Office visit, new patient, moderate complexity (CPT 99204): what Medicare pays
On a hospital bill, CPT 99204 is the code for: New patient office or other outpatient visit with moderate level of medical decision making, if using time, 45 minutes or more. Here is what Medicare pays for it, what is billed on average, and how to question the line on your bill.
CPT 99204 at a glance
| Medicare average allowed amount | $160.28 |
|---|---|
| Average amount billed to Medicare | $410.82 |
| Billed vs. allowed | 2.6 times |
| Services in the data | 11,402,207 |
| Setting and year | Office or clinic, national average, 2024 |
What this code is
This code is for a visit with a doctor or another clinician. The level depends on how complex the visit was.
Why your hospital bill can show more
Medicare pays a national amount for each code. Hospitals set their own list prices, called the chargemaster, so a hospital bill can show a much higher amount for the same code. In a hospital or an emergency room, a separate facility charge is often added. Medicare's amount is not a price the hospital must accept, but it is a fair reference to negotiate.
Common billing problems with CPT 99204
The level of the visit
The level is chosen by the clinician. If the visit was short and simple, ask why this level was billed.
No code on the line
If your bill shows a total without codes, ask for a fully itemized bill. Without codes, nobody can check the charges.
How to question this charge
- Ask the hospital for a fully itemized bill, with the code, date, quantity and price of every line.
- Compare the line with the Medicare amount above.
- Ask in writing for a fair price, the lowest amount they will accept, and any discount for paying in full or for patients without insurance.
- Ask for the hospital's financial assistance policy.
BillCheck reads a photo of your bill on your phone, compares every line and writes the letter. Check my bill.
Related codes
- CPT 99203: Office visit, new patient, low complexity
- CPT 99213: Office visit, established patient, low complexity
- CPT 99214: Office visit, established patient, moderate complexity
Frequently asked questions
How much does CPT 99204 cost?
It depends on where it is done. In 2024, Medicare's average allowed amount for CPT 99204 in an office setting was $160.28, and providers billed Medicare $410.82 on average. Hospitals can bill more. If you have no insurance, ask for the self-pay price before you pay.
What is the difference between CPT 99204 and CPT 99203?
CPT 99204 is Office visit, new patient, moderate complexity. CPT 99203 is Office visit, new patient, low complexity. Medicare's average allowed amounts were $160.28 and $105.33 in 2024.
How do I question this charge?
Ask for an itemized bill, compare the line with the Medicare amount, then ask in writing for a fair price and for financial assistance. BillCheck writes the letter for you.