$172.57
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.
On this page
CMS RVU26D · Effective 2026-10-01
99205 Office visit Medicare reimbursement rates in Vermont
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. Compare 99205 office and facility rates across CMS payment localities in Vermont.
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.
What does Medicare pay for 99205 in Vermont?
Vermont has 1 payment locality in this comparison. Use the service location to choose the applicable amount. These are the supported base rates for the payment area shown below, using the same CMS release.
Office / nonfacility
$229.79
1 of 1 localities have a supported rate.
Payment area: Vermont
One mapped payment locality.
Facility setting
$154.07
1 of 1 localities have a supported rate.
Payment area: Vermont
One mapped payment locality.
These are locality ranges, not averages or address-specific quotes. A facility-setting amount covers the physician service; it does not include a hospital’s separate bill. Choose a locality below to inspect its calculation, compare other payment areas, or price a percentage of Medicare.
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 Vermont, from the same CMS release.
$188.01
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
No office rateOff/op consltj new/est hi 55
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.
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.
Compare 99205 by payment locality
Find the payment area for your service address, then open its rate page for calculation inputs, release history and the percentage-of-Medicare tool. A city may cross payment-area boundaries; the ZIP lookup above helps resolve the location.
1 of 1 payment localities
Vermont →
Office / nonfacility
$229.79
Facility
$154.07
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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 Vermont.
PPRRVU2026_Oct_nonQPP.csv
13,012
- Code
- 99205
- Physician work
- 3.50
- Practice expense
- 3.23
- Malpractice
- 0.36
GPCI2026.csv
105
- Locality
- Vermont
- Physician work
- 1.000
- Practice expense
- 0.990
- Malpractice
- 0.506
| Component | RVU | Locality factor | Adjusted |
|---|---|---|---|
| Physician work | 3.50 | × 1.000 | 3.5000 |
| Practice expense | 3.23 | × 0.990 | 3.1977 |
| Malpractice | 0.36 | × 0.506 | 0.1822 |
| Total RVUs | 6.8799 | ||
| Conversion factor | × 33.4009 | ||
Office / nonfacility rate, Vermont$229.79
Explore RVUs, geographic factors and the full formula
Office / nonfacility
| Component | RVU | Local GPCI |
|---|---|---|
| Work | 3.5 | 1 |
| Practice expense | 3.23 | 0.99 |
| Malpractice | 0.36 | 0.506 |
(3.5 × 1 + 3.23 × 0.99 + 0.36 × 0.506) × $33.4009 = $229.79
Facility
| Component | RVU | Local GPCI |
|---|---|---|
| Work | 3.5 | 1 |
| Practice expense | 0.94 | 0.99 |
| Malpractice | 0.36 | 0.506 |
(3.5 × 1 + 0.94 × 0.99 + 0.36 × 0.506) × $33.4009 = $154.07
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.
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.
13,00999202,,Office o/p new sf 15 min,A,,0.93,1.25,,0.23,,0.07,2.25,1.23,0,XXX,0.00,0.00,0.00,0,0,0,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00
13,01099203,,Office o/p new low 30 min,A,,1.60,1.76,,0.38,,0.16,3.52,2.14,0,XXX,0.00,0.00,0.00,0,0,0,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00
13,01199204,,Office o/p new mod 45 min,A,,2.60,2.47,,0.66,,0.24,5.31,3.50,0,XXX,0.00,0.00,0.00,0,0,0,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00
13,01299205,,Office o/p new hi 60 min,A,,3.50,3.23,,0.94,,0.36,7.09,4.80,0,XXX,0.00,0.00,0.00,0,0,0,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00
13,01399211,,Off/op est may x req phy/qhp,A,,0.18,0.54,,0.04,,0.01,0.73,0.23,0,XXX,0.00,0.00,0.00,0,0,0,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00
13,01499212,,Office o/p est sf 10 min,A,,0.70,1.02,,0.17,,0.06,1.78,0.93,0,XXX,0.00,0.00,0.00,0,0,0,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00
13,01599213,,Office o/p est low 20 min,A,,1.30,1.46,,0.33,,0.09,2.85,1.72,0,XXX,0.00,0.00,0.00,0,0,0,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00
10204412,TX,18,HOUSTON,1.008,0.993,1.376
10304412,TX,99,REST OF TEXAS,1.000,0.949,0.903
10403502,UT,09,UTAH,1.000,0.940,0.898
10514512,VT,50,VERMONT,1.000,0.990,0.506
10611302,VA,00,VIRGINIA,1.000,0.983,0.706
10709202,VI,50,VIRGIN ISLANDS,1.000,1.011,0.985
10802402,WA,02,SEATTLE (KING CNTY),1.050,1.227,0.817