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See a sample rate comparisonCPT 99204 Fee Schedule
Last Verified: October 2026
Healthcare providers use this code to document and receive reimbursement for visits that address moderate-level medical decision-making, often including multiple diagnoses or prescription management.
Office O P New Mod 45 Min, Office Or Other Outpatient Visit For The Evaluation And Management Of A New Patient Which Requires A Medically Appropriate History And Or Examination And 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
| Key Fact | Detail |
|---|---|
| Service Type | Evaluation and Management Office or Other Outpatient Services |
| Common Place of Service | 11 - Office 20 - Urgent Care Facility 22 - On Campus Outpatient Hospital |
| Common Modifiers | None 25 - Significant, separately identifiable E/M service same day 95 - Telemedicine - audio and video |
| Complexity Level | Moderate |
| Medicare Fee Schedule | View Medicare rates for 99204 |
| Medicaid Fee Schedule | View Medicaid rates for 99204 |
National average reimbursement for CPT 99204 by major payers:
$181.72
$181.92
$175.56
$203.29
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CPT 99204
5 of 25 sample ratesHigher to lower in this preview
Brett London
$897.34Published rateAtena Rosak
University Of Maryland St Joseph Medical Group LLC
$331.26Published rateManju Palaniswamy
St Agnes Healthcare Inc
$178.58Published rateEdward Dodge
Grisell Memorial Hospital District 1
$159.66Published rateMounir Abdelshahid
Clark Medical Service LLC
$100.88Published rate
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See a sample payer proposalCPT 99204 vs. Other Office or Other Outpatient Services Codes
The CPT 99204 code is part of the Evaluation and Management services used for Office or Other Outpatient Services. It represents a moderate-complexity encounter and is one of several codes that vary based on time spent, level of medical decision-making, and documentation requirements.
The CPT 99204 code involves more provider time and moderate medical decision-making, unlike lower-level codes that require less time and simpler assessments. It typically includes multiple diagnoses, medication management, or test interpretation, leading to higher reimbursement and more detailed documentation requirements.
| Code | Complexity | Description |
|---|---|---|
| 99202-CPT | Low | Office O P New Sf 15 Min, Office Or Other Outpatient Visit For The Evaluation And Management Of A New Patient Which Requires A Medically Appropriate History And Or Examination And Straightforward Medical Decision Making When Using Total Time On The Date Of The Encounter For Code Selection 15 Minutes Must Be Met Or Exceeded |
| 99203-CPT | Low | Office O P New Low 30 Min, Office Or Other Outpatient Visit For The Evaluation And Management Of A New Patient Which Requires A Medically Appropriate History And Or Examination And Low Level Of Medical Decision Making When Using Total Time On The Date Of The Encounter For Code Selection 30 Minutes Must Be Met Or Exceeded |
| 99204-CPT | Moderate | Office O P New Mod 45 Min, Office Or Other Outpatient Visit For The Evaluation And Management Of A New Patient Which Requires A Medically Appropriate History And Or Examination And 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 |
| 99205-CPT | High | Office O P New Hi 60 Min, Office Or Other Outpatient Visit For The Evaluation And Management Of A New Patient Which Requires A Medically Appropriate History And Or Examination And High Level Of Medical Decision Making When Using Total Time On The Date Of The Encounter For Code Selection 60 Minutes Must Be Met Or Exceeded |
What is a fee schedule?
A fee schedule is a list of fixed prices that healthcare providers charge for specific services, including CPT 99204. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 99204 fee schedule helps patients estimate costs and providers optimize billing for accurate reimbursements.
Factors that affect fee schedules
Medicare & Medicaid Rates
Government-set reimbursement amounts
Private Insurance Rates
Negotiated rates between providers and insurance companies
Geographic Location
Costs may be higher in urban areas.
Provider Type
Hospital providers may have different rates than private practice.
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