Office Visit, Established Patient, Straightforward (10-19 min)
CPT 99212 is the "quick visit" code. It covers a 10 to 19 minute office visit with straightforward medical decision making for an established patient. Think medication refill checks, simple follow-ups, or brief problem-focused visits. Providers charge an average of $113.04, but Medicare pays only $59.45 in an office setting (1.9x markup). Most patients have no idea that a 10-minute check-in for a prescription renewal costs over $100 before insurance.
CPT 99212 at a Glance
- Average provider charge: $113.04
- Medicare physician fee (office): $59.45
- Medicare physician fee (hospital): $31.07 + separate facility fee
- Typical markup: 1.9x over Medicare office rate
- Visit duration: 10 to 19 minutes
- Decision complexity: Straightforward
- Patient type: Established (seen before)
- Beneficiaries (2023): 4.3 million
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How the Medicare Rate Is Calculated
Medicare prices every procedure using Relative Value Units (RVUs) across three components, then multiplies by a national conversion factor of $33.4009 (2026). Here is the exact math for a 99212 visit:
| Component | What It Covers | Office (Non-Facility) | Hospital (Facility) |
|---|---|---|---|
| Work RVU | Physician time, skill, and judgment | 0.70 | 0.70 |
| Practice Expense RVU | Rent, staff, equipment, supplies | 1.02 | 0.17 |
| Malpractice RVU | Professional liability insurance | 0.06 | 0.06 |
| Total RVU | 1.78 | 0.93 | |
| x $33.4009 | 2026 conversion factor | $59.45 | $31.07 |
Medicare Rate by State
Medicare adjusts the national rate based on your location using Geographic Practice Cost Indices (GPCIs). The same 99212 visit pays differently in each state, ranging from about $43 in Arkansas to $59 in Alaska (a 37% 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) | $48.77 | $113.04 | 2.3x |
| California (Los Angeles) | $52.22 | $113.04 | 2.2x |
| New York (Manhattan) | $53.17 | $113.04 | 2.1x |
| Florida (Fort Lauderdale) | $49.02 | $113.04 | 2.3x |
| Ohio | $45.12 | $113.04 | 2.5x |
| Mississippi | $43.30 | $113.04 | 2.6x |
| Arkansas | $42.91 | $113.04 | 2.6x |
| Alaska | $58.67 | $113.04 | 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 $113.04 is the 2023 national average from CMS utilization data. Actual charges vary by provider.
What Insured Patients Actually Pay for a 99212 Visit
If you have health insurance, you do not pay the provider's full charge of $113.04. Your insurer has a negotiated rate with the provider, typically 120% to 200% of the Medicare rate. For a 99212 visit, that negotiated rate is usually $70 to $120. 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 specialist or primary care visit |
| Coinsurance plan (deductible met) | $14 to $24 | 20% of the negotiated rate ($70 to $120) |
| High-deductible plan (deductible NOT met) | $70 to $120 | You pay the full negotiated rate until your deductible is met |
| Medicare Part B | $11.89 | 20% of the Medicare-approved amount ($59.45) |
| Medicaid | $0 to $4 | Minimal or no cost-sharing in most states |
Should You Use Insurance or Pay Cash?
For a quick 99212 visit, the cash-pay option is often surprisingly competitive. Many providers charge $50 to $80 for a brief established patient visit without insurance. If your deductible is not met, you could be paying $70 to $120 through insurance for the same visit.
When Cash-Pay Wins
- Your deductible is not met and the cash rate is lower than the negotiated rate
- You need a simple medication refill and want to avoid insurance complexity
- You are between insurance plans or have a coverage gap
- Telehealth options for refills may be even cheaper ($25 to $50)
When Using Insurance Wins
- Your copay is $20 to $30 (cheaper than most cash-pay rates)
- You are close to meeting your annual deductible
- You need the visit on record for a referral or prior authorization
- Lab work or other services are being ordered at the same visit
Common Billing Problems with 99212
Upcoding to 99213
A 99213 visit (low complexity, 20 to 29 minutes) pays $95.19, while a 99212 pays $59.45. That 60% jump is a strong incentive to upcode. If your visit was genuinely a 10 to 15 minute straightforward check-in (blood pressure check, single medication refill, a brief follow-up on a resolved issue), it should be coded as 99212. Ask for the visit notes if you see 99213 on your bill and the visit felt quick.
Should have been 99211 (nurse visit)
CPT 99211 is for visits that may not require a physician's presence, such as a nurse-administered injection, blood pressure check, or simple wound check. It pays about $25. If you came in only for a nurse to check your vitals or administer a previously ordered injection, and a physician barely stepped into the room, the visit may be more appropriately coded as 99211 rather than 99212.
Stacking unnecessary add-on codes
Some practices add a separate charge for services that should be included in the office visit. For example, billing a 99212 plus a separate charge for reviewing your medication list or discussing test results. These activities are part of the evaluation and management service and should not be billed separately. Check your bill for any additional E/M codes or "consultation" charges on the same date.
Telehealth visits billed at the same rate
Many providers bill telehealth visits at the same CPT code and rate as in-person visits. While Medicare allows this with appropriate modifiers, the overhead for a telehealth visit is lower. If you had a 5-minute video call for a medication refill and were billed $113 for a 99212, consider whether a lower-cost telehealth-specific service would have been more appropriate.
Related Office Visit Codes
| Code | Description | Time | Medicare (Office) | Avg. Charge |
|---|---|---|---|---|
| 99211 | Established, may not require physician | N/A | ~$25 | ~$48 |
| 99212 | Established, straightforward | 10-19 min | $59.45 | $113.04 |
| 99213 | Established, low complexity | 20-29 min | $95.19 | $179.97 |
| 99214 | Established, moderate complexity | 30-39 min | $135.61 | $263.55 |
| 99215 | Established, high complexity | 40-54 min | $192.39 | $381.33 |
Frequently Asked Questions
How much does a quick doctor visit (99212) cost without insurance?
Without insurance, a quick office visit billed under CPT 99212 costs $75 to $175 depending on the provider and location. The national average charge is $113.04. Many providers offer a cash-pay discount of 20 to 40%, bringing the price closer to $70 to $90. For comparison, Medicare pays $59.45 for this visit in an office setting.
What is the difference between 99211 and 99212?
CPT 99211 is a nurse-level visit that may not require a physician to be present, typically for simple tasks like blood pressure checks or injection administration. It pays about $25. CPT 99212 requires a physician (or qualified provider) and involves straightforward medical decision making over 10 to 19 minutes. If your visit was handled entirely by a nurse for a routine check, it may be more appropriately coded as 99211.
Can a 10-minute medication refill really cost $113?
Yes. The national average provider charge for CPT 99212 is $113.04, even though the visit may only last 10 to 15 minutes. This includes the provider charge only, not lab work or other tests. If you have insurance, you will pay less (your copay or coinsurance). But if uninsured or on a high-deductible plan, ask your provider about their cash-pay rate, which is often $50 to $80 for this type of visit.
How do I know if my visit was upcoded from 99212 to 99213?
Check your Explanation of Benefits (EOB) or medical bill for the CPT code. If it shows 99213 but your visit lasted under 20 minutes and addressed a single straightforward issue (like a routine medication refill), you may have been upcoded. You can request your visit notes from the provider, which must document the time spent and the complexity of medical decision making to justify the code billed.
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