Office visit for a new patient
CPT® Code 99204 is used to report an office or other outpatient visit for the evaluation and management (E/M) of a new patient. This code applies when the total time spent on the date of the encounter is 45 to 59 minutes, or when the medical decision making (MDM) is of moderate complexity. It is one level below the most complex new patient visit code (99205) and is typically used for new patients presenting with multiple or moderately complex medical concerns.
When to use CPT® Code 99204
This code is appropriate when:
- The patient is new to the practice, and the visit includes an in-depth history and physical examination.
- The conditions addressed are of moderate complexity and may require a workup, coordination of care, or new treatment decisions.
- The provider performs a visit that involves 45–59 minutes of total time on the date of the encounter.
- The visit requires the provider to engage in moderate-level data review, evaluation, and management.
The service may be selected based on either medical decision making or total time spent on the date of the encounter.
Medical decision making requirements
To use medical decision making (MDM) as the basis for selecting 99204, the visit must involve moderate complexity MDM, which includes:
- Number and complexity of problems addressed: One or more chronic illnesses with mild exacerbation or progression, or an acute illness with systemic symptoms.
- Amount and/or complexity of data reviewed and analyzed: Moderate amount of data, such as review of multiple documents, ordering of tests, or independent interpretation.
- Risk of complications and/or morbidity or mortality: Moderate risk associated with diagnostic procedures or management decisions.
Time requirements
When using total time to determine code selection, all activities performed by the provider on the date of the encounter may be included. For CPT 99204, total time must be 45 to 59 minutes and includes:
- Reviewing the patient’s history and external records
- Performing an exam and evaluation
- Educating and counseling the patient or family
- Ordering tests or referrals
- Documenting clinical findings in the EHR
- Coordinating care with other healthcare professionals
- Interpreting results and communicating them to the patient (if not separately reported)
Note: Do not include time spent on unrelated administrative work, general research, or teaching not specific to the patient.
Key documentation tips
- Document whether the code is based on MDM or total time.
- If using time, clearly state the total minutes spent and describe the work performed.
- Ensure the documentation supports moderate complexity, particularly if MDM is the basis for code selection.
- Include history, exam findings, orders, risk factors, and decision-making rationale to substantiate the level of service.
How OptiMantra supports accurate coding for CPT® 99204
OptiMantra makes it easier for providers to properly document and code new patient visits, including those at the moderate-complexity level like CPT 99204. The platform offers:
- Integrated time tracking, which logs provider time across the patient encounter for accurate time-based coding
- Smart EHR templates tailored to new patient visits, prompting for key elements such as history, exam, and MDM
- Real-time coding suggestions based on entered data and encounter complexity
- Audit-ready documentation, with structured, timestamped records aligned with payer and CMS requirements
- Seamless billing workflows, reducing the chance of denials or delays
By using OptiMantra, healthcare providers can improve documentation compliance, capture the full value of services provided, and spend more time focusing on patient care — not paperwork.
Try OptiMantra for free.
