99204 CPT Code: New Patient Visit (45–59 Minutes)

What 99204 Covers

CPT 99204 is used for new patients whose conditions require substantial clinical evaluation and moderate MDM because of uncertain diagnoses, prescription drug management, or a moderate risk of complications. It covers reviewing medical records, performing a medically necessary examination, and assessing the patient’s condition.

CPT 99204 does not include diagnostic tests with their CPT codes, prolonged services beyond the code’s requirements, or services performed on established patients. 

When to Use it

Use 99204 for a new patient’s first visit when the encounter involves moderate clinical complexity. This includes a first psychiatric evaluation with medication planning, a new referral with multiple comorbidities, or an initial visit requiring significant data review and clinical decision-making.

To avoid under- or over-coding, compare 99204 with these related levels:

• 99203 vs. 99204: 99203 requires low MDM or 30 to 44 minutes. 99204 is the step up to moderate complexity.
• 99205 vs. 99204: 99205 requires high MDM or 60 to 74 minutes. Reserve it for new patients presenting with severe, unstable, or diagnostically uncertain conditions requiring high-risk decision-making. 
• 99204 vs. 99214: 99214 is the established-patient equivalent of 99204, requiring moderate MDM or 30 to 39 minutes. 

Documentation that Keeps it Paid

99204 carries elevated audit exposure because it is a high-value, first-visit code. Payers verify both new-patient status and the complexity level supported by the note:

• The record should not show prior visits with the same group practice within three years.
• Records should meet or exceed moderate complexity in at least two out of three categories. Ex: acute illness with systemic symptoms and external provider discussion.
• Record the exact time within the 45–59 minutes range.

Common Denial and Audit Triggers

• Patient billed as new when another provider in the same group practice has seen them within three years. 
• Total time documented at less than 45 minutes.
• Notes with missing history, incomplete MSE reference, or absent treatment plan. 
• Billing moderate MDM without documenting all three elements sufficiently. 
• Billing 99204 alongside 90791 or 90792 for the same provider and patient on the same date. 

Telehealth Billing

99204 is payable via telehealth for Medicare and most commercial payers. Use modifier 95 for real-time audio-video and modifier 93 for audio-only where covered. 

POS 02 applies when the patient is not in their home, whereas POS 10 applies for home-based telehealth. 

However, some payers, especially commercial ones, restrict audio-only coverage for new-patient visits. Confirm before scheduling a first visit as audio-only.

How 99204 Pairs with Other Codes

99204 can be billed on the same date as psychotherapy add-on codes 90833, 90836, or 90838 when a prescribing provider delivers both an E/M service and interactive psychotherapy during the same new-patient encounter. 

99204 cannot be billed alongside 99203 or 99205 for the same patient and provider on the same date, nor can it be combined with 90791 or 90792 by the same provider without confirming payer-specific same-day rules. 

Frequently Asked Questions

Can I bill 99204 every new-patient visit?

No. The visit must meet moderate MDM or the 45–59-minute total-time threshold.

What is the difference between 99204 and 99203?

99203 requires low MDM or 30–44 minutes total time. 99204 requires moderate MDM or 45–59 minutes. The difference is both the complexity threshold and the time floor.

Can I bill more than one unit of 99204 on the same day?

No. Only one E/M service of this type is reported per patient per date of service. Additional work is captured through the MDM/time level or, when prolonged-service codes are attached to higher-level visits.