CPT Code 99204 Guide for Usage and Billing

CPT code 99204 is one of the most commonly used codes for office visits of new patients with moderate to high complexity medical decision-making (MDM). For healthcare providers to be reimbursed to their fullest potential, they need to understand how it’s used, how long it takes, how it is billed, and the potential payment they’ll receive. In this article, we summarize the essential knowledge about CPT code 99204, including updates made for 2025.

1. What Is the 99204 CPT Code? (Definition & Purpose)

CPT code 99204 is defined as a New Patient Office Visit, Level 4, and involves moderate to high complexity MDM. DMPS 20 – LEVEL 1 COMPREHENSIVE evaluates elements of health and disease for a new patient when the provider completes a comprehensive history, performs a comprehensive and/or detailed level examination, and participates in a Level 1, high-level MDM. Most of these visits include a complete examination of the patient’s health status and possible treatment alternatives.

Comparison with Other New Patient Codes (99203, 99205)

• 99203: For less complex cases with 30-44 minutes of total visit time. It involves moderate-level MDM.
  
• 99205: For the most complicated new patient office visits, significant MDM, and a recorded visit time of 60 minutes or more.
  

2. When to Use CPT Code 99204? (Key Requirements)

Time Requirement: 45-59 Minutes

CPT 99204 is used when the total visit time, including face-to-face interactions (e.g., reviewing notes, coordinating care) and non-face-to-face interactions (reviewing records, etc.), is between 45-59 minutes. This is not just the doctor’s time with the patient but the total time spent on them.

Medical Decision Making (MDM): Moderate to High Complexity

For CPT 99204, the level of complexity for the decision-making process should be moderate to high. This includes:

• Multiple diagnoses or management options.
  
• Risk of complications or morbidity.
  
• Significant data interpretation.
  

History & Exam: No Longer Strictly Required (After 2021 E/M Changes)

Since 2021, history and examination are not mandatory components for billing 99204. Providers may now focus on time-based or MDM-based billing, enabling them to document what reflects the complexity of care accurately. This aligns with the best practices in revenue cycle management and ensures accurate billing without unnecessary documentation.

3. 99204 vs. 99205: How to Choose the Right Code

The choice between the two CPT Codes 99204 and 99205 is clearer in MDM and time thresholds.

• 99204: Requires moderate complexity MDM and 45-59 minutes of total time.
  
• 99205: Requires high complexity MDM and at least 60 minutes of total time.
  

Examples of Cases for 99204 vs. 99205

• 99204: A patient with an increased need for counseling or guidance due to multiple chronic issues in the past or present but without an urgent need for a detailed examination.
  
• 99205: A patient who is substantially ill, requiring significant intervention beyond a history and physical examination.
  

4. 99204 CPT Code Reimbursement Rates (2025 Updates)

The average payment for 99204 can vary depending on geographic location, payer policies, and the complexity of the visit. As of 2025, Medicare and private insurance generally pay within the following price ranges:

• Medicare: Approximately $120 – $150.
  
• Private Insurance: Charges will fluctuate, commonly between $150 – $250.
  

Factors Affecting Reimbursement

• Geographical Location: Some states or regions may have more generous reimbursement paradigms.
  
• Payer Guidelines: Various insurance organizations might reimburse at different levels for the same code.
  

5. Documentation Requirements for 99204 (Avoiding Denials)

Proper documentation is crucial to avoid claim denials or audits. The following essential elements must be included in the note:

• Patient Information: Record relevant details, even if a detailed examination is not required.
  
• MDM Details: Emphasize the complexity of the case, diagnosis, treatment options, and any risk variables.
  
• Total Time Spent: Accurately document the total time spent on the patient (45-59 minutes) for time-based billing.
  

Common Audit Triggers

• Inaccurate Timekeeping: Not documenting the time used precisely may result in downcoding or denial.
  
• Lack of Thorough MDM: Failure to detail the medical decision-making process could trigger an audit.
  

Effective medical billing services can help healthcare providers ensure that all documentation is complete and up to date, minimizing the risk of audits and ensuring proper reimbursement.

6. Recent Changes to 99204 CPT Code (2025 Guidelines)

There have been significant changes in the Evaluation and Management (E/M) codes as of 2025:

• MDM and Time Focus: Earlier, the focus was on history and exam. Now, greater emphasis is placed on MDM and total time spent on the patient.
  
• No Specific History and Physical Exam Requirement: Providers can now focus on medical decision-making or total time spent rather than having to provide a detailed history and exam.
  

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7. Billing Tips for 99204: Maximizing Reimbursement

How to Properly Document Time-Based Billing

• Report the full time spent on the patient, ensuring it falls within the 45-59 minute range.
  
• Log the time spent on each activity (e.g., patient visits, patient charts, coordinating with other healthcare professionals) to ensure accuracy.
  

Best Practices for Avoiding Downcoding or Denials

• Be comprehensive in your note regarding MDM, including any appropriate trials, lab work, or patient visits.
  
• Check Payer Policies: Some carriers have special guidelines for billing 99204, so keeping current with their requirements can prevent denial.
  

8. FAQs About CPT Code 99204

Can 99204 be Used for Telehealth?

Yes, 99204 can be billed via telehealth as long as the requirements for total time and moderate to high complexity MDM are met.

What if the Visit Exceeds 59 Minutes?

If the visit exceeds 59 minutes, consider using CPT code 99205. Be sure to note the extra time taken and provide a clear explanation for the additional time.

How Often is 99204 Audited?

CPT 99204 is frequently audited, particularly by Medicare and health insurance companies. To reduce audit risks, ensure that your documentation is comprehensive, accurate, and consistent with current coding guidelines.