CPT 2026 · E/M

CPT 99204

Global XXX Active

Office o/p new mod 45 min

Effective 2026-04-01 Conv. factor $33.4009

$181.58

National Avg (Non-Fac)

5.31

Total RVU

NCCI Partners

109

MPFS Localities

CPT 99204 Billing & Documentation Guide

CPT code 99204 (Office o/p new mod 45 min) is classified under E/M with a global period indicator of XXX. The 2026 Medicare Physician Fee Schedule assigns a work RVU of 2.6, a non-facility practice expense RVU of 2.47, and a malpractice RVU of 0.24, a total non-facility RVU of 5.31 and facility RVU of 3.5. With the current conversion factor of $33.4009, the national average non-facility reimbursement is approximately $181.58, though rates vary from $161.84 to $222.54 based on MAC locality and Geographic Practice Cost Indices (GPCIs).

When billing 99204, ensure documentation supports medical necessity and the specific components required for the code's level of service. For E/M codes, document MDM (medical decision-making) elements: problems addressed, data reviewed, and risk. For procedural codes, document the indication, technique, and any complications. Always verify NCCI edits before bundling 99204 with related codes; this code has 10 PTP bundling relationships on file (see table below).

Coding Tips for 99204

Real-world specialist guidance from the PayerReady Medical Coding Team, not generic boilerplate.

New patient 99204 (moderate complexity) requires 45-59 minutes or moderate MDM. Averages $165 Medicare non-facility reimbursement. Matches 99214 MDM thresholds but with the 3-year new-patient rule.

High-value time-based code: if patient encounter exceeds 45 minutes with any documentation of history, exam, or MDM, 99204 is defensible even if MDM alone would only support 99203.

Audit target: ensure "new patient" is verified. Groups with multiple locations often bill new patient in error when the patient saw a different location of the same TIN within 3 years.

Modifier 25 reminder: When billing this E/M with a same-day procedure (injection, EKG, vaccine administration), append modifier 25 to the E/M and document a separately identifiable problem beyond the routine pre-procedure evaluation. OIG audits show 42% of modifier 25 claims fail documentation review.

Payment Status & Global Period

CMS Status Indicator

Active code (paid under MPFS)

Global Period

XXX

No global period (E/M and other non-procedural services)

MUE Limit (Medically Unlikely Edits)

Max units per beneficiary per date of service

Rationale: CMS Policy

Adjudication: Date of Service (Policy)

Source: CMS NCCI MUE Practitioner Services, effective 2026-04-01.

Submitting more than 1 units of 99204 for the same patient on the same date triggers automatic line denial unless an appropriate modifier and supporting documentation justify the higher quantity.

RVU Breakdown, CPT 99204

Component	Non-Facility	Facility
Work RVU	2.6	2.6
Practice Expense RVU	2.47	0.66
Malpractice RVU	0.24	0.24
Total RVU	5.31	3.5
Conversion Factor	$33.4009

2026 Medicare Reimbursement by State, CPT 99204

State-level averages across all MAC localities. Non-facility rates typically apply to office-based services; facility rates apply to hospital outpatient / inpatient.

State	Non-Facility	Facility	Range (Non-Fac)	Localities
California	$191.92	$120.39	$183.04 - $219.66	29
Florida	$185.22	$124.57	$177.76 - $193	3
Georgia	$175.27	$117.6	$169.99 - $180.55	2
Illinois	$182.18	$123.77	$174.69 - $188.76	4
Michigan	$175.6	$118.82	$171.22 - $179.97	2
North Carolina	$168.94	$112.53	$168.94 - $168.94	1
New York	$193.89	$126.45	$170.85 - $205.38	5
Ohio	$170.25	$115.05	$170.25 - $170.25	1
Pennsylvania	$177	$117.79	$170.15 - $183.85	2
Texas	$175.99	$116.47	$169.36 - $181.4	8

Source: CMS PFSRVU 2026 · Updated 2026-04-01. Full locality-level detail available for all 53 states, contact us for custom reports.

NCCI Bundling Edits, CPT 99204

Procedure-to-procedure (PTP) edits. If you bill any of these codes with 99204 on the same date of service, review the modifier indicator and payer policy before submission.

Partner Code	Relationship	Modifier Allowed	Rationale
0074T	Column 1 (primary), can be billed with modifier	9	CPT Manual or CMS manual coding instruction
0115T	Column 1 (primary), can be billed with modifier	Yes	Misuse of Column Two code with Column One code
0116T	Column 1 (primary), can be billed with modifier	Yes	Misuse of Column Two code with Column One code
0359T	Column 1 (primary), can be billed with modifier	Yes	Misuse of Column Two code with Column One code
0360T	Column 1 (primary), can be billed with modifier	Yes	Misuse of Column Two code with Column One code
0361T	Column 1 (primary), can be billed with modifier	Yes	Misuse of Column Two code with Column One code
0362T	Column 1 (primary), can be billed with modifier	Yes	Misuse of Column Two code with Column One code
0362T	Column 1 (primary), can be billed with modifier	Yes	Misuse of Column Two code with Column One code
0363T	Column 1 (primary), can be billed with modifier	Yes	Misuse of Column Two code with Column One code
0364T	Column 1 (primary), can be billed with modifier	Yes	Misuse of Column Two code with Column One code

Frequently Asked Questions, CPT 99204

What does CPT code 99204 mean? +

CPT code 99204 represents: Office o/p new mod 45 min. It's in the E/M category with a global period of XXX.

What is the Medicare reimbursement for CPT 99204? +

The 2026 Medicare national average non-facility payment for CPT 99204 is $181.58. Rates range from $161.84 to $222.54 across 53 states depending on MAC locality and GPCIs.

What modifiers can I use with CPT 99204? +

E/M codes commonly use modifier 25 (significant separately identifiable E/M on same day as a procedure), 57 (decision for major surgery), 24 (unrelated E/M during global period), 95 (synchronous audio+video telehealth), 93 (audio-only telehealth), and AI (principal physician of record on admission). Surgical modifiers like 50, 51, 59 do not apply to E/M.

What bundling edits apply to CPT 99204? +

This code has 10 NCCI PTP bundling relationships. See the NCCI Bundling section below for full list.