CPT Code 99204 – A Complete Guide to Reimbursement, Cost, and Billing Accuracy

Q: What is the representative diagnosis code for CPT code 99204?

The CPT code 99204 diagnosis code varies by patient condition. Common examples include: 9 (Type 2 diabetes) I10 (Hypertension) 1 (Generalized anxiety disorder) Examination codes must align with the familiar medical decision-making.

Q: What are the CPT code 99204 billing guidelines?

Use for new patients only Document either time-based or MDM-based requirements Apply modifier 25 when another procedure is done Make sure analysis codes justify the level of service Avoid up coding use 99203 or 99202 if complexity is lower

Understanding CPT Code 99204 is essential for medical providers and billing professionals handling new patient visits. At Express Medical Billing, we’ve helped countless practices reduce denials and improve claim accuracy by mastering how to correctly use this code.

Let’s break down what this code means, how it compares to others like 99214 and 99203, and how you can optimize reimbursement.

What Is CPT Code 99204?

CPT code 99204 is used for new patient office or other outpatient visits involving moderate to high complexity in both medical decision-making and time. According to the American Medical Association (AMA), this procedure includes:

A medically appropriate history and/or examination
Moderate to high complexity MDM (Medical Decision Making)
Total time spent: 45–59 minutes with the patient and/or family

This is one of the most commonly used new patient CPT codes for internal medicine, family practice, and specialties alike.

CPT Code 99204 Description & Time Requirement

Medical Code 99204 is appropriate when providers spend significant face-to-face time evaluating a new patient.
As of 2021 E/M guideline updates, time-based billing is allowed. You must document total time (45–59 minutes) on the day of the encounter.

Real Experience Tip: At Express Medical Billing, we’ve seen many claims denied because providers didn’t clearly document time or complexity. Adding that extra detail upfront saves time during appeals.

CPT 99204 vs 99214 - Key Differences

Code	Visit Type	Complexity	Time Requirement
99204	New Patient	Moderate to High	45–59 minutes
99214	Established Patient	Moderate	30–39 minutes

99204 CPT Code is for new patients, whereas procedure code 99214 is for established ones.
Requirements for 99214 include less documentation than 99204, but the decision-making must still be moderate.

CPT 99204 vs 99203

While both codes apply to new patients, 99203 cpt code only requires low complexity MDM and 30–44 minutes of time.

If your documentation reflects moderate complexity, then 99204 is the better (and more accurately reimbursed) code.

CPT Code 99204 Fact Sheet - At-a-Glance

Service: New patient office visit
Time: 45–59 minutes
MDM: Moderate to High
Typical Reimbursement:
- Medicare: Around $170–$210 (varies by region)
- Private Payers: Often 20–30% higher
Modifier: Modifier 25 may be used if a separate service is performed on the same day.

99204 CPT Code Reimbursement & Cost Insights

CPT Code 99204 Cost: Most insurers pay between $160–$230, depending on contract rates.
CPT Code 99204 Reimbursement (Medicare): The Medicare Physician Fee Schedule typically reimburses around $195, but this varies by location.
We recommend verifying payer-specific rates through your clearinghouse or payer portal.

Does CPT Code 99204 Need a Modifier?

Yes Modifier 25 may be required if you’re billing another procedure on the same day. For example, if a patient is seen and also has a minor procedure done (like a skin lesion removal), Modifier 25 distinguishes the E/M service as separate and necessary.

Billing Experience Insight: At Express Medical Billing, we’ve recovered thousands in denied claims simply by applying the correct modifier to CPT 99204 claims.

What Is CPT Code 99204 Used For?

New patients with multiple complaints or chronic conditions
Visits involving prescription drug management
Complex diagnostic testing or coordination with specialists
Mental health evaluations or comprehensive assessments

Example Use Case: A patient presents with newly diagnosed diabetes and hypertension requiring lab orders, medication adjustments, and coordination with a dietitian. CPT 99204 is appropriate here.

CPT 99204 Modifier 25 & Diagnosis Coding

When using modifier 25, ensure your diagnosis codes (ICD-10) support both the evaluation and the procedure. Otherwise, insurers will bundle them and reduce payment.
- Always pair 99204 Code diagnosis with appropriate ICD-10s such as:
  - E11.9 (Type 2 diabetes mellitus)
  - I10 (Essential hypertension)
  - F32.9 (Depression, unspecified) if a mental health evaluation is performed

Is CPT Code 99204 Covered by Medicare?

Yes, CPT 99204 is covered by Medicare for medically necessary services. Documentation must reflect the complexity and/or time involved.

First-Hand Insight: Medicare auditors often request notes and time logs for CPT 99204. Make sure your EHR auto-captures time spent during charting or face-to-face interaction.

Billing Guidelines for CPT 99204 Code

Here are CPT 99204 Billing Guidelines we follow at Express Medical Billing:
1. Clearly define MDM: Use EHR prompts or templates.
2. Document time precisely if billing based on time.
3. Use Modifier 25 when applicable.
4. Avoid upcoming: If criteria for 99204 aren’t met, downgrade to 99203.
5. Always double-check diagnosis linkages to procedures.

Final Thoughts

In our experience working with clinics across the U.S., accurate billing of CPT 99204 significantly boosts revenue but only if documentation is complete and modifiers are correct.

At Express Medical Billing, our specialists are trained to handle complex E/M coding and payer-specific quirks. We ensure your claims pass the first time, without denials dragging down your revenue.

Let’s Help You Maximize Reimbursement

Need help with CPT 99204 billing, or unsure if you’re using the right codes for your practice?

Contact Express Medical Billing gets paid what you deserve!

Frequently Asked Questions (FAQs)

What is CPT code 99204 used for?

CPT code 99204 is used for new persistent office appointments that include moderate to high complexity medical decision-making and require 45–59 minutes of total time with the patient and/or their family. It's commonly billed for detailed consultations and comprehensive health evaluations.

What is the variance b/w CPT code 99204 and 99214?

The main difference is the patient status and time requirement:

CPT code 99204 is for fresh patients and needs 45–59 minutes.
CPT code 99214 is for reputable patients and typically needs 30–39 minutes with moderate complexity.

How much does CPT code 99204 pay?

CPT code 99204 reimbursement varies:

Medicare pays approximately $170–$210.
Private insurers may pay more, depending on your location and contract.
Always check with your payer for accurate CPT code 99204 cost

Does CPT code 99204 require a modifier?

Yes, modifier 25 is often required when CPT code 99204 is billed with another procedure on the same day (e.g., minor surgery or diagnostic tests). It indicates the E/M service was separately identifiable.

Is CPT code 99204 covered by Medicare?

Yes, CPT code 99204 is enclosed by Medicare as long as the visit is therapeutically necessary and documentation supports the service. Correct coding and justification are essential to avoid denials.

How do I know when to use CPT 99204 vs 99203?

Usage 99204 CPT codes when the case involves moderate complexity and 45–59 minutes of supplier time. Choose 99203 for low complexity and 30–44 minutes. Always refer to MDM criteria and time-based billing rules.

What is the representative diagnosis code for CPT code 99204?

The CPT code 99204 diagnosis code varies by patient condition. Common examples include: