E/M New · CMS status A
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.
Work RVU
2.60
2026 Medicare pays
$177.36
National GPCI · non-facility · CF $33.4009
RVU anatomyWork 2.60 + Practice 2.47 + Malpractice 0.24 = 5.31 total
Work (your effort)Practice expenseMalpractice
Billing guidance for 99204 is locked
- When to use it: the exact clinical situations that support billing 99204
- Documentation checklist: the 6 elements your note needs before submitting
- Common pitfalls: the 5 mistakes that get 99204 downcoded or denied
Start your free 3-month trial →Every new account gets full Pro Max access for 3 months. No card needed.
Common modifiers
2595
Common ICD-10 pairings
E11.9I10Z00.00M81.0F32.9
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.
Pairs well with
Educational reference, not billing or legal advice. Verify against your payer contracts and your compliance team before submission.