Office Visit, New Patient, Moderate Complexity (45-59 min)
CPT 99204 is the most commonly billed new patient office visit code, used over 12.5 million times per year across 8.2 million Medicare beneficiaries. It covers a 45 to 59 minute visit with moderate medical decision making for a patient the provider has not seen before. Providers charge an average of $395.78 for this visit, but Medicare pays only $177.36 for the physician fee in an office setting (2.2x markup). New patient visits always pay more than established patient visits because there is no prior relationship or chart to reference.
CPT 99204 at a Glance
- Average provider charge: $395.78
- Medicare physician fee (office): $177.36
- Medicare physician fee (hospital): $116.90 + separate facility fee
- Typical markup: 2.2x over Medicare office rate
- Visit duration: 45 to 59 minutes
- Decision complexity: Moderate
- Patient type: New (not seen in 3+ years)
- Beneficiaries (2023): 8.2 million
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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 99204 visit:
| Component | What It Covers | Office (Non-Facility) | Hospital (Facility) |
|---|---|---|---|
| Work RVU | Physician time, skill, and judgment | 2.60 | 2.60 |
| Practice Expense RVU | Rent, staff, equipment, supplies | 2.47 | 0.66 |
| Malpractice RVU | Professional liability insurance | 0.24 | 0.24 |
| Total RVU | 5.31 | 3.50 | |
| x $33.4009 | 2026 conversion factor | $177.36 | $116.90 |
The New Patient Premium: 99204 vs 99214
If you are seeing a specialist or any provider for the first time, expect a higher bill than follow-up visits. The new patient premium is significant because the provider must gather a complete history, review medications, and build an assessment from scratch with no prior chart to reference.
| Metric | 99204 (New Patient) | 99214 (Established) | Difference |
|---|---|---|---|
| Medicare rate (office) | $177.36 | $135.61 | +31% |
| Average provider charge | $395.78 | $263.55 | +50% |
| Visit duration | 45-59 min | 30-39 min | +15-20 min |
| Total RVU (office) | 5.31 | 3.23 | +64% |
Medicare Rate by State
Medicare adjusts the national rate based on your location using Geographic Practice Cost Indices (GPCIs). The same 99204 visit pays differently in each state, ranging from about $159 in Arkansas to $214 in Alaska (a 35% 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) | $180.99 | $395.78 | 2.2x |
| California (Los Angeles) | $195.14 | $395.78 | 2.0x |
| New York (Manhattan) | $199.24 | $395.78 | 2.0x |
| Florida (Fort Lauderdale) | $184.30 | $395.78 | 2.1x |
| Ohio | $166.30 | $395.78 | 2.4x |
| Mississippi | $160.40 | $395.78 | 2.5x |
| Arkansas | $158.88 | $395.78 | 2.5x |
| Alaska | $214.01 | $395.78 | 1.9x |
Rates shown are for the non-facility (office) setting using 2026 GPCIs and the $33.4009 conversion factor. The average provider charge of $395.78 is the 2023 national average from CMS utilization data. Actual charges vary by provider.
What Insured Patients Actually Pay for a 99204 Visit
If you have health insurance, you do not pay the provider's full charge of $395.78. Your insurer has a negotiated rate with the provider, typically 120% to 200% of the Medicare rate. For a 99204 visit, that negotiated rate is usually $215 to $395. What you owe depends on your plan design:
| Your Situation | What You Likely Pay | How It Works |
|---|---|---|
| Copay plan (deductible met or N/A) | $40 to $75 | Flat copay per specialist or primary care visit |
| Coinsurance plan (deductible met) | $43 to $79 | 20% of the negotiated rate ($215 to $395) |
| High-deductible plan (deductible NOT met) | $215 to $395 | You pay the full negotiated rate until your deductible is met |
| Medicare Part B | $35.47 | 20% of the Medicare-approved amount ($177.36) |
| Medicaid | $0 to $5 | Minimal or no cost-sharing in most states |
Should You Use Insurance or Pay Cash?
If you have a high-deductible health plan (HDHP) and have not met your deductible, you are paying the full negotiated rate for every visit. For a 99204 new patient visit, this is typically $215 to $395 through insurance. Many providers offer a cash-pay rate of $150 to $275 for the same visit, which can be significantly cheaper.
