CPT · E/M office visits
99204: Level-4 new patient office visit
99204 reports an office or outpatient visit for a new patient at moderate medical decision making, or 45 to 59 minutes of total provider time on the date of the encounter. It is the new-patient counterpart to 99214.
What it covers
Moderate MDM for a new patient typically means multiple problems being sorted for the first time, external records reviewed and interpreted, or management carrying moderate risk such as prescription drug therapy initiated on incomplete history.
The time pathway is 45 to 59 minutes of total provider time on the date of the encounter, which is a meaningfully longer band than the established-patient equivalent.
When to use it
- A new patient presenting with two or more chronic conditions to assume and manage
- An undiagnosed new problem with an uncertain prognosis
- Extensive outside record review as part of establishing care
- Total time on the date of the encounter reaching 45–59 minutes
Where the boundary sits
| Compared with | The deciding rule |
|---|---|
| 99203 | 99203 covers low MDM or 30–44 minutes. Cross into moderate complexity or 45 minutes and 99204 applies. |
| 99205 | 99205 requires high MDM or 60–74 minutes — severe presentations or decisions about hospitalization. |
| 99214 | Use 99214 instead whenever the three-year lookback makes the patient established. |
Documentation that keeps it paid
- Record the external records or results independently reviewed and what they changed
- Show the reasoning that makes the problem set moderate
- If billing on time, state the total and what it included
Denial & audit triggers
Intake volume mistaken for complexity
Collecting a long history is not itself moderate MDM. The note has to show problems, data, or risk at the moderate level.
Established patient billed as new
The single most expensive error on this code, because it is usually systematic rather than occasional.
How it pairs with other codes
- Modifier 25 with a same-day procedure
- 99417 where total time exceeds the band and the payer accepts it
Questions we get asked
- Why is 99204 paid more than 99214?
- The new-patient levels carry additional work value for establishing a history and care plan, and their time bands are correspondingly longer.
Reference only, and typical rather than universal: coverage, modifier requirements, and payment vary by payer, plan, state, and provider type. Confirm current payer policy before billing. CPT is a registered trademark of the American Medical Association; official descriptors are not reproduced here.
How does your A/R and denial rate compare?
Free benchmark tool — enter six numbers, see your bands against published industry sources, and download a branded PDF.