CPT (Current Procedural Terminology) codes are five-digit numbers that describe every medical service or procedure. Your doctor, hospital, and insurance company use them to communicate exactly what was done. Every line on your medical bill has a CPT code, and knowing the code lets you look up what Medicare pays for that same service.

Why do providers charge so much more than Medicare pays?

Providers set their own "chargemaster" prices, which are essentially list prices. Medicare pays a fixed rate based on the resources each service actually requires (the RVU system for procedures, or the Clinical Lab Fee Schedule for lab tests). Commercial insurers typically pay 150% to 250% of Medicare rates. Uninsured patients are often billed the full chargemaster price, which can be 2x to 30x what Medicare pays.

Can I use Medicare rates to negotiate my bill?

Yes. Medicare rates are the closest thing to a "fair price" benchmark in U.S. healthcare. When negotiating, ask the provider what they accept from Medicare for the same CPT code. Most providers will accept 150% to 200% of Medicare for cash-pay patients, which is still far less than their chargemaster price. Many hospital financial assistance policies also use a multiple of Medicare as their discount floor.

How are Medicare rates calculated?

For most procedures, Medicare uses the Resource-Based Relative Value Scale (RBRVS). Each CPT code gets three RVU components: Work (physician time and skill), Practice Expense (overhead), and Malpractice. These are multiplied by geographic adjustment factors (GPCIs) and a conversion factor ($33.4009 in 2026). Lab tests (80000-89999 range) use a separate Clinical Laboratory Fee Schedule with flat national rates.

CPT 99202

New Patient Office Visit, Straightforward (15-29 min)

CPT 99202 is the lowest-level new patient office visit, covering a 15 to 29 minute appointment with straightforward medical decision making. This is the code for establishing care with a new doctor for a simple, single issue. Providers charge an average of $167.44, but Medicare pays only $75.15 in an office setting (2.2x markup). The most common billing problem: upcoding to 99203, which is a 57% price jump from $167 to $257. If your visit was brief and addressed one straightforward concern, it should be 99202.

Updated May 2026Source: CMS Physician Fee Schedule

CPT 99202 at a Glance

Average provider charge: $167.44
Medicare physician fee (office): $75.15
Medicare physician fee (hospital): varies + separate facility fee
Typical markup: 2.2x over Medicare office rate

Visit duration: 15 to 29 minutes
Decision complexity: Straightforward
Patient type: New (first visit or 3+ year gap)
Beneficiaries (2023): 908,893

How the Medicare Rate Is Calculated

Medicare does not set prices arbitrarily. Every procedure is valued using Relative Value Units (RVUs) across three components, then multiplied by a national conversion factor of $33.4009 (2026). Here is the exact math for a 99202 visit:

Component	What It Covers	Office (Non-Facility)	Hospital (Facility)
Work RVU	Physician time, skill, and judgment	0.93	0.93
Practice Expense RVU	Rent, staff, equipment, supplies	1.25	0.23
Malpractice RVU	Professional liability insurance	0.10	0.10
Total RVU		2.28	1.26
x $33.4009	2026 conversion factor	$75.15	$42.08

Why the hospital rate is lower but you pay more: The $42.08 facility rate only covers the physician's portion. The hospital bills a separate facility fee (typically $100 to $250) on top. Combined, visits at hospital-owned practices often cost patients more than the same visit at an independent office. For a straightforward new patient visit, the independent office may be significantly cheaper.

Medicare Rate by State

Medicare adjusts the national rate based on your location using Geographic Practice Cost Indices (GPCIs). The same 99202 visit pays differently in each state, ranging from about $54 in Arkansas to $75 in Alaska (a 38% spread).

Medicare Rate by State (2026)

Medicare adjusts payments by location using Geographic Practice Cost Indices (GPCIs). Select your state to see the adjusted rate.

Sample State Rates (Office Setting)

State	Medicare Pays	Avg. Charge	Markup
Texas (Austin)	$62.03	$167.44	2.7x
California (Los Angeles)	$66.26	$167.44	2.5x
New York (Manhattan)	$67.77	$167.44	2.5x
Florida (Fort Lauderdale)	$62.76	$167.44	2.7x
Ohio	$57.31	$167.44	2.9x
Mississippi	$54.94	$167.44	3.0x
Arkansas	$54.45	$167.44	3.1x
Alaska	$74.53	$167.44	2.2x

Rates shown are for the non-facility (office) setting using 2026 GPCIs and the $33.4009 conversion factor. The average provider charge of $167.44 is the 2023 national average from CMS utilization data. Actual charges vary by provider.

What Insured Patients Actually Pay for a 99202 Visit

If you have health insurance, you do not pay the provider's full charge of $167.44. Your insurer has a negotiated rate with the provider, typically 120% to 200% of the Medicare rate. For a 99202 visit, that negotiated rate is usually $90 to $150. What you owe depends on your plan design:

Your Situation	What You Likely Pay	How It Works
Copay plan (deductible met or N/A)	$20 to $50	Flat copay per primary care or specialist visit
Coinsurance plan (deductible met)	$18 to $30	20% of the negotiated rate ($90 to $150)
High-deductible plan (deductible NOT met)	$90 to $150	You pay the full negotiated rate until your deductible is met
Medicare Part B	$15.03	20% of the Medicare-approved amount ($75.15)
Medicaid	$0 to $5	Minimal or no cost-sharing in most states

Key concept: the negotiated rate. Your insurer contracts with providers for a discounted rate below the sticker price. This negotiated rate is what your deductible, coinsurance, and copay are calculated against. You should never pay the full billed charge of $167.44 if you are in-network. If your Explanation of Benefits (EOB) shows the full charge applied to your balance, call your insurer.