When Cash-Pay Wins
- You are unlikely to meet your deductible this year (low expected utilization)
- The provider's cash rate is below the insurer's negotiated rate
- You want to see an out-of-network specialist without a referral
- You are seeing a new doctor for a one-time consultation
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 documented for insurance continuity of care
Common Billing Problems with 99204
Upcoding from 99203 to 99204
A 99203 visit (new patient, low complexity, 30 to 44 minutes) pays $107.05, while a 99204 pays $177.36. That 66% jump creates a significant financial incentive to code visits at the higher level. If your first visit was straightforward (for example, a new PCP visit for a single mild issue like a prescription refill or a simple rash), it may warrant 99203 rather than 99204. You can request the visit notes to verify the documented complexity level.
Returning patients coded as "new"
Some practices code returning patients as "new" if they have not been seen in a while. The official CMS rule is that a patient is "new" only if they have not received face-to-face professional services from the physician (or same specialty in the same group practice) within the past 3 years. If you returned to the same doctor after 2.5 years and were coded as a new patient with 99204 instead of established patient with 99214, that is incorrect billing. The difference is $41.75 in Medicare rates alone, and even more on commercial insurance. Contact the billing department and request a correction.
Facility fee on top of the physician charge
If your doctor's office is owned by or affiliated with a hospital system, your new patient visit may be billed as a hospital outpatient visit. The physician charge drops from $177.36 to $116.90, but the hospital adds a facility fee of $150 to $400, making the total higher. Check your bill for a separate "facility fee" or "outpatient hospital" line item. This is especially common with specialist offices that have been acquired by health systems.
Time-based billing errors
Since 2021, E/M office visits can be coded based on either medical decision making or total time. If time-based, 99204 requires 45 to 59 minutes of total time (including chart review and care coordination, not just face-to-face time). If your visit was 40 minutes total, it should be coded as 99203, not 99204. Providers sometimes round up on time documentation. Your patient portal may show appointment duration that contradicts the billed code.
Related Office Visit Codes
| Code | Description | Time | Medicare (Office) | Avg. Charge |
|---|---|---|---|---|
| 99203 | New patient, low complexity | 30-44 min | $107.05 | $241.62 |
| 99204 | New patient, moderate complexity | 45-59 min | $177.36 | $395.78 |
| 99205 | New patient, high complexity | 60-74 min | $224.41 | $508.44 |
| 99213 | Established, low complexity | 20-29 min | $95.19 | $179.97 |
| 99214 | Established, moderate complexity | 30-39 min | $135.61 | $263.55 |
Frequently Asked Questions
How much does CPT 99204 cost without insurance?
Without insurance, a new patient office visit billed under CPT 99204 typically costs $150 to $275 for cash-pay patients. The national average provider charge is $395.78. Many providers offer a cash-pay discount of 20 to 40%, bringing the price down significantly. For comparison, Medicare pays $177.36 for this visit in an office setting.
What is the difference between 99204 and 99214?
CPT 99204 is for new patients (not seen by the physician or same specialty group in the past 3 years), while 99214 is for established patients. Both require moderate complexity medical decision making, but the new patient code pays 31% more ($177.36 versus $135.61 under Medicare). New patient visits are longer (45 to 59 minutes versus 30 to 39 minutes) because there is no prior relationship or chart to reference.
Why is a new patient visit more expensive than a follow-up?
New patient visits require more time and effort because the provider has no prior relationship or medical records to work from. A complete history must be gathered, medications reviewed, and a new assessment built from scratch. The RVU values reflect this: 99204 has a total RVU of 5.31 compared to 3.23 for 99214, which translates to $177.36 versus $135.61 under Medicare.
Can a returning patient be billed as a new patient?
Only if the patient has not received face-to-face professional services from the physician (or same specialty in the same group practice) within the past 3 years. If you returned to the same doctor after 2.5 years and were coded as a new patient, that is incorrect billing. The financial impact is real: $177.36 (99204) versus $135.61 (99214) under Medicare, and even larger differences on commercial insurance. Contact the billing department and request a correction.
How do I know if my visit should have been 99203 instead of 99204?
CPT 99203 covers a new patient visit with low complexity medical decision making (30 to 44 minutes), while 99204 requires moderate complexity (45 to 59 minutes). If your first visit was for a single straightforward issue, like a new PCP visit for a prescription refill or a simple skin concern, it likely qualifies as 99203 ($107.05) rather than 99204 ($177.36). The 66% price difference makes this a common upcoding opportunity. Request your visit notes and compare the documented complexity and time to the code billed.
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