CPT 99204 is an office or outpatient visit for a new patient that requires a moderate level of medical decision making, or at least 45 minutes of the provider’s total time on the date of the visit. It is the most common level for a new patient with a real problem to work up or a chronic condition to take over.
CPT 99204 description
99204 is a new patient office or other outpatient visit with a medically appropriate history and/or examination and a moderate level of medical decision making. When time is used to choose the level, 45 minutes must be met or exceeded.
Who counts as a new patient?
Under CPT, a new patient has not received any professional services from the physician or other qualified health care professional, or from another physician or professional of the exact same specialty and subspecialty in the same group practice, within the past three years. A patient seen by a different specialty in the same group can still be new to you. If the patient was seen within three years by your group in the same specialty, bill the established patient codes, such as 99214.
New patient levels at a glance
| New patient code | Medical decision making | Or total time on the date of the visit |
|---|---|---|
| 99202 | Straightforward | 15 minutes or more |
| 99203 | Low | 30 minutes or more |
| 99204 | Moderate | 45 minutes or more |
| 99205 | High | 60 minutes or more |
Moderate medical decision making: what supports 99204
Two of the three elements must reach moderate. The same MDM table applies to new and established patients:
| Element | Low (99213) | Moderate (99214) |
|---|---|---|
| Problems addressed | 2 or more self-limited or minor problems; or 1 stable chronic illness; or 1 acute, uncomplicated illness or injury; or 1 stable acute illness | 1 or more chronic illnesses with exacerbation, progression or side effects of treatment; or 2 or more stable chronic illnesses; or 1 undiagnosed new problem with uncertain prognosis; or 1 acute illness with systemic symptoms; or 1 acute complicated injury |
| Data reviewed and analyzed | At least 1 of: any 2 of reviewing prior external notes, reviewing a test result, or ordering a test (each unique); or an assessment requiring an independent historian | At least 1 of: any 3 of the low-level data items (notes, test results, tests ordered, independent historian); or independent interpretation of a test performed by another provider; or discussing management or a test with an external physician or other appropriate source |
| Risk of patient management | Low risk of morbidity from further testing or treatment | Moderate risk, for example prescription drug management, or a decision about minor surgery with risk factors |
Typical 99204 visits
- A new patient with two chronic conditions, such as hypertension and type 2 diabetes, with medications reviewed and adjusted.
- A referral for a new problem with an uncertain outcome, with tests ordered and outside records reviewed.
- An acute illness with systemic symptoms treated with a prescription.
Billing 99204 by time
New patient visits often take longer because records must be reviewed. Count the practitioner’s total time on the date of the visit, including:
- Preparing to see the patient, such as reviewing tests
- Getting or reviewing separately obtained history
- Performing a medically appropriate exam
- Counseling and educating the patient, family or caregiver
- Ordering medications, tests or procedures
- Referring and communicating with other professionals (when not separately reported)
- Documenting in the record
- Independently interpreting results (when not separately reported) and coordinating care
Common 99204 mistakes
- Wrong patient status: billing a new patient code for someone the group saw in the same specialty within three years. Payers deny these.
- Level by habit: billing 99204 for every new patient regardless of MDM or time.
- Time across days: only time on the date of the visit counts.
Frequently asked questions
What is the difference between 99204 and 99214?
Both need moderate MDM. 99204 is for new patients and needs 45 minutes when billed by time; 99214 is for established patients and needs 30 minutes.
Can a nurse practitioner bill 99204?
Yes, when the NP is credentialed with the payer and the patient is new. Be careful with patient status: Medicare generally treats a nurse practitioner or physician assistant who works with a physician as the same specialty as that physician, so a patient the physician saw within three years is usually established for the NP too. Commercial payers set their own rules.
Related guides
- CPT 99213: low-complexity established visit
- CPT 99214: moderate-complexity established visit
- 99213 vs. 99214: how to choose the level
- CPT 99215: high-complexity established visit
- CPT 99203: low-complexity new patient visit
- CPT 99205: high-complexity new patient visit
- CPT 99212: straightforward established visit
- CPT 99202: straightforward new patient visit
- CPT 99211: nurse visit for an established patient
- CPT 99417: prolonged office visit add-on
- Primary care billing services
- Medical coding services
CPT is a registered trademark of the American Medical Association. This guide summarizes the office visit E/M rules in effect since 2021, with the 2024 time wording, and the CMS Evaluation and Management Services guide (MLN006764) (opens in a new tab). Payer policies and your documentation decide what is billable.
New patient visits getting denied?
We check patient status and visit level before claims go out, so new patient codes are billed only when they apply.