the RVU calculator →

Explore RVUs, geographic factors and the full formula

Office / nonfacility

Office / nonfacility calculation inputs
ComponentRVULocal GPCI
Work3.51.017
Practice expense3.231.096
Malpractice0.360.536

(3.5 × 1.017 + 3.23 × 1.096 + 0.36 × 0.536) × $33.4009 = $243.58

Facility

Facility calculation inputs
ComponentRVULocal GPCI
Work3.51.017
Practice expense0.941.096
Malpractice0.360.536

(3.5 × 1.017 + 0.94 × 1.096 + 0.36 × 0.536) × $33.4009 = $159.75

The office and facility calculations use their respective practice-expense RVUs. The facility amount here is the physician fee, not a separate hospital or facility bill.

How this rate has changed

99205 · Office / nonfacility

$243.58

Effective 2026-10-01

The base rate is $22.57 higher than on 2025-10-01, moving from $221.01 to $243.58 (10.2%).

It is unchanged from the immediately preceding available release, effective 2026-07-01.

Base rate by release · bars start at $0 · select a bar to compare

One bar per available release, ordered by effective date. Missing rates remain gaps. These comparisons hold the code, setting and locality identifiers constant; they do not isolate which policy or input caused a change.

What changed, release by release

  1. January 1, 2026

    RVU26A

    $221.01changed to$243.58

    • Conversion factor 32.3465 changed to 33.4009
    • Practice expense RVU 2.83 changed to 3.23
    • Malpractice RVU 0.34 changed to 0.36
    • Work GPCI 1.014 changed to 1.017
    • Practice expense GPCI 1.093 changed to 1.096
    • Malpractice GPCI 0.560 changed to 0.536

    Held through RVU26B, RVU26C, RVU26D.

  2. January 1, 2025

    RVU25A

    Earliest loaded release: $221.01

    Held through RVU25B, RVU25C, RVU25D.

Explore release dates and calculate this code in an earlier period →

Each row uses the accepted CMS release effective on that date and the same contractor and locality identifiers. Missing rates stay visible. Historical boundaries may differ; verify the service address for an older claim.

Inspect every release and its CMS source
Effective fromOffice / nonfacilityFacilityCMS release
2026-10-01$243.58$159.75RVU26D
2026-07-01$243.58$159.75RVU26C
2026-04-01$243.58$159.75RVU26B
2026-01-01$243.58$159.75RVU26A
2025-10-01$221.01$177.17RVU25D
2025-07-01$221.01$177.17RVU25C
2025-04-01$221.01$177.17RVU25B
2025-01-01$221.01$177.17RVU25A

99205 billing questions

How is 99205 distinguished from 99204?

99205 requires high medical decision making or at least 60 minutes of total time; 99204 requires moderate decision making or at least 45 minutes. A severe problem alone does not establish high decision making: two of the three decision-making elements must reach the high level.

What counts toward the 60 minutes?

Count the billing practitioner's qualifying work on the encounter date, such as record review, examination, counseling, ordering, documentation, and care coordination. Exclude clinical staff time and time spent on separately reported services.

How is prolonged time reported beyond 99205 for Medicare?

Medicare uses G2212 with 99205 for prolonged office or outpatient time; the first unit begins at 89 total minutes, with additional units at subsequent 15-minute thresholds. Payers following CPT prolonged-service rules may instead use 99417, with its first unit beginning at 75 minutes.

Can 99205 be billed when a Medicare patient is referred for a consultation?

Medicare does not pay office consultation codes 99242–99245. Report the appropriate office or outpatient visit code, including 99205 when the patient qualifies as new and the level is supported.

When is modifier 25 needed with 99205?

Append modifier 25 when a significant, separately identifiable E/M service is performed on the same date as a minor procedure. Document evaluation beyond the work normally included with that procedure.

Can G2211 be added to a new patient visit?

Yes, when the visit reflects the practitioner's continuing role as a focal point for care or ongoing care for a serious or complex condition. Medicare generally excludes G2211 when modifier 25 is appended, but permits it when the same-day service is an annual wellness visit, vaccine administration, or Medicare Part B preventive service.

Where these rates come from

FeeBase calculates base physician payments from CMS work, practice-expense, and malpractice RVUs, adjusted by each locality’s geographic indices and the applicable conversion factor. Unavailable or separately priced services are labeled rather than assigned a made-up amount.

Source: RVU26D. Effective 2026-10-01 through the day before 2027-01-01.

RVUs for 99205PPRRVU2026_Oct_nonQPP.csv, line 13,012 (RVU26D)
Geographic factors for ModestoGPCI2026.csv, line 16 (RVU26D)
Open CMS sourceHow this rate is calculatedBuild a fee sheet