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CPT 99204 Medicare Reimbursement & Commercial Rate Comparison

CPT 99204

- Office Or Other Outpatient Visit For The Evaluation And Management Of A New Patient Which Requires A Medically Appropriate History And/Or Examinationand Moderate Level Of Medical Decision Making. When Using Total Time On The Date Of The Encounter For Code Selection 45 Minutes Must Be Met Or Exceeded. (Desc Rvsd 1/1/2024).

Below, you'll find the 2025 Medicare reimbursement amount as published in the official CMS fee schedule for locality 00000, along with a side-by-side comparison of national commercial rates from Aetna, Cigna, United Healthcare, and Blue Cross Blue Shield.

Medicare Reimbursement for CPT 99204

Non-facility rates apply in clinics or offices, where the provider covers all costs, so rates are typically higher.

Facility rates apply when services are done in hospitals or similar settings. Medicare covers overhead separately.

View Reimbursement by Medicare Locality →

$163.35

Non-Facility Rate

National

$129.06

Facility Rate

National

Compare to National Avg. In-Network Commercial Rates

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$181.72

$181.92

$244.74

$175.56

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Billing Code (CPT, HCPCS)

What is Medicare fee schedule?

The Medicare fee schedule is the list of payment amounts that Medicare uses to reimburse healthcare providers for services. It's updated annually and varies by geographic locality.

How are Medicare rates determined?

Medicare rates are calculated using the Resource-Based Relative Value Scale (RBRVS), which considers physician work, practice expenses, and malpractice costs, adjusted for geographic location.

Why do Medicare rates vary by location?

Medicare adjusts rates based on Geographic Practice Cost Indices (GPCIs) to account for differences in costs of living, wages, and practice expenses across different geographic areas.