CPT 99204: Federal IDR outcomes
New patient office or other outpatient visit with moderate level of medical decision making, if using time, 45 minutes or more
In 2025 Q1–Q4, the provider or facility offer prevailed in 89.1% of 745 determined Federal IDR dispute line items for CPT 99204. The median prevailing offer was 4.51x the QPA (25th–75th percentile 1.80x–11.75x; n = 682). The median time to a decision was 28 business days (n = 745).
Determined line items
745
2025 Q1–Q4 · 1 split decisions excluded
Provider win rate
89.1%
n = 745 · 2025 Q1–Q4
Median payment vs QPA
4.51x
middle half 1.80x–11.75x · n = 682 · 2025 Q1–Q4
Median days to decision
28
business days, from dispute initiation · n = 745 · 2025 Q1–Q4
Dollar amounts
Total awarded
$785,837
sum of prevailing offers · n = 597 · 2025 Q1–Q4
Total QPA
$119,901
sum of QPAs, same line items · n = 597 · 2025 Q1–Q4
Awarded above QPA
$665,937
total awarded minus total QPA · n = 597 · 2025 Q1–Q4
Median award per line item
$751
mean $1,316 · n = 597 · 2025 Q1–Q4
Median QPA
$168
per line item · n = 597 · 2025 Q1–Q4
Award vs QPA, dollar-weighted
6.55x
total awarded ÷ total QPA · n = 597 · 2025 Q1–Q4
Dollar amounts come from the separate CMS “QPA and Offers” file: line items decided for the provider or the plan with a non-suppressed QPA and prevailing offer. That file cannot be joined to the line items above, so its n differs. Awarded = the prevailing (selected) offer; it is not a record of what was paid. State comes from the file’s geographic region; a metro area that spans states counts in each. How the dollar figures work
Dollar amounts by period
| Period | Line items with $ | Total awarded | Total QPA | Above QPA | Median award | Median QPA | Award ×QPA ($-weighted) |
|---|---|---|---|---|---|---|---|
| 2025 Q1–Q4 | 597 | $785,837 | $119,901 | $665,937 | $751 | $168 | 6.55x |
| 2024 Q3–Q4 | 73 | $107,829 | $12,308 | $95,522 | $1,638 | $164 | 8.76x |
| 2024 Q3–2025 Q4 | 670 | $893,667 | $132,208 | $761,458 | $1,018 | $168 | 6.76x |
| 2023 Q1–2024 Q2 | Not available (see methodology). | ||||||
From the CMS QPA and Offers file (see above). Award ×QPA here is total awarded ÷ total QPA, so large claims weigh more than in the per-line median ratio.
By period
| Period | Line items | Win % | Median ×QPA | 25th–75th | Ratio n | Median days |
|---|---|---|---|---|---|---|
| 2025 Q1–Q4 | 745 | 89.1% | 4.51x | 1.80x–11.75x | 682 | 28 |
| 2024 Q1–Q4 | 147 | 85.7% | 8.97x | 4.85x–11.75x | 124 | 34 |
| 2023 Q1–Q4 | Fewer than 30 determined line items; not shown. | |||||
| 2023 Q1–2025 Q4 | 895 | 88.6% | 5.40x | 1.88x–11.75x | 807 | not pooled |
Line items = determined dispute line items (n). Win rate excludes split decisions and includes default decisions. Ratio n = line items reporting a payment-to-QPA ratio. Days are business days as reported by CMS (2023–2024: from IDR entity assignment; 2025: from initiation) and are never pooled.
By state
| State (place of service) | Line items | Win % | Median ×QPA | Ratio n | Median days |
|---|---|---|---|---|---|
| Wisconsin | 254 | 88.6% | 1.71x | 219 | 26.5 |
| Texas | 248 | 91.9% | 8.99x | 230 | 31 |
| California | 91 | 87.9% | 25.24x † | 89 | 26 |
| Tennessee | 55 | 78.2% | 2.58x | 54 | 26 |
| New Jersey | 45 | 84.4% | 16.94x | 44 | 41 |
2025 Q1–Q4 · rows with n ≥ 30 determined line items · sorted by n.
Dollar amounts by state
| State (region) | Line items with $ | Total awarded | Median award | Median QPA | Award ×QPA |
|---|---|---|---|---|---|
| Texas | 152 | $185,457 | $1,638 | $164 | 7.51x |
| Wisconsin | 132 | $60,555 | $466 | $226 | 1.83x |
| California | 72 | $287,926 | $4,750 | $149 | 18.08x |
| Tennessee | 48 | $19,283 | $474 | $155 | 2.44x |
| New Jersey | 41 | $79,760 | $2,250 | $133 | 14.35x |
| New York | 41 | $79,760 | $2,250 | $133 | 14.35x |
| Pennsylvania | 41 | $79,760 | $2,250 | $133 | 14.35x |
2025 Q1–Q4 · CMS QPA and Offers file · rows with n ≥ 30 line items with dollar amounts · sorted by n · Award ×QPA = total awarded ÷ total QPA.
By specialty
| Specialty group | Line items | Win % | Median ×QPA | Ratio n | Median days |
|---|---|---|---|---|---|
| Emergency medicine and emergency departments | 454 | 93.4% | 3.46x | 404 | 28.5 |
| Hospital medicine (hospitalists) | 63 | 82.5% | 2.73x | 62 | 27 |
| Plastic and reconstructive surgery | 36 | 86.1% | 15.02x | 36 | 27 |
| Internal and family medicine | 34 | 94.1% | 7.54x | 32 | 31 |
| Neurosurgery and spine surgery | 33 | 93.9% | 29.13x † | 33 | 27 |
| Orthopedic surgery | 30 | 90.0% | – | 28 | 29 |
2025 Q1–Q4 · rows with n ≥ 30 determined line items · sorted by n.
Section: Evaluation and management (99202–99499)
FAQ
What is the Federal IDR provider win rate for CPT 99204?
In 2025 Q1–Q4, the provider or facility offer was selected in 89.1% of 745 determined dispute line items for CPT 99204. Split decisions are excluded from the denominator and default decisions are included. Withdrawn, settled and ineligible disputes are not in the CMS data.
How do Federal IDR payments compare with the QPA for CPT 99204?
In 2025 Q1–Q4, the median prevailing offer was 4.51x the qualifying payment amount (QPA), with a 25th to 75th percentile range of 1.80x to 11.75x (n = 682 line items). This uses the CMS field Prevailing Party Offer as % of QPA, where 1.00x equals the QPA.
How long do Federal IDR decisions take for CPT 99204?
In 2025 Q1–Q4, the median was 28 business days (n = 745 line items), using the CMS field Length of Time to Make Determination (from dispute initiation).