What is included in CPT code 99204?

CPT code 99204 includes an office or outpatient evaluation and management (E/M) visit for a new patient that requires a moderate level of medical decision-making or a total time of 45 to 59 minutes on the date of the encounter.

According to guidelines maintained by the American Medical Association, here is a breakdown of what the code entails and how it is qualified:

Core Requirements

You can select and bill CPT 99204 using either Medical Decision-Making (MDM) or Total Time:

• By Medical Decision-Making (Moderate Complexity): Must meet at least two of the three MDM elements:
  • Number and complexity of problems addressed (e.g., one or more chronic illnesses with exacerbation, or two or more stable chronic illnesses).
  • Amount and/or complexity of data reviewed and ordered.
  • Risk of complications and/or morbidity or mortality of patient management.
• By Total Time (45–59 Minutes): Includes face-to-face and non-face-to-face time spent by the provider on the date of the encounter (such as reviewing records, counseling, and documenting the visit).

What Else is Included?

• Patient Status: Applies only to a "new patient"—someone who has not received any professional services from the provider (or another physician of the same specialty in the same group practice) within the past 3 years.
• History and Examination: Requires a medically appropriate history and/or physical examination, meaning the clinician decides the exact clinical scope needed based on the patient's presentation.

The primary difference between CPT code 99204 and 99214 is that 99204 is used for a new patient, while 99214 is used for an established patient. Both codes share a moderate level of medical decision-making (MDM), but they differ in time requirements and patient history status.

Patient Status Definition

• CPT 99204: Reserved for a new patient—someone who has not received any professional services from the provider (or another provider of the exact same specialty in the same group practice) within the past three years.
• CPT 99214: Reserved for an established patient—someone who has seen the provider or a same-specialty colleague in the same practice within the last three years.

Time Requirements

Under current American Medical Association (AMA) evaluation and management (E/M) guidelines, both codes can be selected based on either total time spent on the date of the encounter or medical decision-making (MDM):

• CPT 99204 Time: Requires 45 to 59 minutes of total time.
• CPT 99214 Time: Requires 30 to 39 minutes of total time.

Medical Decision-Making (MDM)

Both codes require a moderate level of medical decision-making (which involves analyzing data, assessing patient risk, and addressing multiple or complex conditions). However, because new patients inherently require more initial background work and setup, the overall clinical effort for a new patient at a moderate level (99204) commands a higher relative value unit (RVU) and reimbursement rate than an established patient visit at the same complexity level (99214).

The 2026 national average Medicare reimbursement rate for CPT code 99204 is approximately $177.36 for non-facility (office) settings and $116.90 for facility settings.

Reimbursement Breakdown

• Medicare Office (Non-Facility): ~$177.36 (varies by geographic locality from about $160 to $220).
• Medicare Facility (Hospital Outpatient): ~$116.90 (plus a separate facility fee).
• Commercial Payers (Medicaid/Private): Typically range from $150 to $300, with major private insurers like BCBS, UHC, Aetna, and Cigna averaging around $175 to $203 nationally.
• Medicaid: Varies significantly by state rules and fee schedules.

Code Details

• Description: Outpatient evaluation and management (E/M) visit for a new patient, requiring moderate medical decision-making (MDM).
• Time: 45 to 59 total minutes spent on the date of the encounter.
• Tools: You can check precise geographic adjustments using the CMS Physician Fee Schedule Look-Up Tool or view market analytics on PayerPrice.

Use CPT code 99203 for a new patient office visit lasting 30 to 44 minutes with low-complexity medical decisions, and use 99204 for a visit lasting 45 to 59 minutes with moderate-complexity decisions.

Both codes apply only to new patients. A new patient is someone who has not seen the same doctor or another doctor in the same medical group within the past three years. You can choose the correct code using either total time spent on the date of service or medical decision-making (MDM), as outlined by the American Academy of Family Physicians.

When to Use CPT 99203

• Time: Total provider time is 30 to 44 minutes on the date of the visit.
• Medical Decision-Making: Low complexity. At least two of the three decision-making elements must be low:
  • Problems: One stable chronic illness or one simple acute problem.
  • Data: Minimal or limited data and records to review.
  • Risk: Low risk of complications or harm from treatment.

When to Use CPT 99204

• Time: Total provider time is 45 to 59 minutes on the date of the visit.
• Medical Decision-Making: Moderate complexity. At least two of the three decision-making elements must be moderate:
  • Problems: Multiple chronic illnesses or a chronic illness with a flare-up, or multiple acute problems.
  • Data: Moderate amount of outside records, test results, or history sources to review.
  • Risk: Moderate risk, such as starting or managing prescription drugs that require side-effect monitoring.

Key Rules for Deciding

• Don't mix methods: Pick either total time or MDM for the visit, not both.
• Watch single elements: Prescribing a new medication counts as moderate risk, but if the patient only has a single simple problem and minimal data, the overall MDM remains low (supporting 99203 rather than 99204).
• You can learn more detailed breakdowns via the Vinali Group Guide.

CPT code 99204 does not require a modifier for a standard, standalone new-patient office visit.

You only need to append a modifier when specific clinical circumstances occur during the encounter.

Common Modifiers Used with 99204

• Modifier 25: Add this when you perform a significant, separately identifiable evaluation and management (E/M) service on the same day as a minor procedure.
• Modifier 57: Add this when the E/M service results in the decision to perform a major surgery with a 90-day global period.
• Modifier 95: Add this for synchronous audio-video telehealth encounters.
• Modifier 93: Add this for audio-only telehealth encounters, if allowed by your payer.