New patient office or outpatient visit requiring moderate medical decision making, or 45–59 minutes of total provider time on the date of the encounter.

Verified May 8, 2026 · 6 sources ↓

Medicare: $177.36
Total RVUs: 5.31
Global, days
Region: General

Drawn from CMSAMAAAPC

Documentation requirements

What must appear in the operative or office note to support the claim.

Source · Editorial brief grounded in 6 cited references ↓

Patient status confirmed as new — no face-to-face encounter with provider or any same-group-same-specialty provider within the past 3 years
Total provider time on the date of the encounter stated explicitly in minutes (required when billing by time; must meet or exceed 45 minutes)
Medical decision making documented across all three elements if MDM basis is used: number and complexity of problems addressed, amount and complexity of data reviewed, and risk of complications or morbidity
Prescription drug management or other moderate-risk decision documented if using the risk element to support moderate MDM
Medically appropriate history and/or examination recorded — scope driven by clinical need, not by a mandatory element count
For time-based billing, all contributing activities performed on the date of the encounter listed (e.g., record review, care coordination, ordering, documentation)

Applicable modifiers

Modifiers commonly billed with this code.

Source · AMA CPT modifier descriptors · CMS NCCI Policy Manual

25 Significant separate E/M 52 Reduced services 57 Decision for surgery 76 Repeat, same physician 95 Modifier

What this code covers

Source · Editorial summary grounded in 6 cited references ↓

99204 is the level-4 new patient office visit code. It requires either moderate medical decision making (MDM) or total provider time on the date of the encounter of 45–59 minutes — provider selects whichever basis better supports the visit. Moderate MDM means at least two of the three MDM elements hit the moderate threshold: multiple chronic conditions or a new problem with uncertain prognosis; review of external records, independent interpretation of a test, or independent historian; and moderate risk such as prescription drug management, decision for minor surgery with identified patient risk factors, or diagnosis limited by social determinants of health.

For orthopedic practices, 99204 fits a new patient presenting with a complex musculoskeletal complaint — a new diagnosis requiring imaging review, a patient being started on prescription medication, or a surgical candidate requiring a thorough pre-decision workup. The code carries a global period of XXX, meaning it has no associated global period and is not subject to global surgery bundling rules.

When billing by time, document the total provider time on the date of the encounter — not just face-to-face time. Include pre- and post-encounter work such as reviewing records, ordering tests, and completing documentation. Payers audit time-based claims by checking whether the note contains a specific time statement and whether the documented activities are consistent with that time claim. Missing a stated total time or logging activities that don't credibly fill 45 minutes is the fastest path to a downcode.

RVU & reimbursement

Component RVUs and Medicare national rate. Actual payment varies by GPCI locality.

Source · CMS Physician Fee Schedule, RVU26A · January 2026

Work RVU	2.6
Practice expense RVU	2.47
Malpractice RVU	0.24
Total RVU	5.31
Medicare national rate	$177.36
Global period	days

Payment by site of service

Medicare pays different rates by setting. HOPD typically pays substantially more than ASC for the same procedure.

Source · CMS OPPS Addendum B·ASC HCPCS payment rates·2026

Setting	Medicare rate (national)
Office (PFS non-facility) Procedure performed in physician's office	$177.36

Common denial reasons

The recurring reasons claims for CPT 99204 get rejected.

Source · Editorial brief grounded in CMS NCCI edits, AAOS coding appeals, and cited references ↓

Established patient billed as new — patient seen within 3 years by same provider or same-group same-specialty provider
No explicit time statement in the note when time was used as the basis for level selection
MDM documented at only one element at moderate level, failing to meet the two-of-three threshold required for moderate MDM
Code downcoded to 99203 when documented activities or MDM elements are consistent with low rather than moderate complexity
Same-day procedure billed without modifier 25 on the E/M — payer bundles the visit into the procedure payment

Frequently asked questions

Source · Generated from the editorial pipeline, verified against 6 cited references ↓

01Can I bill 99204 if the visit runs under 45 minutes but the MDM is moderate?

Yes. Time and MDM are independent bases for code selection. If moderate MDM is documented across at least two of the three elements, you can bill 99204 regardless of visit length. Time only matters when you elect to use time as your selection basis.

02Can I bill 99204 and a procedure on the same day?

Yes, but modifier 25 is required on the 99204. The E/M must reflect a separately identifiable service above and beyond the pre-procedure assessment. Document the decision-making or clinical discussion that is distinct from the procedure itself.

03What's the difference between 99204 and 99205 for new orthopedic patients?

99205 requires high MDM or 60–74 minutes of total time. High MDM means at least one problem that poses a threat to life or bodily function, extensive data review (including independent interpretation of tests), and high risk such as decision for major surgery. If you're seeing a new patient for an elective joint replacement consult with a clear diagnosis and no significant comorbidities, 99204 is typically the right level.

04Does 99204 have a global period I need to worry about?

No. The global period for 99204 is XXX, which means CMS has determined this code is not subject to global surgery payment rules. It does not suppress or get absorbed into any surgical global period.

05Can 99204 be billed for telehealth visits?

Yes. CMS covers 99204 via telehealth for Medicare beneficiaries. Bill with place of service 02 (telehealth, patient not in their home) or 10 (telehealth, patient in their home), and append modifier 95 for synchronous audio-video encounters where applicable under your MAC's policy.

06What time activities count toward the 45-minute threshold?

Total time on the date of the encounter includes face-to-face time plus pre- and post-encounter work performed that day: reviewing outside records, ordering tests, interpreting results, counseling, documenting the note, and care coordination. Time spent by clinical staff does not count — only the billing provider's time.

Sources & references

Editorial content was developed using the following public sources. Last verified May 8, 2026.

Mira AI Scribe

Mira's AI scribe captures total provider time on the date of the encounter, documents all contributing activities (record review, ordering, care coordination), flags the patient's new-patient status, and structures MDM across all three elements — number/complexity of problems, data reviewed, and risk tier. That prevents the two most common 99204 downcodes: a missing time statement when billing by time, and an MDM note that only clears one of the three required elements at moderate level.

See how Mira captures CPT 99204 documentation