CPT 99204: New Patient Office Visit, Moderate Complexity
CPT 99204 reports a new patient office or outpatient visit with moderate medical decision making or 45-59 minutes of total time. In 2026 Medicare pays about $177.36 non-facility (5.31 total RVUs times the $33.4009 conversion factor) and about $116.90 in a facility.
- Code type
- New patient E/M (office/outpatient)
- 2026 non-facility
- $177.36 (5.31 RVUs)
- 2026 facility
- $116.90 (3.50 RVUs)
- Time (if used)
- 45-59 minutes total on the date
What is CPT 99204 used for?
CPT 99204 is an office or outpatient visit for a new patient requiring moderate medical decision making or 45-59 minutes of total time. It is the level-4 new-patient code and, for many outpatient specialties, the most common new-patient level because initial evaluations legitimately carry moderate problem and data complexity.
Under the 2021 E/M rules you pick the level by MDM or by total time; history and exam must be medically appropriate but no longer drive the code. Confirm new-patient status first: no face-to-face professional service from you, or a same-specialty and subspecialty physician in your group, within three years. If that test fails, the visit is an established one and this code does not apply.
How much does 99204 pay in 2026?
99204 carries 5.31 non-facility RVUs and 3.50 facility RVUs. At the 2026 conversion factor of $33.4009:
| Setting | Total RVUs | 2026 Medicare allowed |
|---|---|---|
| Non-facility (office) | 5.31 | ~$177.36 |
| Facility | 3.50 | ~$116.90 |
Medicare pays 80 percent of the allowed amount after the deductible; the balance is patient or secondary coinsurance. Check your locality with the Medicare fee calculator.
How do you support a 99204?
A new-patient level 4 needs documented moderate complexity, not just a long note. Moderate MDM generally means one chronic illness with exacerbation, two or more stable chronic conditions, an undiagnosed new problem with an uncertain prognosis, or prescription drug management, combined with moderate data review or moderate risk. Example: a new patient presents with newly elevated blood pressure and type 2 diabetes; you order a metabolic panel and A1c, review outside records, and start an antihypertensive. That is prescription drug management plus an undiagnosed problem plus data review, comfortably 99204 at about $177.36.
- 99202 - straightforward, 15-29 min.
- 99203 - low, 30-44 min.
- 99204 - moderate, 45-59 min.
- 99205 - high, 60-74 min.
When you are the continuing focal point for the patient's care, add G2211 for the visit complexity of longitudinal care.
Frequently asked questions
By time, 99204 requires 45-59 minutes of total time on the date of service, including chart review, the face-to-face encounter, and documentation and orders finished before midnight. New-patient visits reach these times readily because you are collecting a full history and building the record. If you code by MDM, moderate complexity controls.
The 2026 national non-facility allowed amount is about $177.36 (5.31 total RVUs times $33.4009). In a facility it is about $116.90 (3.50 RVUs). Medicare pays 80 percent after the deductible; the remainder is patient or secondary coinsurance.
Moderate MDM typically means one chronic illness with exacerbation, two or more stable chronic conditions, an undiagnosed new problem with uncertain prognosis, or prescription drug management, combined with moderate data review or moderate risk. Document the problem load, the data reviewed, and the management decisions so the moderate level is auditable.
Sources & further reading
Reviewed by the ImmediCare Solutions RCM team
Certified billers and coders handling claims across 50+ specialties nationwide. This entry is reviewed against current payer policy and CMS rules. Last review: Jul 5, 2026.
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