In today’s fast-paced healthcare landscape, understanding and correctly using the 99204 CPT code can significantly impact your practice’s revenue. Whether you’re a physician, medical coder, or billing expert, getting it right means smoother claims, faster payments, and fewer denials.
CPT Code 99204 is used for new patient office visits that require a comprehensive history and exam, along with moderate complexity medical decision-making or 45–59 minutes of total encounter time. This code typically reimburses between $167–$250, depending on payer contracts, with Medicare averaging around $180. Thorough documentation and correct coding are key to preventing claim denials and receiving full reimbursement.
At Cures Services, we’ve worked with countless practices across specialties. Our team has seen firsthand how confusion around coding can lead to revenue loss.
CPT code 99204 applies to new patient office visits that require a detailed medical history, an in-depth physical exam, and medical decision-making of moderate complexity. It’s typically billed when the provider spends 45 to 59 minutes face-to-face with the patient on the date of the encounter. This code ensures proper reimbursement for more in-depth evaluations during a patient’s first visit.
CPT code 99204 is assigned to new patient office or outpatient visits that involve moderately to highly complex evaluation and management services.
According to CPT guidelines, medical code 99204 requires:
In short, this code is typically used when new patients require more attention than a standard visit but not quite as much as a high-complexity case.
The official 99204 CPT code description is:
This code describes an office or outpatient appointment for a new patient that includes a medically appropriate history and/or physical exam, along with moderate-level medical decision-making.
This code is most often used in internal medicine, family medicine, psychiatry, and other primary care settings.
Real Tip from Our Billing Team: Always document thoroughly. A missing element, like insufficient history or vague MDM, can result in down-coding or denial.
When time is the determining factor, 99204 CPT code times must fall between 45 and 59 minutes. This includes:
If the total visit time exceeds this range, CPT 99205 may be more appropriate.
The cost of CPT code 99204 can vary based on payer, location, and contract rates. On average:
Reimbursement for 99204 CPT codes is highly dependent on accurate documentation and proper coding. That’s where professional billing support makes a real difference.
Here’s where various providers get up to 99214 CPT codes for recognized patients, whereas 99204 is for new patients.
Code | Patient Type | MDM | Time |
99204 | New | Moderate | 45–59 mins |
99214 | Established | Moderate | 30–39 mins |
First-hand Insight: In our experience, practices mistakenly using 99214 for new patients often see claim denials or audit flags. Aays verify the patient’s status.
Through real-world billing audits, we’ve seen a few recurring mistakes. Here are the utmost communal and how to escape them:
We understand the day-to-day chaos of running a practice. You shouldn’t have to choose between patient care and claim accuracy. At Cures Billing Services, we specialize in:
Prepared to improve you’re billing correctness and reduce errors? Let our expert team support your practice.
The 99204 CPT codes play a critical role in healthcare reimbursement. When used correctly, it helps ensure you’re compensated for the time, expertise, and care you deliver, especially during longer, more complex patient visits.
By understanding its definition, time requirements, cost, and documentation needs, your practice can bill confidently and correctly. And if you ever need a trusted billing partner, Cures Medical Billing Company is here to help.
Healthcare providers should report CPT code 99204 when a new patient visit involves more in-depth care than 99203 this includes a longer duration (typically 45 to 59 minutes), a comprehensive evaluation, and moderate complexity in clinical decision-making.If the visit is shorter or less complex, 99203 may be more appropriate.
Yes, CPT 99204 can be billed for telehealth visits if all documentation and time-based criteria are met, and appropriate telehealth modifiers like 95 or GT are used.
Incomplete or vague documentation can lead to claim denials or down coding. To secure full reimbursement, providers must clearly record time, history, exam findings, and medical decision-making level.
CPT 99204 is not limited to primary care. Specialists including psychiatrists, cardiologists, and neurologists can use it if the visit meets the necessary criteria for time and complexity.
Common denial reasons include missing time documentation, incorrect patient status (billed as new when they are established), and lack of supporting exam or MDM details.
No. CPT 99204 should only be used when the patient encounter involves moderate complexity and meets all required elements. For simpler visits, 99202 or 99203 are more appropriate choices.
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