CPT 99212E&M

Office o/p est sf 10 min

CPT code 99212 is billed for a straightforward office visit with a patient your practice has seen before, typically lasting 10 minutes and involving minimal medical decision-making.

Showing rates for

National Average

Base Medicare rate

$54.99

This calculator gives a typical-case estimate using standard Medicare modifier rules. Actual payment depends on payer policies, documentation, code-specific CMS status indicators, and locality. Verify before billing.

RVU breakdown

Work RVU

0.7

PE RVU (NF)

0.95

MP RVU

0.05

Total RVU

1.7

Conversion factor: 32.3465 · Source: CMS MPFS RVU25A · Confidence: High

NCCI bundling edits

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Billing tips

Time-based coding option: Track total time on date of encounter (including non-face-to-face activities like care coordination, documentation, results review) - 99212 requires 10-19 minutes total time
Impact: Undercoding is common with 99212; if total time reaches 20+ minutes, upcoding to 99213 increases reimbursement from $54.99 to approximately $93.05 (+$38.06 per visit)
Document medical decision-making elements: For MDM-based coding, ensure documentation shows 2 of 3 elements at straightforward level (minimal diagnosis/management, minimal data, minimal risk)
Impact: Clear MDM documentation prevents downcoding audits that could reduce reimbursement or support appropriate upcoding when complexity warrants
Verify established patient status: Patient must have been seen by same physician or another physician of exact same specialty in same group within past 3 years
Impact: Incorrect established patient designation can trigger claim denial; new patient code 99202 reimburses at $49.28, requiring appeal and reprocessing delays
Use modifier 25 appropriately with same-day procedures: Document separate, significant E&M service beyond procedural work to justify modifier
Impact: Proper 99212-25 documentation prevents denial of $54.99 E&M payment; however, excessive or inappropriate use triggers focused audits
Bill non-facility rate when applicable: Ensure place of service code 11 (office) is used for true office settings, not POS 22 (hospital outpatient)
Impact: Non-facility rate pays $54.99 vs facility rate $33.96, a difference of $21.03 per encounter (38% higher reimbursement)
Leverage incident-to billing when appropriate: When NP/PA sees established patient for stable condition, bill under physician NPI with incident-to requirements met

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Frequently asked questions

How much does Medicare pay for CPT code 99212 in 2025?

Medicare pays $54.99 for CPT 99212 in non-facility settings (physician offices) and $33.96 in facility settings (hospital outpatient departments) based on the 2025 Medicare Physician Fee Schedule national average. Actual reimbursement may vary by geographic locality due to GPCI adjustments.

What is the difference between 99211 and 99212?

99211 is a nurse-level visit that may not require physician presence and involves minimal or no medical decision-making, while 99212 requires a physician or qualified healthcare professional to perform straightforward medical decision-making or spend 10-19 minutes on the encounter. 99212 reimburses at $54.99 compared to approximately $26 for 99211.

Can I bill 99212 for a 5-minute visit?

No, if using time-based coding, 99212 requires 10-19 minutes of total time on the date of encounter. However, if using medical decision-making (MDM) for code selection, visit duration is irrelevant - you only need to meet straightforward MDM criteria regardless of time spent, as long as medically appropriate history/exam is performed.

What RVU value does 99212 have?

CPT 99212 has a total RVU of 1.7 for 2025, consisting of 0.7 work RVU, 0.95 practice expense RVU (non-facility), 0.3 practice expense RVU (facility), and 0.05 malpractice RVU. These RVUs multiplied by the 2025 conversion factor of $32.3465 determine Medicare payment rates.

When should I use modifier 25 with 99212?

Use modifier 25 with 99212 when you perform a significant, separately identifiable evaluation and management service on the same day as a minor procedure or other service. The E&M must be beyond the usual pre- and post-procedure work, though it does not require a different diagnosis. Common scenarios include addressing a new problem during a scheduled procedure visit.

Can nurse practitioners bill 99212?

Yes, nurse practitioners and physician assistants can bill 99212 when performing services within their scope of practice. Medicare reimburses NPPs at 85% of the physician fee schedule rate ($46.74) when billing under their own NPI, or 100% ($54.99) when using incident-to billing with proper physician supervision for established patients with stable conditions.

How do I choose between 99212 and 99213?

Choose based on either medical decision-making complexity or time. 99212 requires straightforward MDM or 10-19 minutes total time, while 99213 requires low complexity MDM or 20-29 minutes. Low complexity MDM involves limited problems, limited data review, or low risk - a step up from straightforward. If your total time reaches 20+ minutes or MDM is low complexity, code 99213 for higher reimbursement ($93.05 vs $54.99).