At Billing Care Solutions, we help practices improve accuracy and ensure full reimbursement for E/M services, including proper use of the 99204 code.
What Is CPT Code 99204?
CPT 99204 represents an office or outpatient visit for a new patient that requires a moderate level of medical decision-making (MDM) OR 45–59 minutes of total provider time on the date of service.
This code also requires that the patient is new, meaning they have not been seen by the same specialty within the practice in the past 3 years.
Key Requirements for Billing 99204
To bill 99204 correctly, one of the following must be documented:
1. Moderate Medical Decision-Making (MDM)
Moderate MDM includes:
Multiple or complex diagnoses
Moderate amount or complexity of data reviewed
Moderate risk of complications, morbidity, or mortality
Examples:
New problem requiring workup
Chronic condition with exacerbation
Prescription drug management with moderate risk
2. Total Time: 45–59 Minutes
This includes all qualifying time on the date of service, such as:
Reviewing records
Performing the exam
Counseling and educating the patient
Ordering tests
Documenting in the EMR
Coordinating care
Important: Time does not include staff time—only the provider’s.
Typical Clinical Scenarios for 99204
Physicians commonly use CPT 99204 for:
Complex new patient evaluations
Patients presenting with multiple symptoms needing differential diagnosis
Moderate-risk medication decisions (e.g., controlled substances, anticoagulants)
New patients with chronic disease flares
Conditions requiring diagnostic imaging or labs
Behavioral health visits with moderate risk
These situations usually meet either moderate MDM or the 45–59 minute time range.
Common Denials Related to 99204
Payers frequently deny or downcode 99204 when:
❌ Documentation does not support moderate MDM
❌ Provider time is not clearly documented
❌ The patient is incorrectly classified as “new”
❌ Note templates don't reflect clinical complexity
❌ Visit notes are copied forward without detailed new-patient evaluation
❌ Medical necessity is unclear
At Billing Care Solutions, we see these issues often—especially with high-volume primary care, internal medicine, and urgent care visits.
Tips for Avoiding 99204 Denials
✔ Clearly Document Medical Decision-Making
Include differential diagnoses, clinical reasoning, and any potential risks.
✔ Record Exact Time Spent
Use specific time statements like:
“Total time spent on the date of service: 49 minutes.”
✔ Avoid Overusing Templates
Personalize notes to the patient’s unique condition; avoid “clone” documentation.
✔ Ensure the Patient Is Truly New
Use your practice management system to verify patient status.
✔ Include Prescription Risk Language
If prescribing new medications, document the risk level and monitoring plan.
Reimbursement for CPT Code 99204
While reimbursement varies by payer, CPT 99204 reimburses at a higher rate than 99203 because it reflects a more detailed and time-consuming evaluation.
Medicare, Medicaid, and commercial payers each set their own allowable amounts, but 99204 typically pays significantly more due to its complexity.
If you want, I can provide approximate reimbursement ranges for your state or region.
When NOT to Bill 99204
Do not use 99204 if:
The MDM is straightforward or low
Your total time is under 45 minutes
The patient is established (use 99214/99215 instead)
The visit is preventive (use 99381–99387)
You are billing a nurse practitioner or PA with split/shared rules that don’t apply
Using the wrong E/M level can create compliance risks and trigger audits.
How Billing Care Solutions Helps Providers Bill 99204 Correctly
At Billing Care Solutions, we support medical practices with:
Accurate E/M level auditing
Denial prevention and appeals
Documentation improvement
Training on CPT rules and time-based coding
Identifying trends in payer downcoding
Ensuring proper use of MDM vs time billing
Our goal is to help you maximize reimbursement while staying fully compliant.
Conclusion
The 99204 CPT code is essential for documenting moderate-complexity new patient visits, but it must be used correctly to ensure proper reimbursement. Whether you bill based on MDM or time, clear documentation is critical.
If your practice struggles with E/M level denials or wants to increase accuracy and compliance, Billing Care Solutions is here to help.
