CPT 99204E&M

Office o/p new mod 45 min

CPT code 99204 is used when a doctor sees a new patient in the office for a moderately complex visit that typically takes 45-59 minutes. This code covers the examination, medical decision-making, and time spent discussing the patient's health concerns.

Showing rates for

National Average

Base Medicare rate

$163.35

This calculator gives a typical-case estimate using standard Medicare modifier rules. Actual payment depends on payer policies, documentation, code-specific CMS status indicators, and locality. Verify before billing.

RVU breakdown

Work RVU

2.6

PE RVU (NF)

2.21

MP RVU

0.24

Total RVU

5.05

Conversion factor: 32.3465 · Source: CMS MPFS RVU25A · Confidence: High

NCCI bundling edits

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Billing tips

Use total time on date of encounter rather than MDM when the visit exceeds 45 minutes and time is documented
Impact: Time-based coding may be simpler and more defensible; can capture compensation for counseling/coordination time that doesn't add MDM complexity
Document the specific moderate-risk element if coding by MDM (prescription drug management, acute illness with systemic symptoms, or chronic illness with exacerbation)
Impact: Missing moderate risk documentation is the most common reason for downcoding from 99204 to 99203, reducing reimbursement by approximately $52
Verify new patient status - patient must not have received professional services from the same physician/specialty within past 3 years
Impact: Incorrect new vs established designation can result in overpayment recovery; 99204 pays $34-48 more than equivalent established patient code 99214
Bill non-facility rate ($163.35) for office settings; facility rate ($129.06) applies only to hospital outpatient departments
Impact: Difference of $34.29 per encounter; ensure place of service code matches actual location to avoid underpayment
When billing same day as procedure, append modifier 25 to 99204 and ensure documentation shows separately identifiable E&M service
Impact: Without modifier 25, the E&M will be denied as bundled, resulting in $163.35 loss per encounter
Review MDM elements quarterly - 2021 guidelines allow using either MDM or time, choose whichever supports higher code level
Impact: Providers often under-code by defaulting to MDM when time would support 99204 or even 99205, leaving revenue on the table

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Frequently asked questions

What is the Medicare reimbursement rate for CPT 99204 in 2025?

The 2025 Medicare national average reimbursement for 99204 is $163.35 for non-facility settings (private offices) and $129.06 for facility settings (hospital outpatient departments). Actual payment may vary based on geographic locality adjustments.

How long does a 99204 visit need to be?

A 99204 visit requires 45-59 minutes of total time spent on the date of encounter if using time-based coding. Alternatively, you can bill 99204 based on moderate medical decision-making regardless of time spent. The typical time of 45 minutes is a guideline, not a requirement when coding by MDM.

What is the difference between 99204 and 99205?

99204 requires moderate complexity medical decision-making or 45-59 minutes of time, while 99205 requires high complexity medical decision-making or 60-74 minutes. The 2025 Medicare payment difference is approximately $75, with 99205 paying around $238 compared to 99204's $163.35.

Can you bill 99204 and a procedure on the same day?

Yes, you can bill 99204 with a procedure on the same day by appending modifier 25 to the 99204, but only if the E&M service is separately identifiable and above and beyond the usual pre- and post-service work of the procedure. Documentation must clearly show the distinct nature of the E&M service.

What qualifies a patient as new for CPT 99204?

A patient is considered new if they have not received any professional services from the same physician or another physician of the same specialty in the same group practice within the previous 3 years. If the patient was seen within 3 years, you must use established patient codes (99211-99215).

What RVU value does CPT 99204 have?

CPT 99204 has a total RVU of 5.05 for 2025, consisting of 2.6 work RVUs, 2.21 practice expense RVUs (non-facility), 1.15 practice expense RVUs (facility), and 0.24 malpractice RVUs. These multiply by the 2025 conversion factor of 32.3465 to determine payment.

How do you document moderate medical decision-making for 99204?

Moderate MDM requires meeting 2 of 3 elements: moderate number/complexity of problems (such as 1+ chronic illness with exacerbation or 2+ stable chronic illnesses), moderate data (review of external records, independent historian, or ordering of unique tests), or moderate risk (prescription drug management, acute illness with systemic symptoms, or decision for minor surgery).