New vs. Established Patient wRVU Values: How Your Visit Mix Shapes Annual Pay

Why the same visit can be worth different wRVUs depending on who the patient is

If you bill a level 4 office visit today for a patient you have never seen before, and tomorrow bill another level 4 for a patient you have been treating for three years, those two visits look identical in your schedule — but they do not produce the same wRVU credit. The new patient visit (code 99204) generates 2.60 wRVUs under the 2026 CMS Physician Fee Schedule. The established patient visit at the same complexity level (code 99214) generates 1.92 wRVUs — about 26% less, despite the same complexity level.

This gap is intentional. CMS assigns higher work relative value units to new patient codes because first encounters require gathering a complete medical history from scratch, reviewing records from previous providers, and establishing a care plan in the absence of any prior knowledge of the patient. The established patient visit carries a lower work value because a significant portion of that cognitive work was already done at previous visits. The per-visit wRVU differential is CMS's way of recognizing that the work intensity is genuinely different — even when the encounter looks similar on the surface.

For a physician under a wRVU-based compensation contract, understanding this gap matters. The share of your visits that are new versus established — your visit mix — directly determines your average wRVU per patient, and your average wRVU per patient determines how close you get to your annual production threshold.

The 2026 wRVU values, side by side

The table below shows the current work RVU values for standard outpatient office visit codes under the 2026 Medicare Physician Fee Schedule. These values come from CMS's published fee schedule and are the basis for how most physician employment contracts measure production — regardless of payer mix.

The differentials between comparable levels are meaningful: a level 3 new patient visit (99203) is worth 23% more than a level 3 established visit (99213). At level 4, the gap widens to 35%. At level 5, it narrows slightly to 25%. Even at the lower end, a level 2 new patient visit (99202, 0.93 wRVU) is 33% more than a level 2 established visit (99212, 0.70 wRVU).

One important clarification: these wRVU values are entirely separate from Medicare's billing payment rate. The 2026 Medicare conversion factor — approximately $33.40 — translates wRVUs into Medicare reimbursement to your practice. It has nothing to do with the $/wRVU rate in your employment contract, which is a separate negotiated figure that typically falls well above that billing rate. The $/wRVU in a physician employment agreement represents what the employer pays you for each unit of production, not what Medicare pays your practice for billing a code.

How your visit mix shapes the production math

Because every new patient visit credits you more wRVUs than an equivalent established visit, the proportion of new patients in your schedule — even holding total visit volume constant — directly moves your annual production total.

Consider a physician seeing 15 patients per day across 200 clinical days per year: 3,000 total visits. Suppose their typical new patient is a moderate-complexity visit (99204, 2.60 wRVU) and their typical established patient is a low-to-moderate complexity visit (roughly 1.50 wRVU on average across 99213 and 99214). Under those assumptions:

Moving from a 5% to a 30% new-patient mix — with the same 3,000 visits and no change in documentation habits — produces roughly 825 additional wRVUs per year in this illustration. At a pay rate of $55 per wRVU, that gap is worth about $45,000 annually. The actual numbers will vary by specialty, coding level, and contract rate, but the direction is consistent: a higher new-patient percentage raises per-visit wRVU production even when you are not seeing more patients.

These are illustrative figures. Your own production will depend on your visit volume, the actual complexity distribution of your cases, and how your employer defines and tracks new versus established status. The point is that two physicians practicing identically in terms of daily patient volume can show meaningfully different annual wRVU totals if their panels differ in new-patient share.

The ramp-up effect in a new or growing practice

When you begin a new employment position or launch a new practice, most patients on your schedule are seeing you for the first time. That makes the early months disproportionately rich in new-patient codes, which boosts per-visit wRVU production beyond what you will sustain as the same patients return for follow-up visits.

As your panel matures — typically over the first one to three years — those patients convert to established status. The volume of new patients as a share of your schedule gradually decreases. Your total visit count may continue rising as the panel fills, but your per-visit wRVU average tends to decline as the new-patient proportion shrinks. For a physician on a uniform multi-year threshold, this means the early years of a contract can feel more production-friendly than later years, even with identical clinical habits and comparable visit volume.

This is not a problem unique to any one physician — it is a structural feature of how outpatient practices grow. But it matters when evaluating a contract with a fixed threshold that applies identically in year one and year three. A ramp-period provision — which temporarily lowers the threshold in the first year or two — can account for this, but it does not always do so with visit-mix dynamics in mind. Understanding why your per-visit production naturally shifts over time gives you the context to recognize when a target is realistic and when it may need to be renegotiated.

What wRVU benchmarks assume about your mix

When MGMA, SullivanCotter, AMGA, and other survey organizations report annual wRVU production figures for a given specialty, those figures reflect the actual production of surveyed physicians — including whatever new-to-established ratio those physicians happened to have during the survey year. The benchmark already embeds a mix. It does not represent a pure new-patient panel or a pure established-patient panel; it represents the blend typical of practicing physicians in that specialty and practice setting.

This becomes relevant when your practice's mix differs significantly from what the benchmark assumes. If your employer sets your threshold at the 50th-percentile benchmark for your specialty but your panel is closed to new patients, or predominantly consists of long-established patients with fewer acute needs, your per-visit wRVU average may be structurally below what the benchmark implies. You might be coding accurately and working efficiently, but still falling short of a target built for a panel with a different composition.

The converse is also true: if you work in a setting with unusually high new-patient turnover — a rapid-growth clinic, a new specialty practice, or a service area with limited prior access to your specialty — your per-visit wRVU production during the growth phase may run above benchmark, not because you are coding unusually high but because your panel composition is temporarily new-patient-heavy.

Questions to ask about your threshold and panel

If you are evaluating a new employment contract or renegotiating an existing one, the visit-mix issue suggests a few specific questions worth asking:

• Which survey and percentile anchors my threshold? Knowing whether the threshold is set at the 50th or 75th percentile of a given year's data tells you how much room you have, and whether the target is aspirational or representative of typical performance.
• What practice type does that benchmark reflect? MGMA and similar surveys often break out hospital-employed physicians from independent practices, and some specialties show significant variation between settings. A threshold based on independent-practice data may be harder to hit in a salaried hospital setting where scheduling and panel access are controlled by the institution.
• Will new-patient access be within my control? If the clinic schedules new patients at the employer's discretion, restricts your new-patient slots, or assigns your panel composition without your input, your visit mix is not fully under your control. A threshold should reflect that reality.
• Is there a ramp-period adjustment in year one? If so, how was it calculated — does it account for the fact that year-one production tends to be supported by a high new-patient ratio that will not persist? See the physician ramp-period pay guide for how ramp structures work in general.

None of these questions require adversarial framing. They are simply part of understanding whether the production target in your contract reflects the actual clinical work you will be doing, in the panel and setting you will actually be working in.