CPT Code 99204: Best Practices for Billing New Patient Office Visits

Did you know? Billing new patient visits accurately is essential for outpatient practices, as it impacts reimbursement, compliance and workflow efficiency.

CPT Code 99204 is used for new patient office or outpatient visits that require a medically appropriate history and examination, along with a moderate level of medical decision-making (MDM). Alternatively, providers can use this code if the total time spent on the encounter is between 45 and 59 minutes, including both face-to-face and non-face-to-face activities.

In 2024, Medicare reimburses CPT 99204 at around $167 whereas private insurers may pay up to $245, depending on location and plan. Despite its clear criteria, many providers face challenges in using this code correctly.

To avoid these challenges, following best practices for documenting and billing CPT 99204 is crucial. This article highlights actionable best practices to help healthcare practices streamline their billing processes, reduce errors and optimize revenue.

Best Practices for Billing CPT 99204

Accurately billing CPT code 99204 is essential for new patient office visits that involve moderate complexity. The following best practices ensure proper reimbursement, reduce the risk of claim denials, and maintain compliance with CMS and payer guidelines:

1. Medical Decision-Making (MDM) Documentation

• Capture Number & Complexity of Problems

It is essential to document all problems addressed during the patient encounter, including chronic illnesses with exacerbation or new problems with uncertain prognosis. In fact, clearly describing the complexity of each problem helps demonstrate that the visit meets the moderate MDM requirement.

• Record Data Reviewed and Analyzed

Providers should include all relevant data that has been reviewed or analyzed, such as prior notes, laboratory results, imaging studies, and communications with other healthcare providers. This level of detail demonstrates thorough consideration in clinical decision-making and enhances the documentation for billing purposes.

• Detail Risk Assessment

Clinicians must record any risks associated with the treatment options, including prescription management, surgical considerations and potential complications. In fact, explaining the rationale behind each decision improves transparency and supports the justification for using CPT 99204.

2. Time-Based Billing Accuracy

• Track Total Encounter Time

When selecting 99204 based on time, providers should accurately record the total minutes spent on the date of service, including both face-to-face and non-face-to-face activities. It is important to note that the total time should range from 45 to 59 minutes for CPT 99204.

• Breakdown of Activities Counted

It is helpful to provide a breakdown of the activities that contribute to the total time. It can be chart review, patient counseling, care coordination, documentation and ordering tests or referrals. This detailed record ensures transparency and supports the billing claim.

• Avoid Non-Billable Time

Providers must avoid including administrative tasks unrelated to patient care when calculating total time. Only activities directly associated with the patient visit on the service date should be counted to maintain compliance and reduce audit risk.

3. Comprehensive Patient History and Exam

• Chief Complaint and History of Present Illness (HPI)

Providers should clearly document the patient’s presenting problem, including the onset, duration, severity, and any associated factors. This explanation provides essential context for the visit and supports the moderate complexity of the service.

• Relevant History

A thorough history should include past medical, psychiatric, family and social information relevant to the patient's condition. In fact, comprehensive background details help justify the level of care provided during the encounter.

• Exam Documentation

The physical examination or mental status examination should be detailed and directly related to the presenting problem. Thorough exam documentation strengthens the rationale for MDM and supports accurate billing.

4. Accurate Code Selection and Supporting Codes

• Use E/M Calculators or Decision Trees

Providers should use decision-support tools to ensure that either MDM or total time meets the criteria for CPT 99204. This step helps prevent errors in code selection and ensures compliance with current guidelines.

• Add Supplementary Codes

Clinicians should include supporting codes for laboratory tests, imaging or referrals whenever applicable. These supplementary codes provide a complete picture of the services rendered and strengthen the billing claim.

• Avoid Overcoding and Undercoding

It is essential to select the code that accurately reflects the complexity and time of the encounter. In fact, choosing the correct code prevents claim denials and avoids potential compliance issues.

5. Compliance With Payer and CMS Guidelines

• Stay Updated With 2025 CMS E/M Rules

Providers should always verify the latest requirements through the CMS Physician Fee Schedule and payer manuals to ensure proper code usage. Staying current with updates improves reimbursement accuracy and minimizes compliance risks.

• Audit Preparedness

Maintaining detailed notes, test results and a clear rationale for code selection helps providers respond effectively to audits. In fact proper documentation ensures transparency and supports the justification of CPT 99204.

6. Telehealth and Specialty Considerations

• Telehealth Visits

Providers must document the modality (video or phone), obtain patient consent, and ensure that MDM or total time requirements are met for telehealth encounters. Proper telehealth documentation safeguards both compliance and reimbursement.

• Psychiatry and Behavioral Health

Mental health providers should emphasize the importance of detailed patient histories, comprehensive mental status exams, careful medication management and consideration of psychosocial factors. These elements support the moderate complexity requirement and justify billing 99204 for new patient visits.

7. Internal Training and Support Systems

• Provider Education

Clinicians and staff should receive ongoing training on E/M guidelines and the documentation requirements for CPT 99204. Educated teams are less likely to make coding errors and more likely to maintain compliance.

• Use of Templates Wisely

Though templates can be helpful, they should be personalized to reflect the provider’s reasoning rather than relying on generic language. In fact, customized notes strengthen documentation quality and reduce audit risk.

Outsourcing Medical Billing and Coding Services

Outsourcing medical coding and billing tasks to 24/7 Medical Billing Services serves as a one-stop solution for practices seeking accurate and efficient CPT 99204 billing. These experienced coding specialists not only reduce the risk of claim denials but also help practices stay up-to-date with constantly evolving payer and CMS guidelines. In fact, such experts ensure that every claim accurately reflects the complexity of the encounter by analyzing documentation and cross-checking MDM or time-based requirements.

Moreover, they can identify patterns in denials or undercoding to provide targeted feedback to improve future documentation. Partnering with these professional medical billing services also strengthens revenue cycle management, increases reimbursement efficiency and safeguards the practice from audit risks. Therefore, outsourcing becomes a critical component of a comprehensive best-practice approach to CPT 99204 billing.

FAQs

Q1. Do ancillary staff activities count toward 99204 times?

Only if the provider personally performs or reviews the activities on the date of service.

Q2. Are lab or imaging orders required for 99204 billing?

No, but including them as supporting codes strengthens the claim.

Q3. Can 99204 be billed for same-day hospital visits?

Yes, if the documentation meets outpatient criteria and the MDM or time requirements are met.

Q4. Does 99204 apply to pediatric patients?

Yes, for new patient visits with moderate MDM or required total time.