99204

Office or other outpatient visit for the evaluation and management of a new patient, level 4

This CPT code represents an office or other outpatient visit for the evaluation and management (E/M) of a new patient, requiring a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 45-59 minutes of total time is spent on the date of the encounter. This visit typically involves a comprehensive assessment of a patient presenting with new or complex medical issues.

Clinical Indications

  • New patient presenting with multiple chronic medical conditions requiring comprehensive assessment and management plan initiation.
  • New patient with a complex acute illness or injury requiring in-depth history, examination, and moderate medical decision making.
  • New patient seeking a second opinion for a significant medical condition.
  • Initial evaluation for a patient referred for specialized care, where the specialty provider has not previously seen the patient.
  • Comprehensive preventive medicine visit for a new patient with significant risk factors or a need for extensive counseling.

Procedure Steps

  1. Review of chief complaint and patient history, including medical, surgical, family, and social history.
  2. Performance of a comprehensive physical examination relevant to the patient's presenting problems.
  3. Evaluation of diagnostic test results and other relevant patient data (e.g., previous medical records).
  4. Establishment or refinement of diagnoses.
  5. Development and documentation of a management plan, including treatment options, referrals, prescriptions, and patient education.
  6. Counseling and/or coordination of care with other providers or specialties, if indicated.
  7. Documentation of the encounter in the patient's medical record, supporting the complexity of the medical decision making or the total time spent.

Coding Guidelines

  • A 'new patient' is defined as one who has not received any professional services from the physician or another physician of the same specialty and subspecialty who belongs to the same group practice, within the past three years.
  • Code selection for 99204 can be based on either the level of medical decision making (moderate) or total time spent (45-59 minutes) on the date of the encounter.
  • All three key components (history, examination, and medical decision making) were previously required for new patient E/M codes prior to 2021 E/M guideline changes, but now only medical decision making or time is required for code selection for outpatient E/M services.
  • The medical record documentation must clearly support the level of service billed, reflecting the complexity of the history, examination, and/or medical decision making.
  • Services typically performed by clinical staff (e.g., rooming the patient, vital signs) are not counted towards the physician's or other qualified healthcare professional's time when using time for code selection.
  • For new patients, a comprehensive history and exam are often performed to establish a baseline, even if the primary code selection criterion is MDM or time.

Associated ICD-10 Codes