99204
Office o/p new mod 45 min
Office or other outpatient visit, new patient, moderate-level medical decision making OR 45-59 minutes of total time on the date of the encounter. The CMS 2026 wRVU for 99204 is 2.60. The default new-patient code in primary care and most outpatient subspecialties.
When to use it
99204 is the default code for most new-patient outpatient encounters in primary care and outpatient subspecialty practice. Use it for a new patient with at least one of: two or more chronic problems with progression or treatment changes; one undiagnosed new problem with uncertain prognosis; prescription drug management.
Full guidance
Common patterns: new patient establishing primary care with multiple chronic comorbidities; new endocrinology consult for poorly controlled T2DM; new cardiology consult for chest pain and an abnormal stress test result. Prescription drug management satisfies moderate risk on its own, which makes 99204 the right code for the vast majority of new-patient continuity encounters. Time-based alternative is 45 to 59 minutes of total time on the date of the encounter.
Documentation checklist
- ✓MDM moderate complexity on at least two of three elements, OR 45 to 59 minutes total time on date of encounter.
- ✓Comprehensive history and exam are not required under 2021 guidelines but support the complexity narrative when present.
- ✓Three-year rule for new-patient status. A patient is new only if neither you nor a same-specialty colleague in your practice has seen them face to face in three years.
- ✓Document prescription drug management explicitly if relying on it for moderate risk; name the prescription and indication.
- ✓If you reviewed external records (e.g., from a referring provider or prior PCP), document the review and what it added to your assessment; that counts as moderate data.
- ✓Time-based: capture all qualifying activities on the date of the encounter, not the day before in chart prep.
Common pitfalls
- !Coding a returning patient as new because they have not been seen recently. The 3-year rule is firm.
- !Forgetting G2211 on new-patient visits where you are the new continuity provider. CMS explicitly clarified that new visits are eligible for G2211 when continuity care is intended.
- !Down-coding to 99203 when the visit clearly involved moderate complexity. Prescription drug management at any complexity level should bump the visit into 99204.
- !Up-coding to 99205 without a high-complexity element. CMS Comparative Billing Reports flag new patient visits with unusual 99205 rates.
- !Failing to bill same-day add-ons (G0444 depression screen, G0537 ASCVD risk, 99406 tobacco cessation) when documented; they are usually billable alongside 99204.
Payer notes
Medicare and Medicare Advantage plans pay 99204 at the standard PFS allowable; documentation requirements match Medicare's MDM rubric. Commercial payers occasionally request records when 99204 is billed at more than 75 percent of new patient visits for a clinician (compared to a roughly 40 to 50 percent specialty average). Telehealth POS rules apply.