What is the difference between 99204 and 99205?

The main difference between CPT code 99204 and 99205 is that 99204 involves moderate-complexity medical decision-making or 45 to 59 minutes of total time, while 99205 involves high-complexity decision-making or 60 to 74 minutes of total time for a new patient visit.

Key Comparison Details

• Patient Status: Both codes apply exclusively to new patients (those who have not received professional services from the physician or same-specialty group within the past three years).
• CPT 99204 (Level 4):
  • Time: 45 to 59 minutes of total provider time on the date of service.
  • Medical Decision-Making (MDM): Moderate complexity (requires meeting moderate levels in at least two of the three MDM elements: problems addressed, data reviewed, and risk of complications).
  • Typical Scenarios: Multiple chronic conditions with a moderate exacerbation, or a new undiagnosed problem with systemic symptoms.
• CPT 99205 (Level 5):
  • Time: 60 to 74 minutes of total provider time on the date of service.
  • Medical Decision-Making (MDM): High complexity (requires meeting high levels in at least two of the three MDM elements).
  • Typical Scenarios: Severe exacerbations posing an immediate threat to life or function, newly diagnosed high-stakes conditions like cancer, or complex multi-system management.

As users on Reddit agree, you can code by either total time or MDM, meaning a visit reaching the 60-minute threshold independently supports 99205 even if the clinical decision complexity is lower.

The American Medical Association deleted 84 codes in the 2026 CPT code set update effective January 1, 2026.

Key Deleted Code Families

• Lower Extremity Revascularization (LER): Long-standing codes 37220 through 37235 were deleted and replaced by new territory-based codes (37254–37299).
• Hearing Device Services: Legacy codes 92590 through 92595 were deleted and replaced by a new 12-code pathway (92628–92642).
• Urology / Prostate Procedures: Select older codes such as laser coagulation code 52647 and previous prostate biopsy codes were removed or restructured in favor of more specific guidance and approach methods.

You can bill CPT code 99204 once per new patient, per date of service, per provider or same-specialty group.

Key Billing Limits for 99204

• New Patient Status: Code 99204 is exclusively for a new patient—defined as 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 3 years.
• Frequency per Lifetime/Years: While it can only be billed once per encounter, a patient can technically be reclassified as a "new patient" again if they return to the same provider after 3 full years without any care from that same specialty group.
• Same-Day Limits: You cannot bill multiple new patient visits for the same patient on the same day by the same provider. If the patient is seen again later for follow-up care, subsequent visits use established patient codes (99211–99215).

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

Key Criteria

• Patient Status: A new patient is someone who has not received any face-to-face professional services from the provider (or another physician of the same specialty in the same practice) within the past three years.
• Medical Decision-Making (MDM): Requires a moderate complexity level, which involves managing multiple diagnoses, reviewing moderate amounts of data or test results, and handling moderate-risk treatment options.
• Time-Based Selection: Alternatively, if coding by time, the total provider time (including face-to-face and non-face-to-face work done on the exact date of the visit) must fall within the 45–59 minute range.

Common Use Cases

• Initial evaluations for a progressing illness or acute injury needing careful medical management.
• Initial psychiatric or specialty consultations where a comprehensive history is taken and a new medication plan or treatment strategy is initiated.
• Outpatient visits addressing multiple interconnected health problems requiring a detailed diagnostic workup.

You can read more detailed guidelines directly from the American Medical Association CPT 99204 Overview.

Insurance reimbursement for CPT code 99204 (a Level 4 evaluation and management visit for a new patient) generally ranges between $150 and $250, though the exact payout depends entirely on the type of insurance, the setting of the visit, and your geographic location.

Average 2026 Payouts by Insurance Type

• Medicare (Doctor's Office): The 2026 national baseline reimbursement rate is $177.36 for non-facility settings. Depending on local adjustments, actual Medicare allowances fluctuate between $170 and $190.
• Medicare (Hospital Outpatient): The rate drops to roughly $116.90 because the hospital facility bills its overhead costs separately.
• Commercial Insurance: Private health insurance plans typically calculate rates based on a percentage of Medicare (often 120% to 250%). The national median commercial payout sits around $181, while 75th-percentile contracts reach up to $247.
• Medicaid: Reimbursement varies widely by state, historically paying lower than commercial lines.

Estimated National Averages by Major Payer

According to payer-transparency fee schedules, national average contracted rates for a standard office setting include:

Why Payouts Vary

1. Geographic Locality: Payers adjust baseline figures using Geographic Practice Cost Indices (GPCI). For instance, the same medical specialty billing 99204 might see median commercial insurance payouts hover at 111% of Medicare in Miami, but jump past 200% in high-cost regions like San Jose or Durham.
2. Provider Contracts: Independent practices negotiate unique fee schedules with commercial networks; premium tier networks or specific multi-specialty groups often command higher allowed amounts.
3. Patient Responsibility: The "insurance payout" reflects the total allowed amount. The actual check sent to the doctor may be less if the patient owes a copay, coinsurance, or has an unmet deductible.