2025 CPT code 99204
(Revised) Effective Date: N/A Revision Date: N/A Evaluation and Management - Office or Other Outpatient Services Evaluation and Management Feed
Office or outpatient visit for a new patient; requires medically appropriate history and/or examination and moderate medical decision-making; total time on the encounter date must be at least 45 minutes.
Modifiers may be applicable in certain situations.Consult the CPT guidelines for modifier usage.
Medical necessity is established when the patient's condition necessitates the level of service provided. The patient's symptoms, history, and physical examination findings should support the need for a comprehensive evaluation and management service.
The physician performs a comprehensive history, physical exam (to the extent deemed medically necessary), and medical decision-making related to the patient's condition. This includes ordering and reviewing tests, counseling the patient, coordinating care with other providers, and documenting the visit.
In simple words: This code is for a doctor's visit for a new patient at their office or clinic. The visit involves a moderate level of complexity and the doctor spends at least 45 minutes with the patient on that day, including time spent before and after seeing the patient.
This CPT code represents an office or other outpatient visit for the evaluation and management of a new patient.The service necessitates a medically appropriate history and/or examination, along with a moderate level of medical decision-making.When using total time spent on the encounter date for code selection, a minimum of 45 minutes must be met or exceeded.Total time includes face-to-face and non-face-to-face time on the encounter date. Non-face-to-face time may include pre-visit preparation, test review, post-visit documentation, communication with other healthcare providers, and care coordination.
Example 1: A new patient presents with chest pain and shortness of breath. The physician conducts a comprehensive history, performs a thorough physical exam, orders an EKG and cardiac enzymes, and consults with a cardiologist. The total time spent on the encounter is 55 minutes., A new patient presents with complex diabetes management needs, requiring the physician to review lab results, adjust medications, and counsel the patient on lifestyle modifications. The total time spent is 45 minutes., A new patient with a chronic condition requires a detailed review of their medical history and a comprehensive physical exam with the doctor spending 60 minutes.
Comprehensive documentation is essential. This should include a detailed history of the present illness, past medical, family, and social history; a thorough review of systems; a complete or focused physical exam (as clinically appropriate); documentation of medical decision-making, including the number and complexity of problems addressed, the amount and complexity of data reviewed, and the risk of complications; and details of any counseling and coordination of care.All documentation should be well-organized and easily understandable.
** Accurate coding of 99204 requires careful documentation to support the level of service.Always ensure that the documentation justifies the use of this code and is compliant with payer guidelines.
- Revenue Code: Office visit revenue codes will vary by payer.Consult your payer's guidelines.
- RVU: RVUs vary depending on geographic location, facility type, and payer. Consult your payer's fee schedule for specific RVU values and reimbursement rates.
- Global Days: This code does not have a global period.Each visit is separately billable.
- Payment Status: Active
- Modifier TC rule: Not applicable.
- Fee Schedule: Historical fee schedules are readily available from CMS and private payers. These change frequently, so you must check the most recent.
- Specialties:This code can be used by many specialties, depending on the patient's condition.Examples include internal medicine, family medicine, cardiology, neurology, and more.
- Place of Service:Office, Outpatient Hospital, Ambulatory Surgical Center