What is the 99204 CPT code?
The 99204 CPT code is the Level 4 office or outpatient visit for a new patient. You bill it when the encounter reaches moderate medical decision making, or when your total time on the date of the encounter is 45 to 59 minutes. As of 2026 it is the workhorse new-patient code in family medicine, used for patients establishing care with multiple or uncontrolled conditions that require a real workup.
What Medicare pays. The 2026 national non-facility rate is roughly $177, against about $105 for 99203 and about $237 for 99205, so the step up to 99204 is worth roughly $70 a visit and varies by locality.
Why it gets downcoded. Payers now review E/M levels with automated programs, and they knock 99204 down to 99203 when the note does not clearly show moderate MDM or the documented time.
New patients only. 99204 applies only if no provider of your specialty in your group has seen the patient in three years; otherwise bill an established-patient visit from 99213 to 99215.
What the 99204 CPT Code Covers
The American Medical Association defines 99204 as an office or other outpatient visit for the evaluation and management of a new patient that requires a medically appropriate history and examination and a moderate level of medical decision making. Two things from the 2021 E/M overhaul govern how you use it. First, history and exam no longer set the level; you perform whatever history and exam are medically appropriate, but the code is chosen on either medical decision making or total time. Second, you pick one pathway, not both. If your decision making is moderate, you bill 99204 no matter how long the visit ran.
For family medicine, 99204 is the workhorse new-patient code. A new patient establishing care with uncontrolled diabetes and hypertension, or arriving with new cardiac symptoms that need a workup, usually lands here. The challenge is not knowing the code; it is documenting the visit so the level holds up when a payer’s software or an auditor looks at it. If you are weighing whether to keep this work in-house, our guide on how to find the right family medicine billing service is a useful starting point.
When to Bill 99204 in Family Medicine
First, confirm the patient is actually new
A new patient is one who has not received a face-to-face professional service from you, or from another provider of the exact same specialty and subspecialty in your group, within the past three years. In a group, if a patient saw a different specialty, they can still be new to your family medicine provider. If they saw your family medicine partner two years ago, they are established, and you bill an established patient visit such as 99213 instead. Getting this wrong is a common, avoidable denial.
Choose your pathway: decision making or time
Moderate decision making requires meeting two of three elements at the moderate level: problems (one or more chronic illnesses with exacerbation or progression, two or more stable chronic illnesses, one new problem with uncertain prognosis, or one acute illness with systemic symptoms); data (a moderate combination of tests and outside records reviewed, an independent historian, independent interpretation of another provider’s test, or discussion with an external physician); and risk (moderate risk, most often prescription drug management or a decision about surgery). You need two of the three. If you bill by time instead, total time on the date of the encounter must reach 45 minutes, with 99205 beginning at 60. There is no rounding rule, so a 44-minute visit is a 99203. Total time counts the work you personally perform that day, including chart review, ordering, counseling, coordination, and documentation, but not staff time.
Typical family medicine 99204 visits
A new patient establishing care with uncontrolled hypertension and new-onset chest pain, where you review the medication list and outside labs, order an EKG, adjust medications, and start a cardiac workup. A new patient with uncontrolled type 2 diabetes and a rising A1c who needs medication started or escalated. A multi-problem intake where a new patient brings several active conditions, you review outside records, and you start or change a prescription. The common thread is real moderate decision making, documented element by element.
99203 vs 99204 vs 99205
All three are new-patient codes. What separates them is the level of medical decision making, and with it the reimbursement and the audit risk.
| Code | MDM | Total time | 2026 Medicare (non-facility, approx.) |
|---|---|---|---|
| 99203 | Low | 30 to 44 min | About $105 |
| 99204 | Moderate | 45 to 59 min | About $177 |
| 99205 | High | 60 to 74 min | About $237 |
Rates are 2026 national non-facility Medicare estimates from the CMS Physician Fee Schedule and vary by locality; commercial payers often pay more. The step from 99203 to 99204 is close to a 65 percent increase, which is exactly why payers scrutinize it. The rule that trips practices up is simple: new does not mean complex. A new patient with one self-limited problem is not automatically a 99204. Code what the note supports, not what the visit felt like.
Documentation That Holds the Level
Auditors score each MDM element, so make two of them obvious. State the problems addressed by name rather than writing multiple issues. Show the data you reviewed, such as reviewed outside cardiology note and March labs, ordered EKG. Name the risk, such as moderate risk given new cardiac symptoms and medication changes. If two elements support the level, the claim holds; if only one does, expect a downcode.
If you bill by time, prove the minutes. A statement like total time 52 minutes, including record review, examination, care coordination, and documentation is defensible; a bare number is not, and neither is a note that leans on time without reaching 45 minutes. Finally, link each diagnosis to the assessment and plan, because mismatched CPT and ICD-10 codes are a leading denial reason and the record has to show why the level of service was necessary.
