CPT 99204 Description, Billing Rules, & Use Cases
CPT 99204 is used to bill for an office or other outpatient visit with a new patient that requires a moderate level of medical decision making and/or at least 45 minutes of total time spent on the date of the encounter.
This code applies when a physician, nurse practitioner (NP), or physician assistant (PA) evaluates and manages a patient in an office or outpatient setting for conditions that require greater clinical effort and risk management than 99203, but do not rise to the high-complexity level of 99205.
The visit may include:
- Collecting a comprehensive medical history and performing a medically appropriate examination
- Counseling and educating the patient or caregiver about treatment and risks
- Ordering and interpreting diagnostic or laboratory tests
- Developing a detailed care plan and documenting the encounter
- Coordinating care with other healthcare professionals as needed
What is CPT Code 99204?
CPT 99204 is an evaluation and management (E/M) code used for new patient office or other outpatient visits that require moderate-complexity medical decision making or at least 45 minutes of total provider time on the date of the encounter.
This code is typically selected when:
- The patient presents with problems of moderate complexity, requiring more detailed data review and risk assessment
- The provider spends 45 minutes or more performing face-to-face and non–face-to-face activities such as reviewing records, documenting, ordering and interpreting tests, counseling, and coordinating care
- The encounter goes beyond the scope of 99203 but does not yet meet the threshold for high-complexity 99205
Examples of services billed under CPT 99204 include:
- Comprehensive evaluation of a new patient with multiple chronic conditions requiring medication adjustments
- Initial work-up of moderately complex symptoms (e.g., chest pain, neurological complaints) requiring diagnostic testing
- Development of a detailed management plan with counseling and coordination across specialties
In short: CPT 99204 represents a moderately complex, extended new patient visit that balances time and clinical intensity between 99203 and 99205.
CPT 99204 Time Thresholds and Code Combinations
CPT 99204 is used to report a new patient office or other outpatient visit when the provider spends at least 45 minutes of total time on the date of the encounter, or when the level of medical decision making is moderate complexity.
Important to Note:
- The 2024 revision specifies that “45 minutes must be met or exceeded” (replacing the old 45–59 minute range).
- Time includes both face-to-face and non–face-to-face provider activities, such as history review, exam, documentation, ordering tests, counseling, and coordinating care.
- Do not report 99204 if less than 45 minutes are spent or if MDM does not meet moderate complexity.
- For shorter or simpler visits, use 99202–99203; for highly complex visits requiring 60+ minutes, report 99205.
When to Use CPT 99204: Common Scenarios and Use Cases
CPT 99204 is appropriate when a physician, nurse practitioner (NP), or physician assistant (PA) sees a new patient in the office or outpatient setting, spends at least 45 minutes on the encounter, and the visit involves moderate-complexity medical decision making.
Here are examples of how CPT 99204 is used in practice:
Comprehensive Diabetes and Hypertension Evaluation
A primary care physician allocates time to:
- Collect a comprehensive medical and medication history
- Perform a detailed physical exam and order lab testing
- Adjust medications and create a coordinated care plan with specialists
Total time: 50 minutes
Billing: 99204
Initial Neurology Consultation for Seizures
A neurologist nurse practitioner allocates time to:
- Review detailed patient and family neurological history
- Perform a neurological exam and review prior imaging results
- Develop a management plan, initiate medication, and counsel the family
Total time: 47 minutes
Billing: 99204
Psychiatric Evaluation for New-Onset Depression
A psychiatric physician assistant allocates time to:
- Gather a comprehensive psychosocial and medical history
- Conduct a structured mental health assessment
- Provide counseling, initiate treatment, and arrange follow-up with behavioral health services
Total time: 52 minutes
Billing: 99204
CPT 99204 Billing Requirements and Eligibility
CPT 99204 is used to report new patient office or other outpatient visits that involve moderate-complexity medical decision making or at least 45 minutes of total provider time on the date of the encounter.
These services must meet eligibility and documentation standards related to patient status, provider qualifications, and service requirements.
Patient Eligibility Criteria
The patient must:
- Be a new patient (not seen by the same provider group in the past three years)
- Present with problems of moderate complexity, requiring more than straightforward or low-level decision making
- Be seen in an office or other outpatient setting (not inpatient, observation, or emergency department)
Provider Requirements
The billing provider must be a:
- Physician (MD or DO)
- Nurse Practitioner (NP)
- Physician Assistant (PA)
The provider must:
- Personally perform the encounter
- Determine the total time or medical decision making level
- Document all services performed in the medical record
Service Requirements
The encounter must include either:
- 45 minutes or more of total provider time (face-to-face and non–face-to-face activities such as reviewing records, conducting a comprehensive exam, counseling, documenting, and ordering/interpreting tests)
OR - Moderate-complexity MDM (multiple problems addressed, moderate amount of data to review, and moderate risk of complications or morbidity)
Additional requirements:
- Time and services must be distinct from other billed encounters
- Documentation must support the MDM elements or the time threshold
CPT 99204 vs Related Codes
- 99203 vs 99204: Use 99203 when the visit involves 30 minutes or low-complexity MDM. Use 99204 when the visit requires 45+ minutes or moderate-complexity MDM.
- 99204 vs 99205: Use 99204 for visits with 45–59 minutes or moderate complexity. Use 99205 when the encounter requires 60+ minutes or high-complexity MDM.
CPT 99204 Billing Documentation Checklist
To support compliant billing for CPT 99204, your records should include the following:
- Clear documentation of at least 45 minutes of provider time or evidence that moderate-complexity medical decision making (MDM) criteria were met
- Time logs (if coding by time) specifying:
- Date of encounter
- Activities performed (e.g., chart review, comprehensive history, physical exam, counseling, ordering and interpreting tests, documentation)
- Total time spent by the physician, NP, or PA
- New patient status confirmed, showing no professional service within the past three years by the same provider group
- MDM documentation that demonstrates:
- Multiple problems addressed with moderate complexity
- A moderate amount and complexity of data reviewed (labs, imaging, specialist notes, etc.)
- Moderate risk of complications, morbidity, or mortality
- Details of encounter services, such as:
- A comprehensive medical and/or psychosocial history
- A medically appropriate physical examination
- Counseling and education provided to patient or caregiver
- Care coordination and referrals as appropriate
- Provider attestation confirming that the services were personally performed and properly documented
- A statement that reported time was distinct from other billed services, including preventive visits or other E/M encounters on the same date
Common CPT 99204 Billing Mistakes (and How to Avoid Them)
❌ Billing Without 45 Minutes of Documented Time
CPT 99204 requires at least 45 minutes if billed by time. Encounters under this threshold should be reported as 99203.
❌ Using 99204 for Established Patients
This code is limited to new patient visits. Established patient visits must be reported with 99211–99215.
❌ Under-Documenting Moderate Complexity MDM
If selecting 99204 by medical decision making, documentation must reflect multiple problems, moderate data review, and moderate risk. Insufficient detail often results in downcoding.
❌ Confusing 99204 With 99205
99204 is for 45–59 minutes or moderate-complexity visits. CPT 99205 is reserved for 60+ minutes or high-complexity MDM. Misuse is a common payer denial trigger.
❌ Counting Non-Provider Time
Only time spent personally by the physician, nurse practitioner, or physician assistant counts. Staff or nursing support activities cannot be included.
❌ Improper Service Setting
CPT 99204 is for office or outpatient visits only. Do not use this code for hospital, observation, or emergency department services, which have their own E/M codes.
