CPT code 99204 reports a new patient office or other outpatient visit at the moderate level. You can support it with moderate medical decision making (MDM) or with 45 to 59 minutes of total time on the date of the encounter.
This guide explains when a patient counts as new, how to score moderate MDM, what time counts and where claims go wrong. It supports the coding step of a clean revenue cycle management workflow.
| Key takeaways 99204 is a new patient office or other outpatient visit. The patient must not have received services from you or a same-specialty group colleague in the past three years.Select the level by moderate medical decision making (MDM) or by 45 to 59 minutes of total time on the date of the encounter.Moderate MDM needs two of three elements: problems, data and risk.History and exam must be medically appropriate, but they do not set the level. |
99204 CPT Code: Description and Level Comparison
The American Medical Association (AMA) gives the description of CPT code 99204 as a new patient office or other outpatient visit with a medically appropriate history and exam and moderate MDM. When time is used instead, it lists 45 to 59 minutes of total time on the date of the encounter.
| Code | MDM level | Total time on the date of the encounter |
| 99203 | Low | 30 to 44 minutes |
| 99204 | Moderate | 45 to 59 minutes |
| 99205 | High | 60 to 74 minutes |
Either basis can support the level, so use the one the note documents best. For urgent care visits, our guide to urgent care E/M coding with 99204, 99213 and 99214 compares the new and established visit codes.
Is the Patient New? The Three-Year Rule
The CMS Evaluation and Management Services booklet defines a new patient as one who has not received professional services from you, or from a same-specialty colleague in your group, within the previous three years. Anyone who has is an established patient.
- Seen by you 20 months ago: established patient.
- Seen 14 months ago by a physician of the same specialty in your group: established patient.
- Seen only by a physician of a different specialty in your group: new patient.
- Last seen more than three years ago: new patient.
Commercial payers apply the same idea but may spell it out differently, so check the payer’s provider manual. A new patient claim also needs the rendering provider enrolled with the payer, which our credentialing and contracting service covers.
Moderate MDM for 99204: Two of Three Elements
MDM has three elements: the problems addressed, the data reviewed and analyzed, and the risk of management. Moderate MDM needs two of the three at the moderate level. The AMA’s E/M descriptors and guidelines list the full definitions.
| Element | What moderate looks like |
| Problems addressed | One of: a chronic illness with exacerbation, progression or side effects; two or more stable chronic illnesses; one undiagnosed new problem with uncertain prognosis; one acute illness with systemic symptoms; or one acute, complicated injury. |
| Data | One of three categories: any combination of three items, such as external notes, unique test results, unique tests ordered or an independent historian; independent interpretation of a test; or discussion of management with an external professional. |
| Risk | Moderate risk of morbidity. Examples: prescription drug management, a decision about minor surgery with identified risk factors, a decision about elective major surgery without risk factors, or care limited by social determinants of health. |
Summary: a new patient with moderate MDM or 45 to 59 minutes of total time is 99204, low is 99203 and high is 99205.
Billing 99204 by Total Time
If you choose time, count total time on the date of the encounter, not just minutes with the patient. The AMA guidelines count preparing to see the patient, reviewing separately obtained history, the exam, counseling, ordering tests or medications, documenting, communicating with other professionals and care coordination. They exclude separately reported services, travel and general teaching.
Document the total minutes and the activities. At 60 minutes or more, review 99205. Prolonged service add-ons are not reported with 99204. Medicare’s G2212 is listed only with 99205, 99215 and 99483.
Sample Chart Notes and the Codes They Support
G2211 and Other Add-Ons
Medicare’s G2211 add-on describes certain complex E/M visits and may be reported with 99202 through 99215, which includes 99204. Medicare does not pay it when the base code carries modifier 25, with exceptions for the annual wellness visit, vaccine administration and Part B preventive services. Our guide to the G2211 add-on code covers the rules.
If a procedure happens at the same visit, review modifier use in our coding modifiers guide. Commercial payers set their own add-on and modifier rules in the contract and provider manual.
Common 99204 Mistakes and How to Prevent Them
- Check status at scheduling. Look up prior visits across the group, by specialty, before booking a new patient slot.
- Use a time statement. Record total minutes and the activities counted.
- Train on level selection. MDM or time sets the level, not history and exam.
Every E/M claim also needs a diagnosis that supports the visit, so see how ICD-10 and CPT codes work together. These slips also appear on lists of common medical coding errors.
What the Provider Should Document
- Whether the patient is new, based on prior visits within the group.
- The problems addressed, data reviewed and risk of management, or the total time with the activities counted.
- A medically appropriate history and exam.
- The diagnoses and the plan of care.
Frequently Asked Questions
What is CPT code 99204?
99204 is a new patient office or other outpatient visit at the moderate level. It needs a medically appropriate history and exam plus moderate MDM, or 45 to 59 minutes of total time on the date of the encounter. The patient must be new to you and your same-specialty group under the three-year rule.
How many minutes is a 99204 visit?
When you choose the level by time, 99204 covers 45 to 59 minutes of total time on the date of the encounter. That includes non-face-to-face work such as reviewing records and documenting. At 60 minutes, 99205 may apply. You can also choose the level by MDM and ignore time.
What is the difference between 99204 and 99214?
Both describe moderate MDM. 99204 is for a new patient and 99214 is for an established patient, meaning one seen by you or a same-specialty group colleague within three years. Their time thresholds differ, so do not use 99204 for a returning patient.
Can you bill G2211 with 99204?
Under Medicare, G2211 may be reported with 99202 through 99215, which includes 99204, when its requirements are met. It is not paid when the base code has modifier 25, except for certain preventive services and vaccines. Commercial payers set their own rules, so check the payer policy.
Do you still document history and exam for 99204?
Yes. Document a medically appropriate history and exam. CMS says they must meet the code descriptor but do not affect the level. The level comes from MDM or total time, so make sure the note clearly supports one of them.
Final Thoughts
Billing the 99204 CPT code comes down to three checks: the patient is new, the level is chosen by MDM or time, and the note supports that choice. Get those right and most downcoding and denial problems disappear.
Need Help With E/M Coding?
If new patient visits keep coming back downcoded or denied, a coding review can show where documentation and billing drift apart. The Zmed Solutions revenue cycle team handles coding and billing, claim scrubbing and denial management. You can reach the team through the contact page.
Sources and note: AMA (CPT code 99204 description; CPT E/M descriptors and guidelines) and CMS (Evaluation and Management Services, MLN006764, May 2026). Educational information only, not legal or medical advice.
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