Why do 99204 claims get downcoded?
Because payers no longer just spot-check. The most visible example is Cigna’s Evaluation and Management Coding Accuracy policy, known as R49, effective October 1, 2025, which adjusts 99204 down to 99203 and 99205 down to 99204 (along with 99214 to 99213 and 99215 to 99214) by one level when the documentation does not meet AMA guidelines. Cigna aimed it at providers whose coding runs higher than their peers and said the majority of in-network providers would not be affected. The policy drew strong provider pushback and a temporary pause after launch, so its exact status keeps shifting, but the direction is clear: automated, records-based E/M review is spreading across payers, and confirming each payer’s current policy is now part of the job.
The most common pattern we see cuts both ways. Some practices get legitimate 99204 visits knocked down to 99203 because the note did not spell out moderate MDM, losing roughly $70 each time. Others default to 99203 out of documentation anxiety and give away that same $70 on visits they earned. Across the billing companies we vet, the ones that protect new-patient revenue scrub the note against the MDM grid before the claim goes out, track downcoding patterns by payer, and appeal wrongful reductions with the record and the AMA guidelines.
Seeing 99204 visits paid at the 99203 rate? That gap is roughly $70 every time, and it is almost always a documentation or payer-scrubbing problem, not a coding one. Get matched with vetted family medicine billing companies that defend E/M levels before claims go out, in about 30 minutes at no cost.
Add-On Codes and Modifiers That Ride With 99204
G2211, the longitudinal-care add-on, recognizes the complexity of being a patient’s continuing focal point for care and can be reported with 99204 when your practice is taking on that ongoing role, which is common when a new patient establishes primary care. It adds a modest amount to the Medicare payment, roughly $16. Note the interaction with modifier 25: under current CMS policy, G2211 is payable with an office visit reported with modifier 25 only when the same-day service is an Annual Wellness Visit, a vaccine administration, or a Medicare Part B preventive service.
Modifier 25 itself applies when you perform a minor procedure during the same new-patient visit; append it to the 99204 to show the evaluation was significant and separately identifiable, and make sure the note supports a distinct evaluation beyond the routine work of the procedure. When you bill by time and the visit runs past the 99204 range, add the prolonged-services code, 99417 for most payers or G2212 for Medicare, with documentation of the added time. Nurse practitioners and physician assistants can bill 99204 when documentation supports moderate MDM or the time threshold; under Medicare their services are generally paid at 85 percent of the physician fee schedule unless incident-to rules apply.
Frequently Asked Questions
A patient transferred from another practice. Are they new?
Usually yes. If no provider of the same specialty and subspecialty in your group has furnished a face-to-face service in the past three years, the patient is new to you and 99204 can apply, even if they were seen at another practice elsewhere.
Is it safer to bill 99204 by decision making or by time?
Use whichever the visit supports and the note proves. Decision making fits most family-medicine visits because you document it anyway. Time is a strong backup when counseling or care coordination dominated the encounter and totaled at least 45 minutes on the date of service.
How much does Medicare pay for 99204 in 2026?
The 2026 national non-facility Medicare rate is roughly $177, versus about $105 for 99203 and about $237 for 99205. Facility rates are lower, and commercial payers often pay more. Actual amounts vary by locality and Medicare Administrative Contractor.
Can I bill 99204 for a telehealth new patient visit?
Many payers allow 99204 for telehealth with the appropriate modifier when the visit meets the same MDM or time requirements. Telehealth and place-of-service rules keep shifting, so confirm current Medicare and payer guidance before billing.
A new patient comes in for a wellness visit and a separate problem. What do I bill?
Report the preventive or wellness service and the problem-oriented visit, appending modifier 25 to the E/M, and confirm the G2211 rules if you add that code. Documentation must clearly support both services as distinct and separately identifiable.
Will the patient owe more for a 99204 than a lower level?
Possibly. Cost share depends on the patient’s plan, and a higher-level office visit can carry more coinsurance or deductible than a lower one. Verify benefits so the front desk can set expectations before the visit.
Can outsourced billing reduce 99204 downcoding?
Yes, when the work happens before submission: scrubbing notes against the MDM grid, flagging payer downcoding patterns, and appealing wrongful reductions with the record and the AMA guidelines. That daily discipline is what protects the level, not a coding cheat sheet.
Next Steps
Billing the return visit instead? See the established-patient counterpart, CPT 99213.
Deciding whether to outsource? Read how to find the right family medicine billing service.
Losing new-patient revenue to downcoding? Get matched with a family medicine billing company in as little as 30 minutes.
Stop losing new-patient revenue to downcoding and undercoding. Billing Service Quotes has matched more than 2,000 providers with vetted billing companies across all 50 states, with rates starting as low as 2.95 percent and over 15 years of medical billing experience. Matching is 100 percent free for providers and takes about 30 minutes.
