CPT 99212: Medicare rates for 2026
99212: Office visit, returning patient, straightforward (Office visit). Description is our plain-language summary.
Which number to compare to
Match the reference to the kind of charge. A hospital visit often produces two bills: the hospital's facility charge and the doctor's professional charge.
| Kind of charge | 2026 national amount | Notes |
|---|---|---|
| Hospital outpatient facility charge | no separate rate | Status B: Not paid under OPPS on this code; a different code may be required for hospital outpatient billing. Source: CMS OPPS Addendum B, October 2026, national unadjusted. |
| Doctor's charge, in a hospital/facility | $31.06 | Paid to the physician; the hospital bills its facility charge separately. Source: CMS Physician Fee Schedule CY2026 (RVU26D, Oct 2026), national unadjusted. |
| Doctor's charge, office or clinic (non-facility) | $59.45 | Includes the practice's overhead; no separate facility charge. Source: CMS Physician Fee Schedule CY2026 (RVU26D, Oct 2026), national unadjusted. |
- All amounts are CY2026 national unadjusted rates (PFS RVU26D October release, conversion factor $33.4009; CLFS 2026 Q4; OPPS Addendum B October 2026). Medicare adjusts them by area, so local amounts differ.
- Rates are per unit. If your line shows more than one unit, multiply.
- Modifiers change the reference: -26 and -TC split imaging/tests; repeat modifiers (76, 77, 91) and distinct-service modifiers (59, XE, XS, XP, XU) mean a repeated line can be legitimate.
What a higher price means
Hospital and doctor list prices are often several times Medicare. That's usually legal, and it isn't proof of a billing error. What you actually owe depends on your insurance, your plan's negotiated rate, or the provider's self-pay price.
Useful next steps if your charge for 99212 looks high:
- If you're insured, compare the bill with your insurer's Explanation of Benefits (EOB). An in-network provider generally can't bill more than the EOB's patient amount.
- Ask for an itemized bill with codes, dates, units and modifiers (free letter).
- If you're uninsured or self-pay, ask for the self-pay price and the hospital's financial assistance policy. If you got a Good Faith Estimate and the bill is $400+ higher, you may be able to use the No Surprises Act dispute process.
Last checked against CMS files October 14, 2026. Not legal, medical, or financial advice.
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