CPT · EVALUATION & MANAGEMENT

99204

Evaluation & management (CPT® descriptor withheld: AMA licence required)

Reimbursement benchmark

RVU26D

$177.36

National benchmark · GPCI 1.000
Non-facility · Non-QP · per service

Behind the number

Each RVU × its geographic practice cost index

Physician work2.600 RVU × 1.000 GPCI2.60000

Practice expense2.470 RVU × 1.000 GPCI2.47000

Malpractice0.240 RVU × 1.000 GPCI0.24000

Conversion factorNon-QP schedule× 33.4009

Estimated fee schedule amount$177.36

Geography makes a difference

Same component, setting, and provider schedule across 109 localities

109 localities

LOWEST LOCALITY$161.84

MEDIAN LOCALITY$180.49

HIGHEST LOCALITY$222.54

National benchmark (GPCI 1.000): $177.36. This is not a utilization-weighted national average.

Modifiers on this code

National · Non-facility

Computed from the CMS payment policy indicators on this code's RVU row, priced in your current context. Where the fee schedule sets no percentage, the row says who decides.

Modifier	Effect	Amount	How it applies to 99204
25	Significant, separately identifiable E/M on the same day No change	$177.36	Appended to the E/M code, not the procedure. The visit is paid in full when the documentation supports work beyond the procedure's usual pre- and post-service work.
26	Professional component Not applicable	—	Physician service only: no professional/technical split exists (PC/TC indicator 0).
TC	Technical component Not applicable	—	Physician service only: no professional/technical split exists (PC/TC indicator 0).
50	Bilateral procedure Not applicable	—	The 150% bilateral adjustment does not apply; a second side is paid at the lower of the billed charge or 100% (indicator 0).
51	Multiple procedures, same session Not applicable	—	No multiple-procedure reduction applies (indicator 0).
59 / XE XS XP XU	Distinct procedural service No change	$177.36	Does not change the amount. It asks the payer to bypass an NCCI pair, which only works when that pair's modifier indicator is 1; hard-stop pairs (indicator 0) deny regardless. See the NCCI conflicts below.
80 / 81 / 82	Assistant surgeon Payer-determined	—	Payment restricted: an assistant is paid only with documentation of medical necessity (indicator 0).
62	Two surgeons (co-surgery) Not applicable	—	Co-surgeons are not permitted for this code (indicator 0).
66	Surgical team Not applicable	—	Team surgery is not permitted for this code (indicator 0).
95 / 93	Telehealth (audio-video / audio-only) No change	$177.36	The fee schedule amount does not change; whether the facility or non-facility rate applies depends on the place of service reported, and whether the service is on the Medicare telehealth list.
22	Increased procedural services Payer-determined	—	Carrier-priced. The schedule sets no percentage; the payer decides any increase from the documentation of substantially greater work.
52	Reduced services Payer-determined	—	Payer-determined reduction from the fee schedule amount; the schedule sets no percentage.
53	Discontinued procedure Payer-determined	—	Payer-determined; documentation must show the procedure was stopped for the patient's wellbeing.
76 / 77	Repeat procedure, same or other physician No change	$177.36	Each repeat is paid at the full fee schedule amount when the documentation supports a separate, medically necessary repeat.

Estimates before payer adjustments and cost sharing. A payer's own policy can differ from Medicare's; verify before billing.

Before this code goes on a claim

Denial prevention

Status indicator AActive and separately payable under the physician fee schedule.

384 hard-stop NCCI pairs309 pairs bundle this code into another code and 75 bundle other codes into it, with no modifier override (indicator 0). Billed together on the same date, the column-2 code denies.

351 pairs allow a modifier304 pairs where this is the bundled code and 47 where it is the primary can be unbundled with 59 or X{EPSU} when the documentation shows a distinct service (indicator 1). Check the claim before submission: this code is the one that denies in 613 active pairs.

Global period XXXThe global period concept does not apply to this code.

Assistant surgeonAssistant-at-surgery claims need documentation of medical necessity or they deny.

Check a claim with this code Rates in every state and locality

Field data from billers

Unavailable

Field data is not available right now.

Structured answers only. No patient details, claim numbers or free text are collected.

Code intelligence

CPT

Payment statusActive

Global periodXXX

PC/TC indicator0

Multiple procedure indicator0

Bilateral surgery indicator0

Assistant surgery indicator0

Raw CMS indicators. Read the release documentation before interpreting a payment policy indicator.

CMS release documentation

PUT THE DATA TO WORK

From a rate to an informed decision.

Understand the RVUs, compare a second code, or evaluate an observed allowed amount.

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RVU-based Medicare benchmark, before payer adjustments, OPPS caps, sequestration, and patient cost sharing. An estimate, not a payment guarantee.