Should You Use Insurance or Pay Cash?

If you have a high-deductible health plan and have not met your deductible, you are paying the full negotiated rate for every visit. For a 99202 new patient visit, this is typically $90 to $150 through insurance. Many providers offer a cash-pay rate of $75 to $125 for a straightforward new patient visit, which can be comparable or cheaper.

When Cash-Pay Wins

You are unlikely to meet your deductible this year
The provider's cash rate is below the insurer's negotiated rate
You want to see a specific out-of-network doctor
You are establishing care for a one-time simple issue (like a form or referral)

When Using Insurance Wins

You are close to meeting your annual deductible
You expect significant medical expenses later this year
Your copay is less than the cash-pay rate
You need the visit to establish a PCP relationship for future referrals

Important trade-off: Cash payments do not count toward your insurance deductible or out-of-pocket maximum. If you pay cash for visits early in the year and then need surgery or hospitalization later, those cash payments will not have moved you closer to your deductible threshold. Factor in your overall expected healthcare spending for the year, not just the cost of this one visit.

Common Billing Problems with 99202

Upcoding from 99202 to 99203 (57% price jump)

A 99202 visit averages $167, while a 99203 averages $257. That is a 57% increase for bumping to the next level. The key difference: 99202 requires straightforward medical decision making (one self-limited problem, minimal testing), while 99203 requires low complexity (two or more problems, or ordering tests). If your visit addressed one simple issue with no labs or imaging ordered, it should be 99202. Request your visit notes and compare the documented complexity to the billed code.

Coded as new patient when you should be established

The 3-year rule determines new vs established status. If you have seen the same doctor (or a doctor of the same specialty within the same group practice) within the past 3 years, you should be coded as established (99212 or 99213) rather than new (99202). An established visit for a similar straightforward issue (99212) averages $113, significantly less than the $167 new patient charge. Verify your last visit date with the practice if you think you should qualify as established.

Add-on charges that inflate the total bill

A 99202 visit should be straightforward by definition, but some providers add lab tests, EKGs, or other procedures on the first visit that significantly inflate the total cost. While establishing baseline labs can be clinically appropriate, ask which tests are urgent versus which can wait for a follow-up. A "new patient package" that bundles $200 to $400 in labs with a straightforward visit may not be medically necessary for your specific concern.

Hospital facility fee on a simple new patient visit

If your new doctor's practice is owned by a hospital system, your straightforward new patient visit may generate both a physician fee and a separate hospital facility fee. For a simple 99202 visit worth $75 in Medicare physician fees, the hospital can add $100 to $200 in facility charges. This is especially wasteful for a straightforward visit. If you have a choice, an independent practice will typically cost less for this type of visit.

Related Office Visit Codes

Code	Description	Time	Medicare (Office)	Avg. Charge
99202	New patient, straightforward	15-29 min	$75.15	$167.44
99203	New patient, low complexity	30-44 min	$113.57	$257.00
99204	New patient, moderate complexity	45-59 min	$177.36	$395.78
99205	New patient, high complexity	60-74 min	$224.54	$508.00
99212	Established patient, straightforward	10-19 min	$63.29	$113.04

Frequently Asked Questions

How much does a new patient office visit (CPT 99202) cost without insurance?

Without insurance, a new patient office visit billed under CPT 99202 costs $100 to $250 depending on the provider and location. The national average charge is $167.44. Many providers offer a cash-pay discount of 20 to 40%, bringing the cost closer to $100 to $135. For comparison, Medicare pays $75.15 for this visit in an office setting.

What is the difference between 99202 and 99203?

CPT 99202 is a 15 to 29 minute new patient visit with straightforward medical decision making (one simple problem, minimal testing). CPT 99203 is a 30 to 44 minute new patient visit with low complexity decision making (multiple problems or more workup needed). The price jump is significant: $167 average for 99202 versus $257 average for 99203, a 57% increase. If your visit was brief and addressed a single simple concern, it should be 99202.

When does the 3-year rule make me a new patient?

If you have not been seen by the same doctor (or a doctor of the same specialty within the same group practice) in more than 3 years, you are coded as a new patient. This means you pay the higher new patient rate. For example, if you saw a PCP in 2022 and return in 2026, you are a new patient again. The rule resets the clock on any gap longer than 3 years from your last face-to-face visit.

Can I ask my doctor to bill 99202 instead of a higher code?

You cannot dictate the code, but you can influence it. If you keep your visit focused on one straightforward issue, avoid bringing up multiple unrelated concerns, and the visit stays under 30 minutes, the documentation should support 99202. You can also request an itemized bill and ask the billing department to review the code if you believe it was upcoded. The medical record must support whatever code is billed.

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